Every finding on record at Ocean Ridge Post Acute

Based on observation, interview, and record review, the facility failed to provide services to improve or maintain range of motion (ROM, full movement potential of a joint) for one of six sampled residents (Residents 61) with ROM concerns by failing to: 1. Ensure Resident 61's Restorative Nursing Aide (RNA, nursing aide program that help residents maintain any progress made after therapy intervention to maintain their function) program was appropriately modified to maintain and improve Resident 61's right arm ROM. 2. Ensure RNA 1 provided active assistive ROM (AAROM, movement at a given joint with a person's own effort and assistance from an external force or another person) exercises to Resident 61's both legs during an RNA session in accordance with physician's orders. These failures had the potential for Resident 61 to experience a further decline in ROM resulting in contracture (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) development and have a decline in physical functioning, mobility (ability to move), and activities of daily living (ADL, basic activities such as eating, dressing, toileting). Findings: 1. During a review of Resident 61's admission Record, the admission Record indicated Resident 61 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including cerebral infarction (stroke, blockage of the flow of blood brain, causing or resulting in brain tissue death), muscle weakness, and contractures (loss of motion of a joint associated with stiffness and joint deformity) of the right shoulder, both hips, both knees, and both ankles.2. During a review of Resident 61's Minimum Data Set (MDS, a resident assessment tool), dated 1/15/2026, the MDS indicated Resident 61 had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 61 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying assistance) for eating, substantial/maximal assistance (helper does more than half the effort) for oral hygiene, personal hygiene, upper body dressing, and rolling to both sides, and was dependent (helper does all the effort) in toileting hygiene, bathing, upper body dressing, and transfers. The MDS indicated Resident 61 had functional limitations in range of motion (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in one arm and one leg. During a review of Resident 61's Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Evaluation and Plan of Treatment note (OT Eval), dated 2/16/2024, the OT Eval indicated Resident 61 had impaired ROM and 0/5 strength (paralysis or no detectable muscle contraction) in the right arm.During a review of Resident 61's RNA Referral form, dated 2/16/2024, the RNA referral form indicated Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) and OT referred Resident 61 to RNA services for passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises to Resident 61's right arm, five times a week or as tolerated. During a review of Resident 61's RNA Referral form, dated 9/22/2025, the RNA referral form indicated for Resident 61's RNA program to be updated to AROM exercises to Resident 61's right arm, five times a week or as tolerated. During a review of Resident 61's Order Summary Report, the Order Summary Report indicated a physician's order, dated 9/22/2025, for RNA to provide active ROM (AROM, performance of ROM of a joint without any assistance or effort of another person) exercises to Resident 61's right arm, five times a week. During an observation on 3/24/2026 at 1:44 p.m. of Resident 61's RNA session, Resident 61 was lying in bed. RNA 1 demonstrated exercises and asked Resident 61 to raise the right arm up and down and out to the side away from the body, 15 times each direction. Resident 61 raised the right arm minimally to less than shoulder height and minimally away from the body and could not move through the full ROM in all directions. RNA did not assist Resident 61 in moving the right shoulder through the full ROM. RNA 1 held and supported Resident 61's upper portion of the right arm and asked Resident 61 to bend and straighten the right elbow. Resident 61 was able to partially bend and straighten the right elbow with a lot of effort, but could not move through the full ROM. RNA 1 did not assist Resident 61 in moving the right elbow through the full ROM. RNA 1 supported Resident 61's right arm by holding the right arm at the forearm and asked Resident 61 to bend the right wrist up and down and open and close the fingers of the hand. Resident 61 partially bent and straightened the right wrist and tried to bend and straighten the fingers of the right hand but could not obtain full ROM. RNA 1 did not assist Resident 61 in moving the right wrist and fingers of the right hand through the full ROM. During an interview on 3/24/2026 at 2:15 p.m. with RNA 1, RNA 1 stated Resident 61's right arm strength had improved significantly since she began working with Resident 61 for RNA about eight months ago. RNA 1 stated Resident 61's right arm was paralyzed and had no active movement. RNA 1 stated Resident 61 was now able to move the right arm minimally on his own but needed assistance moving through the full ROM. RNA 1 stated she did not assist Resident 61 in moving through the full ROM of all the joints of the right arm because the RNA order was changed from PROM exercises to AROM exercises which meant Resident 61 was to move the right arm independently and without physical assistance from RNA. During a concurrent interview and record review on 3/25/2026 at 1:27 p.m. with the Director of Rehabilitation (DOR) and Occupational Therapist 1 (OT 1), the DOR stated Rehab created the RNA programs based on a resident's needs. The DOR stated RNAs were to carry out RNA exercises as ordered. The DOR stated if an RNA program required modification due to a change in a resident's condition, PT and/or OT would re-assess the resident and modify the RNA program based on the resident's needs. The DOR reviewed Resident 61's OT Eval, dated 2/16/2024, and RNA Referral form, dated 2/16/2024, confirmed OT recommended an RNA program for PROM exercises to the right arm due to 0/5 strength in the right arm which meant Resident 61 had no active movement in the arm. The DOR reviewed Resident 61's RNA Referral form, dated 9/22/2025, and confirmed Resident 61's RNA order was modified from PROM to AROM to the right arm but did not know why. OT 1 reviewed Resident 61's Rehab Referral form, dated 9/22/2025, and confirmed OT 1 modified Resident 61's RNA program from PROM exercises to AROM but did not know why. OT 1 stated AROM exercises meant the resident moved the arm or leg through the full available ROM independently and without assistance. OT 1 stated if Resident 61 could not move the right arm fully and independently, AROM exercises as ordered would not be an appropriate modification to the RNA program because Resident 61 would need assistance to move to his end ROM to prevent joint stiffness. During a concurrent observation, interview, and record review on 3/26/2026 at 12:15 p.m. with Occupational Therapist 2 (OT 2), OT 2 reviewed Resident 61's therapy notes and confirmed OT 2 evaluated Resident 61 on 2/16/2024 and recommended RNA for PROM to the right arm because the right arm was paralyzed and had no movement. OT 2 reviewed Resident 61's RNA Referral form, dated 9/22/2025, and confirmed Resident 61's RNA order was changed from PROM exercises to AROM of the right arm but did not know why. OT 2 stated Resident 61's right arm must have improved in strength significantly in order to change Resident 61's RNA program so drastically. OT 2 entered Resident 61's room to assess Resident 61's right arm. Resident 61 wiggled the fingers of the right hand, partially bent and straightened the right elbow, was unable to straighten the right wrist, and minimally lifted the right arm. OT 2 stated Resident 61's right arm strength improved significantly from the last OT evaluation in 2/16/2024 but still had significant weakness on the right arm and could not move through the full ROM on his own. OT 2 reviewed Resident 61's RNA order, dated 9/22/2025, and confirmed Resident 61 had an RNA order for AROM to the right arm. OT 2 stated the RNA program was not modified appropriately and should have been for AAROM, not AROM exercises as Resident 61 needed assistance to move through the full ROM to prevent joint stiffness and maintain and improve right arm ROM. OT 2 stated AROM exercises would not be sufficient to maintain and improve Resident 61's right arm ROM based on his current level of function. OT 2 stated it was important that RNA programs were modified appropriately to ensure the residents received the care and services needed to maintain function and prevent functional decline and contractures. During an interview on 3/26/2026 at 3:23 p.m. with the Director of Nursing (DON), the DON stated Rehab created and modified RNA programs. The DON stated if RNA programs were not created and modified appropriately based on the residents' presentation and current level of function, it could result in ROM and functional decline. 2. During a review of Resident 61's admission Record, the admission Record indicated Resident 61 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including cerebral infarction, muscle weakness, and contractures of the right shoulder, both hips, both knees, and both ankles.During a review of Resident 61's MDS, dated [DATE], the MDS indicated Resident 61 had severely impaired cognition. The MDS indicated Resident 61 required supervision or touching assistance for eating, substantial/maximal assistance for oral hygiene, personal hygiene, upper body dressing, and rolling to both sides, and was dependent in toileting hygiene, bathing, upper body dressing, and transfers. The MDS indicated Resident 61 had functional limitations in range of motion in one arm and one leg.During a review of Resident 61's Order Summary Report, the Order Summary Report indicated a physician's order, dated 3/16/2026, for RNA to provide AAROM exercises to Resident 61's both legs, five times a week.During an observation on 3/24/2026 at 1:44 p.m. of Resident 61's RNA session, in Resident 61's room, Resident 61 was lying in bed. After assisting Resident 61 with right arm ROM exercises, RNA 1 demonstrated the exercises and asked Resident 61 to lift the left leg up and down and inwards and outwards away from the body, 15 times each direction. Resident 61 partially moved the left leg up and down and inwards and outwards towards the body but could not move through the full ROM in all directions. RNA did not assist Resident 61 in moving the left hip through the full ROM. RNA 1 held and supported Resident 61's upper portion of the leg and asked Resident 61 to bend and straighten the left knee, 15 times. Resident 61 was able to partially bend the knee downwards and upwards, but could not move through the full ROM. RNA 1 did not assist Resident 61 in moving the left leg through the full ROM. RNA 1 asked Resident 61 to move the left ankle and all toes of the left foot up and down. Resident 61 tried but was unable. RNA 1 did not assist Resident 61 with left ankle and left toe ROM exercises. RNA 1 moved to the right side of the bed and verbally asked Resident 61 to move the right leg up and down and inwards and outwards away from the body, 15 times in each direction. Resident 61 partially moved the left leg up and down and inwards and outwards towards the body, but could not move through the full ROM. RNA 1 did not assist Resident 61 in moving the right leg through the full ROM. RNA 1 held and supported Resident 61's upper portion of the leg and asked Resident 61 to bend and straighten the right knee and all the toes on the right foot, 15 times in each direction. Resident 61 was able to partially bend the knee downwards and upwards, but could not move through the full ROM. RNA 1 did not assist Resident 61 in moving the right knee through the full ROM. During a concurrent interview and record review on 3/24/2026 at 2:15 p.m. with RNA 1, RNA 1 reviewed Resident 61's physician's order, dated 3/16/2026, and confirmed Resident 61 had an RNA order for RNA to provide AAROM exercises to Resident 61's both legs. RNA 1 stated she did not know what AAROM exercises were and thought the order said AROM exercises which meant Resident 61 performed the ROM exercises on his own with only cueing or demonstration of the exercises and without physical assistance from RNA. RNA 1 stated Resident 61 was unable to fully move both legs independently but did not physically assist with ROM because she thought the order was for AROM and did not know what AAROM exercises were. RNA 1 stated if a resident could not move the arm or leg through the full ROM on his or her own and did not have the proper ROM assistance, it could result in joint stiffness. During a concurrent interview and record review on 3/25/2026 at 1:27 p.m. with the DOR, the DOR stated PT and OT created the RNA programs based on a resident's needs. The DOR stated RNAs were to carry out RNA exercises as ordered. The DOR reviewed Resident 61's physician's orders, dated 3/16/2026, and confirmed Resident 61 had an RNA order for AAROM exercises to Resident 61's both legs. The DOR stated AAROM exercises were typically prescribed to residents who were unable to obtain full ROM on their own and needed the physical assistance of RNA or equipment to help move through the rest of the motion. The DOR stated if an RNA order was written for AAROM exercises to both legs, it was expected that RNA would physically assist Resident 61 through his full available ROM in all joints of both legs because Resident 61 did not have the strength or ability to obtain full range independently. The DOR stated if RNA did not provide Resident 61 with AAROM as ordered, it could result in ROM decline and contracture development. During an interview on 3/26/2026 at 3:23 p.m. with the DON, the DON stated RNAs assisted residents in the facility with activities such as ROM exercises to ensure the residents maintained their current level of function and did not experience a functional decline after discharge from skilled therapy services (services that require specialized training and experience of a licensed therapist or therapy assistant). The DON stated it was important for RNA to provide exercises as ordered to prevent potential declines in ROM function, and to avoid delaying a resident's progress towards goals. During a review of the facility's Policy and Procedure (P/P) titled, Specialized Rehabilitative Services, revised 12/2009, the P/P indicated once a resident met his or her care plan goals, a licensed professional can either discontinue treatment or initiate a maintenance program which either Nursing or Restorative Aides would implement to assure that the resident maintains his or her functional and physical status. During a review of the facility's P/P titled, Resident Mobility and Range of Motion, revised 7/2017, the P&P indicated residents would not experience an avoidable reduction in ROM and residents with limited ROM would receive the treatment and services to increase and/or prevent a further decrease in ROM. The P/P indicated the care plan would be developed by the interdisciplinary team based on comprehensive assessment and include specific interventions, exercises, and therapies to maintain, prevent avoidable decline in, and/or improve mobility and ROM. CROSS-REFERENCE TO F726

Based on observation, interview and record review, the facility failed to provide medically related social services (professional interventions provided by social workers to help residents manage the emotional, social, and financial impacts of illness) for two of six sampled residents (Resident 19 and Resident 45) failing to:A. Ensure Resident 19 was seen by podiatrist (a medical specialist focused on diagnosing, treating, and rehabilitating conditions related to the foot, ankle, and lower leg) as requested.B. Ensure Resident 45 was seen by ophthalmologists (a medical specializing in comprehensive eye and vision care, including medical and surgical treatment) in three months as recommended. These failures had the potential to result in delay in the delivery of care and services.Findings:A. During a review of Resident 19's admission record, the admission record indicated Resident 19 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (the blood supply to part of the brain is blocked or reduced), dementia (a progressive state of decline in mental abilities), muscle weakness, and chronic pain syndrome (pain that persists or recurs for longer than 3 months).During a review of Resident 19's History and Physical (H&P), dated 11/11/2025, the H&P indicated, Resident 19 had no capacity (ability) to understand and make decisions.During a review of Resident 19's MDS, dated [DATE], the MDS indicated Resident 19 required maximal assistance (Helper does more than half the effort) from one staff for toileting hygiene, shower, dressing, personal hygiene, transfer, moderate assistance (Helper does less than half the effort) from one staff for bed mobility, and supervision or touching assistance (Helper provide verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) from one staff for oral hygiene and eating.During a review of Resident 19's Order Summary Report (OSR), dated 3/25/2026, the OSR indicated, consult podiatry as needed for mycotic/hypertrophic nails and or keratotic lesions was ordered on 11/10/2025.During a concurrent observation and interview on 3/23/2026, at 10:59 a.m., with Resident 19 in his room, Resident 19's right toenails were observed. Resident 19's right toenails were thick, long, and dark yellow with some parts turned black. Resident 19's toenails were growing in unnatural position toward right side. Resident 19's top of the big toe had callus (an area of thickened and sometimes hardened skin that forms as a response to repeated friction, pressure, or other irritation). Resident 19 stated, right toenails were long and hurt whenever he stood up to transfer from bed to wheelchair or do therapy. Resident 19 stated, it had been long time since he was seen by podiatrist. Resident 19 stated, he and his Responsible Party (RP) asked multiple times to see podiatrist, but no one helped him yet.During a concurrent interview and record review on 3/25/2026, at 1:04 p.m., with the Social Service Director (SSD), Resident 19's Convalescent Podiatry Care Evaluation and Treatment, dated 12/4/2025 was reviewed. The Convalescent Podiatry Care Evaluation and Treatment indicated, Resident 19 had tinea unguium (a common fungal infection of the fingernails or toenails), toe pains on both, corns (a small, localized area of thickened, hardened skin that develops on the feet, typically on the toes, due to chronic friction or pressure) and callosities (thickened, hardened, or elevated patches of skin resulting from chronic friction, pressure, or irritation). The Convalescent Podiatry Care Evaluation and Treatment indicated, debridement (the medical removal of dead, damaged, or infected tissue) and trimming of nails, corns, and callosities were done. The SSD stated, she should have followed up with podiatrist office for Resident 19 to be seen by a podiatrist more often. The SSD stated she was not aware of Resident 19's right toenails being long and painful when he stood up.B. During a review of Resident 45's admission record, the admission record indicated Resident 45 was admitted to the facility on [DATE] with diagnoses including right eye blindness, muscle weakness, and Acute Kidney Injury (AKI-a sudden and often reversible reduction in kidney function).During a review of Resident 45's H&P, dated 6/24/2025, the H&P indicated, Resident 45 had fluctuating capacity (ability) to understand and make decisions.During a review of Resident 45's MDS dated [DATE], the MDS indicated Resident 45 required moderate assistance from one staff for transfer, dressing, and supervision or touching assistance (Helper provide verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) from one staff for oral hygiene, shower, personal hygiene, toilet hygiene, eating.During a review of Resident 45's Care Plan (CP) titled, Resident 45 has impaired visual function related to blindness on right eye, revised 7/14/2025, the CP Goal indicated, Resident 45 will maintain optimal quality of life within limitation imposed by visual function through by 4/23/2026. The CP Interventions indicated arrange consultation with eye care practitioner as required.During a concurrent observation and interview on 3/23/2026, at 10:37 a.m., with Resident 45 in his room, Resident 45's right eye cornea (the transparent, dome-shaped outer layer at the very front of the eye) was cloudy and opaque (unclear). Resident 45 stated he lost vision in his right eye due to possible glaucoma (a group of eye diseases that damage the optic nerve often due to high fluid pressure inside the eye). Resident 45 stated, he became blind because he missed the optimal time to get treatment. Resident 45 stated he was not seen by his ophthalmologist as frequently as he wanted. Resident 45 stated, he was supposed to see ophthalmologist on 1/2026, but he was not seen by ophthalmologist until 2/2026. Resident 45 stated, he was worried about his left eye, and he asked the staff to arrange an appointment with ophthalmologist multiple times.During a concurrent interview and record review on 3/25/2026, at 1:37 p.m., with the SSD, Resident 45's Ophthalmology Exam/Consult and Report, dated 10/14/2025 was reviewed. The Ophthalmology Exam/Consult and Report indicated, the ophthalmologist recommended follow up in three months. The SSD stated that the follow up visit did not occur in three months and last visit was on 2/12/2026 that was over three months. The SSD stated the staff should have followed through with the follow-up appointment in three months to ensure Resident 45 received the care and treatment as ophthalmologist recommended.During an interview on 3/26/2026, at 2:53 p.m., with the Director of Nursing (DON), the DON stated, the SSD should be proactive with assisting the residents. The DON stated it was SSD's responsibility to assist the residents with all aspects of their lives. The DON stated that it was important to ensure specialty consultancy appointments were made in timely manner and follow through. The DON stated the staff should have identified the residents' needs and arranged necessary services.During a review of the facility's Policy and Procedure (P&P) titled, Job Description: Social Service Director, revised 12/2025, the P&P indicated, The Social Services Director leads and oversees the delivery of social services to residents and their families, ensuring that each individual achieves the highest practicable level of physical, emotional, and psychosocial well-being .Essential Duties: Provide medically related social services so that the highest practicable physical, mental and psychosocial wellbeing of each resident is attained or maintained. Assist in making outpatient appointments as ordered and schedule on-site ancillary patient services to include optometry, podiatry, dentistry and psychiatric services.During a review of the facility's Policy and Procedure (P&P) titled, Social Service, revised 1/2026, the P&P indicated, Policy Interpretation and Implementation: e. Compiling and maintaining up-to-date information about community health and service agencies avail able for resident referrals; f. Making referrals to social service agencies as necessary or appropriate; g. Maintaining appropriate documentation of referrals and providing social service data summaries to such agencies.

Based on observation, interview, and record review the facility failed to:Ensure clean linen carts were accessed only by facility staff.Implement the facility's Policy and Procedure (P&P) titled Departmental (Environmental Services) - Laundry and Linen, which indicated all soiled linens and medical devices must be placed in the laundry area, in a covered laundry hamper which can contain the moisture.These failure had the potential to increase the risk of infection and cross-contamination (the transfer of bacteria, viruses, microorganisms, or other harmful substances from one surface to another through improper or unsanitary equipment, procedures, or products) among facility staff and residents. Findings: A. During an observation on 3/23/2026 at 10:09 a.m., a resident was observed accessing the clean linen cart located in front of room [ROOM NUMBER] without staff assistance. During an interview on 3/24/2026 at 1:13 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated clean linen carts should only be accessed by facility staff to prevent the spread of bacteria. LVN 1 stated if clean linen carts were accessed by residents without assistance from the facility staff, there would be an increased risk for the spread of infection to other residents. During an interview on 3/25/2026 at 2:14 p.m. with the Director of Nursing (DON), the DON stated the importance of making sure clean linen carts were only accessed by facility staff was to ensure the linens were not contaminated. The DON stated if clean linen carts were accessed by residents without assistance from facility staff, there would be potential for an increased risk for cross contamination. During a review of the facility's P&P titled Laundry and Bedding, Soiled dated 2001, the P&P did not indicate procedures for individuals who were designated to access clean linen carts. b. During a concurrent observation and interview on 3/26/2026 at 3:07 p.m., with Laundry Aid (LA) 1, in the laundry area, multiple items were observed leaning against a wall above the hamper next to the washing machine, rather than being placed in a designated hamper or laundry chute. LA 1 stated the items included a resident's hat, soiled clothing, a shower blanket, medical devices; a wedge (essential positioning aids used to prevent pressure ulcers, facilitate turning, and improving comfort for immobile residents), a heel protector (a proactive medical devices designed to prevent pressure injuries in non-ambulatory residents by elevating the heel off the mattress), Intermittent pneumatic compression devices (leg squeezers-inflatable sleeves used in nursing homes to prevent blood blots and improve circulation in immobile residents), and used linens. LA 1 stated the observed items were used (soiled) it is not acceptable to store medical devices in the laundry area or to leave soiled linens outside a designated covered container. During an interview on 03/26/2026 at 4:06 p.m. with the Director of Nursing (DON), the DON stated soiled linens and soiled medical devices must be kept in a designated container. The DON stated these practices are necessary to prevent contamination and infection. During a review of the facility's P&P titled Departmental (Environmental Services) – Laundry and Linen, dated January 2026, the P&P indicated to consider all soiled linen to be potentially infectious, all soiled linen must be placed directly into a covered laundry hamper which can contain the moisture. If laundry chutes are used, only closed and leak-resistant bags will be put into the chute. Loose items will not be placed in the laundry chute.

Based on interview and record review, the facility failed to maintain staff documentation of screening, education, offering, and current Coronavirus Disease 2019 ([COVID-19] a new infectious viral disease that could cause respiratory illness) vaccination status for all licensed practitioners.These failures had the potential to increase the risk of transmission of COVID-19 and other respiratory infections to all residents.Findings:During a concurrent interview and record review on 3/26/2026 at 9:59 a.m. with the Infection Preventionist (IP), the facility updated 2025-2026 COVID-19 vaccine acceptance/declination forms, undated, were reviewed. The IP stated all individuals who provide care or have contact with residents, including the licensed practitioners, are considered staff, and the facility should encourage staff to receive COVID-19 immunization, including providing screening, education, offering vaccination, and maintaining documentation of vaccination status. The IPN stated she did not document or maintain COVID-19 vaccination status for licensed practitioners including screening, education, offering. The IP stated this is essential to prevent the spread of COVID-19 and other respiratory infections, and without tracking vaccination status, resident may be at risk of illness. During an interview on 3/26/2026 at 4:06 p.m. with the Director of Nursing (DON), the DON stated the facility should maintain COVID-19 vaccination records for all staff, including licensed practitioners, to monitor vaccination status and reduce the risk of illness for residents.During a review of the facility's Procedure and Policy (PP) titled Coronavirus Disease (COVID-19)-Vaccination of Staff, dated January 2026, the P&P indicated staff are educated about benefits, risks, and potential side effects of the COVID-19 vaccine. The P&P indicated Staff' means individuals who provide any care, treatment, or other services for the facility and/or its residents, regardless of clinical responsibility or resident contact, including employees, licensed practitioners, students, trainees, and volunteers.

Based on interview and record review, the facility failed to formulate Advance Directives ([AD]-written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) and Physician Orders for Life-Sustaining Treatment ([POLST]- a medical order that helps give people with serious illness more control over their care during a medical emergency) correctly in the medical records of two of 14 sampled residents (Resident 1 and Resident 13) by not:A. Ensuring the AD and the POLST were signed by a designated Responsible Party (RP) for Resident 1.B. Identifying a designated Resident Representative for Resident 13. These failures had the potential to result in delays of care and treatment and/ or inadvertently missed health care wishes/ decisions of the residents during emergencies, end of life, and changes in condition. Findings: A. During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was initially admitted to the facility on [DATE] and last re-admission was on [DATE] with diagnoses including dysarthria (the muscles used for speech are weak or are hard to control), alcoholic cirrhosis of liver (the final, often irreversible stage of alcohol-related liver disease, characterized by severe scarring and chronic inflammation from long-term, heavy alcohol use) with ascites (a buildup of fluid in your abdomen causing a swollen belly), and generalized anxiety disorder (a group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation). During a review of Resident 1's Advance Healthcare Directive Acknowledgement Form, dated [DATE], the Advance Healthcare Directive Acknowledgement Form indicated, it was signed by Resident 1. During a review of Resident 1's History and Physical (H&P), dated [DATE], the H&P indicated, Resident 1 was capable of making medical decisions. During a review of Resident 1's H&P, dated [DATE], the H&P indicated, Resident was capable of making medical decisions. During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated [DATE], the MDS indicated Resident 1 required dependent assistance (Helper does all of the effort) from two or more staff for hygiene, shower/bath, dressing, bed mobility, transfer, and supervision or touching assistance (Helper provides verbal cues and /or touching/steadying and contact guard assistance as resident competes activity) from one staff for eating. During a concurrent interview and record review on [DATE], at 10:07 a.m., with Registered Nurse Supervisor (RNS) 1, Resident 1's Physician Orders for Life-Sustaining Treatment (POLST), dated [DATE] was reviewed. The POLST indicated, Resident 1 had an order for Do Not Attempt Resuscitation (DNR- a medical order written by a doctor to instruct health care providers NOT to do cardiopulmonary resuscitation [CPR] if breathing stops or the heart stops beating). The POLST indicated, the AD was discussed with a legally recognized Decisionmaker for Resident 1 and the POLST was signed by Resident 1's Family Member (FM) 2 as a legally recognized decisionmaker. RNS 1 stated, she could not provide any documentation to prove FM 2 was the legally recognized decisionmaker or Responsible Party (RP) in Resident 1's chart. RNS 1 stated, the POLST was not completed because it was signed by an unauthorized person (FM 2). RNS 1 stated, if the POLST was not complete and accurate, the resident would be treated as a full code and all life sustaining measures would be done during the emergency per policy. RNS 1 stated, the resident would be treated against his/her wish. During a concurrent interview and record review on [DATE], at 10:54 a.m., with the Social Service Director (SSD), Resident1's admission Record, dated [DATE] was reviewed. The admission Record indicated, Resident 1 and FM 1 were documented as Resident 1's RPs. The admission Record indicated, FM 2 was an Emergency Contact, but not the RP. The SSD stated, the RP and legally recognized decisionmaker were different because the legally recognized decision maker should provide documents such as Power of Attorney (POA-a legal document that identifies and empowers a person to speak for someone who wants assistance with financial or healthcare matters) or court appointed Conservatorship (when a judge appoints another person to act or make decisions for the person who needs help). The SSD stated, Both FM 1 and FM 2 did not have any legal documents to prove that they were Resident 1's RP or decisionmaker. The SSD stated, the staff including herself should have ensured and clarified the RP or legal decisionmaker for Resident 1 to honor the resident's wishes regarding care and treatment. During a concurrent interview and record review on [DATE], at 2:36 p.m., with the Director of Nursing (DON), Resident 1's The Subjective, Objective, Assessment and Plan (SOAP-a standardized method for documenting patient encounters by healthcare providers) Note, dated [DATE] was reviewed. The SOAP Note indicated, Resident was capable of making medical decisions. The DON stated, the staff should have reviewed and clarified all clinical and legal documents to decide who would be RP or legal decisionmaker. The DON stated, all recent H&P and SOAP notes indicated, Resident 1 had the capacity (ability) to make his own medical decisions and did not require an RP or a legal decision maker. The DON stated, if the resident had the capacity to make decisions, there was no need for an RP to make the decisions for Resident 1. The DON stated, important medical decisions such as AD and POLST should be discussed and signed by an RP or legal decisionmaker to honor residents' wishes. The DON stated, identifying an RP and legal decisionmaker was important to ensure right person to make right decision for the residents, especially during the emergency. During a review of the facility's Policy and Procedure (P&P) titled, Advance Directives, revised 1/2026, the P&P indicated, Decision-Making Capacity:1. Upon admission the interdisciplinary team assesses the resident's decision-making capacity and identifies the primary decision-maker if the resident is determined not to have decision-making capacity. 2. The interdisciplinary team conducts ongoing review of the resident's decision-making capacity and invokes the resident representative or health care agent if the resident is determined not to have decision-making capacity. Changes are documented in the care plan and medical record. During a review of the facility's Policy and Procedure (P&P) titled, Physician Orders for Life-Sustaining Treatment (POLST) Policy, revised 1/2026, the P&P indicated, Guidelines for completing POLST: 5. A legally recognized decisionmaker may execute the POLST form only if the patient lacks capacity or has designated that the decisionmaker's authority is effective immediately. 6. To be valid a POLST form must be signed by (1) a physician, or by a nurse practitioner or a physician assistant acting under the supervision of a physician and within the scope of practice authorized by law and (2) the patient or decisionmaker. During a review of the facility's Policy and Procedure (P&P) titled, Responsible Party, undated, the P&P indicated, Definition: Responsible Party (RP): An individual identified by the resident (or legal representative) to assist with care coordi­nation, communication, and administrative matters. Legal Representative: A court-appointed or legally authorized decision-maker (e.g., conservator, power of attorney for healthcare) . Procedure: 2. Documentation must include name and contact information, relationship with resident, and scope of involvement . 5. Responsible party shall not: Make medical decisions unless legally authorized. Override resident decisions (if resident has capacity). During a review of the facility's Policy and Procedure (P&P) titled, Capacity to Make Decisions, undated, the P&P indicated, Procedure: 5. If a resident has a capacity, resident makes decisions independently and staff must respect refusal of care, provide education on risks/benefits, and document informed refusal. 6. Family input does not override resident decisions. B. During a review of Resident 13's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), metabolic encephalopathy, and palliative care. The admission Record indicated Resident 13 was self responsible. During a review of Resident 13's H&P regarding a hospice hospice [end of life care focused on comfort and pain control] physician face to face encounter dated [DATE], the H&P indicated Resident 13 did not have full medical capacity to make decisions. The H&P indicated the next of kin information was not specifically identified during this visit, though the hospice care decisions suggest appropriate surrogate decision-maker involvement. During a review of Resident 13's MDS, dated [DATE], the MDS indicated Resident 13 had moderate cognitive impairment. The MDS indicated Resident 13 was dependent on bathing, lower body (waist below) dressing, rolling left to right, sit to lying, lying to sitting on side of bed, chair/bed-to-chair transfer, required substantial assistance (helper does more than half the effort) for upper body (waist above), toileting hygiene, personal hygiene, required partial assistance (helper does less than half the effort) for oral hygiene, and required supervision for eating. The MDS indicated Resident 13 had impairments on both sides of the upper (arms/shoulder) and lower (hips/legs) extremities. During a concurrent interview and record review on [DATE] at 3:18 p.m., with the Social Service Director (SSD), the SSD indicated she did the initial visits, checks the residents Brief Interview for Mental Status (BIMS, tool that help facilities monitor cognitive function), checks the H&P, and would ask the resident if they would like to add a family as a responsible party. The SSD stated if the resident did not have the capacity to designate a responsible party, they would ask the son/daughter. If there is a power of attorney (POA, legal document that allows someone to manage financial and legal affairs when you become incapacitated) the SSD stated requested documents to determine the responsible party and next of kin. The SSD stated Family Member 13 (FM 13) was involved in Resident 13's care as Resident 13 had periods of confusion. The SSD stated Resident 13 did not have the capacity to be self-responsible and there were no notes specifying who Resident 13's decision maker was. The SSD stated the Interdisciplinary Team (IDT health care professionals who work together with the resident to plan the residents plan of care) put the resident as self-responsible. The SSD stated they would want to know who the decision maker was for Resident 12. The SSD stated responsible parties are also designated in emergencies to make medical decisions and indicated she would refer the resident to a conservator but did not since Resident 13 had FM 13. The SSD stated on Resident 13's admission Record, Resident 13 was designated as self and FM 13 was not specified. During an interview on [DATE] at 2:49 p.m., with the DON, the DON stated it was important to have a representative for Resident 13 who does not have the capacity to make decisions, as it was legally binding and necessary in emergency situations to implement the residents wishes. During a review of the facility's P&P titled, Capacity To Make Decisions, undated, the P&P indicated the facility shall assess, respect, and support each resident's decision-making capacity and right to make informed choices regarding care, treatment, and services in accordance with state and federal regulations. When a resident lacks capacity, decisions shall be made by a legally authorized representative in accordance with applicable laws. Informed Consent—a process in which a resident or a legally authorized representative voluntarily agrees to care after being informed of diagnosis, proposed treatment, risks/benefits, and alternatives (including no treatment). Legally authorized representative – includes a Health Care Agent (via Advance Directive/Durable Power of Attorney (DPOA), Court-appointed Conservator or a Surrogate decision-maker per California law. If a resident lacks capacity, facility may identify appropriate legally authorized representative, verify legal authority (e.g., DPOA, conservatorship documents), obtain informed consent, and continue to involve resident to the maximum extent possible. During a review of the facility's P&P titled, Responsible Party, undated, the P&P indicated the facility recognizes the role of a Responsible Party (RP) as an individual designated by the resident to assist with communication, care coordination, and administrative matters. The Responsible Party does not assume financial liability unless they have independently agreed to such responsibility. The facility shall ensure that the Responsible Party's role is clearly defined, compliant with federal and California regulations, and does not infringe upon the residents' rights. Responsible Party (RP): An individual identified by the resident (or legal representative) to assist with care coordination, communication, and administrative matters. Legal Representative: A court-appointed or legally authorized decision-maker (e.g., conservator, power of attorney for healthcare). The resident may voluntarily designate a Responsible Party upon admission or at any time. Documentation must include name and contact information, relationship with resident, and scope of involvement. The designation must be signed by the resident or legal representative included in the medical record and admission agreement.

Based on observation, interview, and record review, the facility failed to ensure the Case Manager (CM) reported one of six sampled resident's (Resident 51) multiple refusals for Orthopedic (specialty area in medicine referring to the management of the muscles, bones, and their connective structures) follow up appointments to the physician. This deficient practice resulted in a delay of Resident 51's care and had the potential for worsening of Resident 51's left shoulder and left ankle fractures, delayed healing, and a decline in mobility (ability to motion, range of motion (ROM, full movement potential of a joint), activities of daily living (ADL, basic activities such as eating, dressing, toileting), physical comfort and psychosocial well-being. Findings:During a review of Resident 51's admission Record, the admission Record indicated Resident 51 was admitted to the facility on [DATE] with diagnoses including systemic involvement of connective tissue (group of disorders where the immune system attacks its own healthy tissues causing widespread inflammation and damage to skin, blood vessels, joints [where two bones meet], and organs), muscle weakness, and polyneuropathy (damage of the nerves that can cause weakness, numbness, and burning pain).During a review of Resident 51's History and Physical (H&P), dated 11/11/2025, the H&P indicated Resident 51 was transferred to the facility from a hospital on [DATE] for rehabilitation after being hit on the left side of the body while crossing the street on 11/3/2025. The H&P indicated Resident 51 sustained multiple fractures, which included a left humerus fracture, a left distal fibula fracture (break in the smaller of the two lower leg bones between the knee and the ankle), a left tibia dislocation (knee injury where the shin bone loses contact with the lower part of the thigh bone), and a left medial malleolus fracture (break in the bony bump on the inner side of the ankle). The H&P indicated Resident 51 had surgery to re-align Resident 51's left ankle dislocation on 11/3/2025 and had additional surgeries to repair the bone fractures of the left ankle and left humerus on 11/5/2025.During a review of Resident 51's Minimum Data Set (MDS, a resident assessment tool), dated 2/16/2026, the MDS indicated Resident 51 had severe cognitive (mental action or process of acquiring knowledge and understanding) impairment. The MDS indicated Resident 51 required set up/clean up assistance (helper sets up or cleans up) for eating, oral hygiene, and rolling to both sides, supervision or touching assistance (helper provides verbal cues and/or touching and/or contact guard assistance as resident completes the activity) for toileting hygiene, bathing, dressing, and personal hygiene and partial/moderate assistance (helper does less than half the effort) for putting on and taking off footwear. The MDS indicated Resident 51 had functional limitations in range of motion (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in one arm and one leg.During a review of Resident 51's Orthopedic Consultation note (Ortho Note), dated 12/17/2025, the Ortho Note indicated Resident 51's left arm was to be non-weightbearing (NWB, restriction in which a person is not allowed to put any weight through the operated body part) and Resident 51's left leg was weightbearing as tolerated (WBAT, a person is medically cleared to place as much weight through the affected arm or leg to the point of comfort or tolerance) while wearing a Controlled Ankle Motion boot (CAM boot, orthopedic device used to immobilize the foot, ankle, or lower leg in a fixed position and removing some of the weight off the foot and ankle while walking) boot. The Ortho Note indicated Resident 51 to follow up with orthopedics on 1/28/2026 at 11 a.m.During a review of Resident 51's Order Summary Report, the Order Summary Report indicated a physician's order, dated 12/17/2025, to follow up with orthopedics on 1/28/2026 at 11 a.m.During a review of Resident 51's Order Summary Report, the Order Summary Report indicated a physician's order, dated 12/23/2025, for Resident 15 to continue with NWB precautions to the left arm.During a review of Resident 51's Order Summary Report, the Order Summary Report indicated a physician's order, dated 12/23/2025, for Resident 51's left leg to be WBAT while wearing a CAM boot.During a review of Resident 51's Interdisciplinary Team (IDT, team of health care professionals that work together with the resident and/or resident's representative to prioritize the resident 's needs and goals) Progress Note, dated 1/22/2026, the IDT Progress Note indicated an IDT meeting was held at Resident 51's bedside due to Resident 51's refusal to wear the left leg CAM boot when walking. The IDT Progress Note indicated Occupational Therapist 1 (OT 1) educated Resident 51 that a front wheeled walker (FWW, mobility device with two wheels in the front used for support when standing or walking) would not be provided if Resident 51 did not wear the left leg CAM boot due to increased risk of re-injury to the left leg. The IDT Progress Note indicated an orthopedic follow up appointment was scheduled for 1/28/2026 at which time Resident 51 would discuss possibly discontinuing the left leg CAM boot with the physician. The IDT Progress Note indicated therapy services would work on transfers only, not walking, until further clarification from the orthopedics physician. During a concurrent observation and interview on 3/23/2026 at 1:26 p.m. with Resident 51 in Resident 51's room, Resident 51 was sitting at the edge of the bed wearing slippers on both feet. Resident 51 stated she broke her left shoulder and left ankle in November 2025 when she was hit by a car while crossing the street. Resident 51 minimally raised the left arm and stated she was unable to move the left arm well because it felt very heavy and her left hand felt numb. Resident 51 removed both slippers, moved both ankles up and down, and stated she needed a massage to the left leg because she had cramps (sudden, involuntary tightening of the muscle) and tightness in the calf muscle (lower part of the leg). Resident 51 stated she walked with a FWW in the room without the CAM boot and puts weight through her left arm. Resident 51 stated she refused the scheduled orthopedics appointment in January 2026 because she did not want to leave her husband (who was also a resident at the facility) unattended. Resident 51 stated was unsure what happened because staff never followed up with scheduling another orthopedics appointment and she had not heard anything regarding the status of her left arm and ankle for over two months. During a concurrent interview and record review on 3/25/2026 at 9:49 a.m. with the Case Manager (CM), the CM stated she was responsible for scheduling follow up consultation appointments for the residents in the facility. The CM stated if a resident missed or refused a follow up consultation appointment, the CM must attempt to re-schedule the appointment, document the reason for missed appointments or refusals in the clinical record, notify the physician, create a care plan, conduct an IDT meeting, and continue to follow up with the resident to investigate the reason for refusal, offer accommodations, and re-schedule the appointment. The CM reviewed Resident 51's clinical record and confirmed Resident 51 was supposed to follow up with orthopedics on 1/28/2026 but did not. The CM stated she scheduled a follow up orthopedic appointment for Resident 51 on 1/28/2026 but Resident 51 refused to attend and the CM did not document the refusal in the clinical record. The CM stated she tried to schedule additional follow up orthopedic appointment's multiple times with Resident 51, but Resident 51 refused each time and the CM did not document the re-scheduling attempts and did not notify nursing or the physician of Resident 15's repeated refusals. The CM stated she should have followed up and rescheduled Resident 51's orthopedic appointment, investigated the reasons for Resident 51's refusals and offered possible accommodation, notified the physician, developed a care plan, and held an interdisciplinary team meeting, but did not. The CM stated it was important for staff to notify the physician of Resident 51's refusals to follow up with orthopedics because the physician could have reassessed the situation and directed the team in the proper management of Resident 51's care. During a concurrent interview and record review on 3/25/2026 at 2:59 p.m. with the Director of Rehabilitation (DOR), the DOR reviewed Resident 51's IDT Progress Note, dated 1/22/2026, and confirmed PT and OT could not issue Resident 51 a FWW and safely work on walking exercises with Resident 51 until Resident 51 followed up with orthopedics on 1/28/2026. The DOR stated Resident 51 reached her highest practical level in therapy, mobility, and ADLs with the NWB restrictions to the left arm and Resident 51's refusal to wear a CAM boot when walking per physician's orders and needed guidance from the orthopedic physician to safely progress Resident 51 in therapy. The DOR reviewed Resident 51's clinical record and stated he was unsure if Resident 51 attended her scheduled orthopedic appointment on 1/28/2026 because there were no ortho notes or progress notes in the chart. The DOR stated he was unsure why there was a delay in Resident 51's follow up with orthopedics and was unaware Resident 51 refused to attend her scheduled appointment on 1/28/2026. The DOR stated the facility should have notified the physician of Resident 51's refusal to follow up with orthopedics and followed up sooner to determine Resident 51's plan of care for the management of the left arm and the left ankle as it affected Resident 51's ability to progress in therapy with mobility, ADLs, and ROM. During an interview on 3/26/2026 at 3:23 p.m. with the Director of Nursing (DON), the DON stated any resident refusals for follow up appointments should be documented in the clinical record, care planned, discussed in an IDT meeting, and reported to the physician, nursing, and the resident's family. The DON stated if the physician was not informed of a resident's refusal to follow up with orthopedics, the physician would be unable to follow up with the resident's care potentially resulting in a functional decline and lack of necessary treatment and services. During a review of the facility's Policy and Procedure (P/P) titled, Change in a Resident's Condition or Status, revised 1/2026, the P/P indicated the facility promptly notified the resident, his or her attending physician, and the resident representative of changes in the resident's medical condition and/or status. The P/P indicated the nurse would notify the resident's attending physician or physician on call when there was a refusal of treatment or medications two or more consecutive times and if there was a need to alter the resident's medical treatment significantly.

Based on interview and record review, the facility failed to ensure two of five sampled residents (Resident 10 and Resident 12) were free from unnecessary psychotropic (any drug that affects brain activity related to mental processes and behavior) medications by failing to:1.Ensure Resident 10 had an appropriate diagnosis before starting treatment with Xanax [(generic name - alprazolam) a prescription medication that slows down brain activity which helps reduce anxiety (constantly feeling worried and nervous)]. 2.Ensure Resident 12 had an appropriate diagnosis before starting treatment with Depakote [(generic name - valproic acid or divalproex sodium) a prescription medication that helps calm overactive brain activity which helps control seizures (sudden bursts of abnormal electrical activity in the brain), stabilizes mood, and sometimes prevents migraines (a severe, strong, and throbbing headache that affects an individual's ability to function)].These failures had the potential to place Resident 10 and Resident 12 at risk for unnecessary exposure to psychotropic medications and adverse drug reactions (a harmful or unwanted effect caused by a medication when taken normally and correctly), which could result in impairment or decline in the residents' physical and functional condition, and mental and psychosocial status.Findings:A. During a review of Resident 10's admission Record, the admission Record indicated the facility admitted Resident 10 on 9/4/2024 and was readmitted on [DATE] with diagnoses including bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), schizophrenia (a mental illness that is characterized by disturbances in thought) and depression (a mental health condition where someone feels very sad, empty, or loses interest in things for a long time).During a review of Resident 10's History and Physical (H&P) dated 2/26/2025, the H&P indicated Resident 10 had the capacity for making decisions.During a review of Resident 10's Minimum Data Set (MDS - a resident assessment tool) dated 3/4/2026, the MDS indicated Resident 10 had moderate cognitive (ability to think or make decisions) impairment. The MDS indicated Resident 10 needed setup or clean-up assistance (helper assists only prior to or following the activity) with eating, supervision with oral hygiene, maximum assistance (helper does more than half the effort to complete the activity) with showering, and moderate assistance (helper does less than half the effort to complete the activity) with upper body and lower body dressing, putting on and taking off footwear, and toileting and personal hygiene. The MDS indicated Resident 10 had active diagnoses of depression, bipolar disorder, and schizophrenia. The MDS did not indicate Resident 10 had an active diagnosis of anxiety. The MDS indicated Resident 10 was taking antipsychotic [a drug that helps reduce symptoms of hallucinations (seeing, hearing, or feeling something that is not actually there), delusions (strong beliefs that are not true) or severe confusion], antianxiety (a drug that help with feeling calmer and less worried), and antidepressant (a drug that helps with the feeling of sadness and improves an individual's mood) medications.During a review of Resident 10's Order Summary Report (a document containing a summary of all active physician orders) dated 3/25/2026, the order summary report included the following physician orders:-Monitor side effects (S/E) Anti-Anxiety Drug: Xanax - Sedation, Drowsiness, Lethargy (feeling abnormally sleepy, sluggish, or unresponsive, beyond ordinary tiredness), Confusion, Memory, Impairment, Fatigue, Dizziness, Depression, Nausea and/or Vomiting, Change in Appetite, Headaches, Blurred Vision, Impaired Coordination, Possible Falls, Subdued Behavior, Withdrawal Compared to Baseline, or a Limitation in Functional Capacity. every shift Side effects observed. + yes, - no, order date 11/4/2025, start date 11/4/2025.-Xanax Oral Tablet 0.25 MG [milligrams - metric unit of measurement, used for medication dosage and/or amount] Give 1 tablet by mouth two times a day for Anxiety manifested by (M/B) inability to relax, order date 11/6/2025, start date 11/6/2025.During a concurrent interview and record review on 3/25/2026 at 8:58 a.m. with Registered Nurse Supervisor (RNS) 1, Resident 10's diagnosis information in the admission record, order summary report, history and physical dated 2/26/2026, and psychiatrist note dated 3/4/2026 were reviewed. RNS 1 stated the diagnosis list did not indicate Resident 10 had a diagnosis of anxiety. RNS 1 stated the physician order indicated Xanax oral tablet 0.25 mg give 1 tablet by mouth two times a day for anxiety manifested by inability to relax was ordered 11/6/2025 and was started on 11/6/2025. RNS 1 stated the history and physical dated 2/26/2026 did not indicate Resident 10 had a diagnosis of anxiety. RNS 1 stated the psychiatrist note dated 3/4/2026 did not indicate a diagnosis of anxiety but indicated that Resident 10 was prescribed Xanax for anxiety. RNS 1 stated the importance of having a diagnosis prior to starting any medication was to ensure the resident needed the medication to control or treat the diagnosis. RNS 1 stated if the resident did not have a diagnosis of anxiety prior to starting an antianxiety medication there was potential that the resident would experience adverse effects from the medication.During an interview on 3/26/2026 at 10:52 a.m., with the Assistant Director of Nursing (ADON), the ADON stated the importance of ensuring the resident was prescribed a medication for existing diagnoses prior to starting any medication was to ensure the resident was assessed for any signs and symptoms or behaviors that may be treated or controlled by prescription medications. The ADON stated if the resident did not have a diagnosis of anxiety and was prescribed antianxiety medication there was potential for the resident to experience negative effects or the opposite effect of the medication.B. During a review of Resident 12's admission Record, the admission Record indicated the facility admitted Resident 12 on 3/20/2025 and was readmitted on [DATE] with diagnoses including anxiety disorder (constantly feeling worried and nervous), depression (a mental health condition where someone feels very sad, empty, or loses interest in things for a long time), and schizophrenia (a mental illness that is characterized by disturbances in thought).During a review of Resident 12's History and Physical (H&P) dated 1/8/2026, the H&P indicated Resident 10 had the capacity to make decisions.During a review of Resident 12's MDS dated [DATE], the MDS indicated Resident 12 had moderate cognitive impairment. The MDS indicated Resident 12 needed moderate assistance (helper does less than half the effort to complete the activity) with lower body dressing and putting on or taking off footwear and supervision with eating, showering, upper body dressing, toileting, and oral and personal hygiene. The MDS indicated Resident 12 had active diagnoses of anxiety, depression, and schizophrenia. The MDS did not indicate an active diagnosis of bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). The MDS indicated Resident 12 was taking antipsychotic medications.During a review of Resident 12's Order Summary Report dated 3/25/2026, the order summary report included the following:-Monitor behavior episodes of Anticonvulsant/mood stabilizer use DEPAKOTE m/b bipolar disorder as evidenced by sudden angry outbursts Attempt Non-Pharmacological interventions: 0= No Non-Pharmacological interventions needed 1 = Re-positioning/limb elevation 2=Reassurance/Emotional Support 3 = Provide Distraction/Diversionary Activities 4 = Exercise/ROM/Ambulation/Stretching 5= Rest Period/Quiet Environment 6 = Deep Breathing/Relaxations Exercise every shift, order date 1/7/2026 and start date 1/7/2026-Depakote Oral Tablet Delayed Release 250 MG [milligrams - metric unit of measurement, used for medication dosage and/or amount] (Divalproex Sodium) Give 2 tablet by mouth two times a day for bipolar disorder manifested by mood changes as evidenced by sudden angry outbursts give 2 tabs = 500 mg) order date 1/6/2026 and start date 1/6/2026During a concurrent interview and record review on 3/25/2026 at 8:16 a.m., with Registered Nurse Supervisor (RNS) 1, Resident 12's diagnosis list, order summary report, history and physical dated 1/8/2026, and psychiatrist notes dated 2/3/2026 and 3/4/2026 were reviewed. RNS 1 stated Resident 12's diagnosis list did not indicate bipolar disorder as one of the diagnoses. RNS 1 stated Resident 12's order summary report indicated Resident 12 was prescribed Depakote oral tablet delayed release 250 mg give to tablet by mouth two times a day for bipolar disorder manifested by mood changes as evidenced by sudden angry outbursts give 2 tabs. RNS 1 stated Resident 12's history and physical dated 1/8/2026 did not indicate a diagnosis of bipolar disorder. RNS 1 stated Resident 12's psychiatrist notes dated 2/3/2026 and 3/4/2026 did not indicate a diagnosis of bipolar disorder but indicated Resident 12 was prescribed Depakote for Bipolar disorder. RNS 1 stated it was important to ensure the resident had a diagnosis and needed the medication to control or treat the specific diagnosis. RNS 1 stated if the resident did not have a diagnosis of Bipolar disorder prior to starting an antianxiety medication there would be potential that the resident will experience adverse effects.During a concurrent interview and record review on 3/26/2026 at 10:59 a.m., with the ADON, Resident 12's diagnosis information in the admission record and order summary report were reviewed. The ADON stated Resident 12's diagnosis information in the admission record indicated bipolar disorder, the bipolar disorder diagnosis was added on 3/25/2026 and the order summary report indicated Resident 12 was prescribed Depakote for bipolar disorder on 1/6/2026 (78 days before Resident 12 was diagnosed with Bipolar). The ADON stated the importance of having a diagnosis prior to starting any medication was to ensure the resident was assessed for any signs and symptoms or behaviors that may be treated or controlled by prescription medications. The ADON stated if the resident did not have a diagnosis of Bipolar and was prescribed antianxiety medication there would be potential for the resident to experience negative side effects or the opposite effect the medication was intended to produce.During a review of the facility's policy and procedure (P&P) titled Psychotropic Medication Use dated 2001, the P&P indicated .Adequate Indications for Psychotropic Medication Use.5. Diagnosis alone does not necessarily warrant the use of psychotropic medication a. If a psychiatric diagnosis is part of the rationale for the use of psychotropic medication, there will be sufficient supporting documentation that the resident meets the criteria for that diagnosis (based on the current Diagnostic and Statistical Manual of Mental Disorders).

Based on interview and record, the facility failed to ensure a Minimum Data Set ([MDS] - a resident assessment tool) assessment was completed accurately for three of 23 sampled residents (Resident 10, 12, and 19) by failing to:1. Ensure Resident 10 and Resident 12's mental health diagnoses was reflected in the resident assessment.2. Ensure Resident 19's dental health status was reflected in the resident assessment.This deficient practice resulted in incorrect data being transmitted to the Centers for Medicare and Medicaid Services (CMS) and had the potential to negatively affect the plan of care and delivery of care and services for Resident 10, 12, and 19.Findings: A. During a review of Resident 10's admission Record, the admission Record indicated the facility admitted Resident 10 on 9/4/2024 and was readmitted on [DATE] with diagnoses including bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), schizophrenia (a mental illness that is characterized by disturbances in thought) and depression (a mental health condition where someone feels very sad, empty, or loses interest in things for a long time). During a review of Resident 10's History and Physical (H&P) dated 2/26/2025, the H&P indicated Resident 10 had the capacity for making decisions. During a review of Resident 10's Minimum Data Set (MDS – a resident assessment tool) dated 3/4/2026, the MDS indicated Resident 10 had moderate cognitive (ability to think or make decisions) impairment. The MDS indicated Resident 10 needed setup or clean-up assistance (helper assists only prior to or following the activity) with eating, supervision with oral hygiene, maximum assistance (helper does more than half the effort to complete the activity) with showering, and moderate assistance (helper does less than half the effort to complete the activity) with upper body and lower body dressing, putting on and taking off footwear, and toileting and personal hygiene. The MDS indicated Resident 10 had a active diagnoses of depression, bipolar disorder, and schizophrenia. The MDS did not indicate Resident 10 had an active diagnosis of anxiety. The MDS indicated Resident 10 was taking antipsychotic [a drug that helps reduce symptoms of hallucinations (seeing, hearing, or feeling something that is not actually there), delusions (strong beliefs that are not true) or severe confusion], antianxiety (a drug that help with feeling calmer and less worried), and antidepressant (a drug that helps with the feeling of sadness and improves an individual's mood) medications. During a review of Resident 10's Order Summary Report (a document containing a summary of all active physician orders) dated 3/25/2026, the order summary report included the following physician orders: -Xanax Oral Tablet 0.25 MG [milligrams - metric unit of measurement, used for medication dosage and/or amount] (Alprazolam) Give 1 tablet by mouth two times a day for Anxiety (constantly feeling worried and nervous) manifested by (M/B) inability to relax, order date 11/6/2025, start date 11/6/2025. During a concurrent interview and record review on 3/26/2026 at 10:05 a.m., with the Minimum Data Set Nurse (MDSN), Resident 10's MDS dated [DATE] was reviewed. The MDSN stated Resident 10's MDS dated [DATE] did not indicate a diagnosis of anxiety. The MDSN stated she should have conducted another assessment upon the start of the new medication for anxiety. The MDSN stated the importance of conducting another assessment was to ensure that the resident's new diagnosis was reflected accurately. The MDSN stated if the assessment was not conducted accurately there would be a potential the resident's plan of care would be inadequate and inaccurate. B. During a review of Resident 12's admission Record, the admission Record indicated the facility admitted Resident 12 on 3/20/2025 and was readmitted on [DATE] with diagnoses including anxiety disorder constantly feeling worried and nervous), depression (a mental health condition where someone feels very sad, empty, or loses interest in things for a long time), and schizophrenia. During a review of Resident 12's History and Physical (H&P) dated 1/8/2026, the H&P indicated Resident 10 had the capacity to make decisions. During a review of Resident 12's Minimum Data Set (MDS – a resident assessment tool) dated 1/13/2026, the MDS indicated had moderate cognitive (ability to think or make decisions) impairment. The MDS indicated Resident 12 needed moderate assistance (helper does less than half the effort to complete the activity) with lower body dressing and putting on or taking off footwear and supervision with eating, showering, upper body dressing, toileting, and oral and personal hygiene. The MDS indicated Resident 12 had active diagnoses of anxiety, depression, schizophrenia. The MDS did not indicate an active diagnosis of bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). The MDS indicated Resident 12 was taking antipsychotic [a drug that helps reduce symptoms of hallucinations (seeing, hearing, or feeling something that is not actually there), delusions (strong beliefs that are not true) or severe confusion] and antianxiety (a drug that helps with feeling calmer and less worried) medications. During a review of Resident 12's Order Summary Report (a document containing a summary of all active physician orders) dated 3/25/2026, the order summary report indicated the following: -Depakote Oral Tablet Delayed Release 250 MG [milligrams - metric unit of measurement, used for medication dosage and/or amount] (Divalproex Sodium) Give 2 tablet by mouth two times a day for bipolar disorder manifested by mood changes as evidenced by sudden angry outbursts give 2 tabs = 500 mg) order date 1/6/2026 and start date 1/6/2026 During a concurrent interview and record review on 3/26/2026 at 10:02 a.m., with the Minimum Data Set Nurse (MDSN) Resident 12's MDS assessment dated [DATE] was reviewed. The MDSN stated Resident 12's MDS assessment dated [DATE] did not indicate a diagnosis of bipolar disorder and should have been included in the assessment. The MDSN stated if the diagnosis of bipolar was not included in the assessment there would be potential for inappropriate or lack of treatment and services which could contribute to the delay in progress of the resident's medical condition. During an interview on 3/26/2026 at 11:20 a.m. with the Director of Nursing (DON), the DON stated the importance of an accurate MDS assessment was to ensure the facility submitted accurate data to CMS and to develop a plan of care that includes the residents' new mental health diagnosis. The DON stated if the MDS assessment did not have accurate resident data, there would be potential for the residents' to not receive the proper plan of care and lack the treatment, monitoring, and follow-up regarding the new mental health diagnosis. C. During a review of Resident 19's admission record, the admission record indicated Resident 19 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (the blood supply to part of the brain is blocked or reduced), dementia (a progressive state of decline in mental abilities), and dysphagia (difficulty swallowing). During a review of Resident 19's History and Physical (H&P), dated 11/11/2025, the H&P indicated, Resident 19 had no capacity (ability) to understand and make decisions. During a review of Resident 19's MDS, dated [DATE], the MDS indicated Resident 19 required maximal assistance (Helper does more than half the effort) from one staff for toileting hygiene, shower, dressing, personal hygiene, transfer, moderate assistance (Helper does less than half the effort) from one staff for bed mobility, and supervision or touching assistance (Helper provide verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) from one staff for oral hygiene and eating. During a concurrent observation and interview on 3/23/2026, at 10:59 a.m., with Resident 19 in his room, Resident 19 was watching television in bed and missing upper front teeth were observed during the interview. Resident 19 stated, he lost his partial dentures while he was in General Acute Care Hospital (GACH) prior to admission to this facility. Resident 19 stated, his wife and he told the nursing staff that he had lost his partial dentures, but no one helped him. Resident 19 stated, it was painful to chew hard food items like chopped chicken or diced unripe melon. During a concurrent interview and record review on 3/25/2026, 3:17 p.m., with the Minimum Data Set Nurse (MDSN), Resident 19's MDS section L-Oral/Dental Status, dated 11/17/2025 and 12/16/2026 was reviewed. The MDS section L-Oral/Dental Status indicated, Resident 19 did not have any broken or loosely fitting full or partial dentures. The MDS section L-Oral/Dental Status indicated, Resident 19 did not have any mouth or facial pain, discomfort or difficulty with chewing. The MDSN stated, she was not aware of Resident 19's missing upper front teeth and she should have assessed the resident thoroughly before documenting in MDS. The MDSN stated, the staff did not document Resident 19's dental status, and she thought there was no problem. MDSN stated, MDS coding should be done accurately because it affects the resident's plan of care and treatment. During a concurrent interview and record review on 3/26/2026, at 2:46 p.m., with the Director of Nursing (DON), Resident 19's Dental Progress Note (DPN), dated 1/9/2026 was reviewed. The DPN indicated, Resident 19 had broken teeth. The DON stated, MDSN should have reviewed the DPN and should have assessed Resident 19's dental status thoroughly before documenting MDS. The DON stated, all assessment in MDS should be coded correctly because this would affect resident's overall care and treatment negatively. The DON stated, assessments should be accurate to get a clear representation of the residents. During a review of the facility's Policy and Procedure (P&P) titled, Certifying Accuracy of the Resident Assessment, revised 11/2019, the P&P indicated, Policy Interpretation and Implementation: 2. Any person who completes any portion of the MDS assessment, tracking form, or correction request form is required to sign the assessment certifying the accuracy of that portion of that assessment . 4. The Resident Assessment Coordinator is responsible for ensuring that an MDS assessment has been completed for each resident. During a review of the facility's Policy and Procedure (P&P) titled, Resident Assessments, revised 1/2026, the P&P indicated, Policy Interpretation and Implementation: 12. Information in the MDS assessments will consistently reflect information in the progress notes, plans of care, and resident observations/interviews. 13. All resident assessments completed within the previous 15 months are maintained in the resident's active clinical record. The results of the assessments are used to develop, review, and revise the resident's comprehensive care plan.

Based on interview and record review, the facility failed to ensure four of 23 sampled residents (Residents 3, 10, 11, and 12) Preadmission Screening and Resident Review (PASARR) were reassessed appropriately by:Failing to ensure Resident 3 was reassessed for PASARR Level II upon readmissionFailing to ensure PASARR Level I was resubmitted when Resident 10 and Resident 12 had a new medication and diagnosis.Failing to ensure PASARR Level I was followed through with and reassess Resident 11's PASARR Level II upon admission. This deficient practice placed Residents 3, 10, 12 and 11 at risk of not receiving necessary care and services they need. Findings: a) During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities) schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool), dated 2/19/2026, the MDS indicated Resident 3 had mild cognitive (judgement, planning, organization to manage average demands in one's environment) impairment. The MDS indicated Resident 3 was dependent on facility staff for personal hygiene, lower body (waist below) dressing, toileting hygiene, bathing, lying to sitting on side of bed, required substantial assistance (helper does more than half the effort) for upper body (waist above), roll left to right, sit to lying, required partial assistance (helper does less than half the effort) for oral hygiene and required supervision for eating. The MDS indicated Resident 3 had impairments on both sides of the upper (arms/shoulder) and lower (hips/legs) extremities and utilized a wheelchair. During a review of Resident 3's Notice of Attempted Evaluation dated 5/5/2025, the Notice of Attempted Evaluation indicated the Level II evaluation for serious mental illness (SMI) was not completed due to Resident 3 being temporarily transferred to the hospital for treatment. During a concurrent interview and record review on 3/25/2026 at 12:39 p.m., with Registered Nurse Supervisor 1 (RNS 1), RNS 1 stated when a resident is admitted to the facility, facility staff review the PASARR and continue with ensuring an assessment for Level II if indicated. RNS 1 stated Resident 3 was not assessed for Level II on 5/5/2025 due to being sent out to the hospital. RNS 1 stated after Resident 3 was readmitted to the facility, there should have been a follow up to do the second evaluation and indicated the attempt to reassess Resident 3 was missed. During an interview on 3/26/2026 at 3:50 p.m., with the Director of Nursing (DON), the DON stated PASARR is done to ensure the facility would be able to care for the residents appropriately and meet their mental health needs. The DON stated if the residents are not reassessed, the residents will not get the follow up they need and will not be able to address or care for the residents appropriately. (b) During a review of Resident 10's admission Record, the admission Record indicated the facility admitted Resident 10 on 9/4/2024 and was readmitted on [DATE] with diagnoses including bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), schizophrenia (a mental illness that is characterized by disturbances in thought) and depression (a mental health condition where someone feels very sad, empty, or loses interest in things for a long time). During a review of Resident 10's History and Physical (H&P) dated 2/26/2025, the H&P indicated Resident 10 had the capacity for making decisions. During a review of Resident 10's MDS dated [DATE], the MDS indicated Resident 10 had moderate cognitive (ability to think or make decisions) impairment. The MDS indicated Resident 10 needed setup or clean-up assistance (helper assists only prior to or following the activity) with eating, supervision with oral hygiene, maximum assistance (helper does more than half the effort to complete the activity) with showering, and moderate assistance (helper does less than half the effort to complete the activity) with upper body and lower body dressing, putting on and taking off footwear, and toileting and personal hygiene. The MDS indicated Resident 10 had active diagnoses of depression, bipolar disorder, and schizophrenia. The MDS did not indicate Resident 10 had an active diagnosis of anxiety. The MDS indicated Resident 10 was taking antipsychotic [a drug that helps reduce symptoms of hallucinations (seeing, hearing, or feeling something that is not actually there), delusions (strong beliefs that are not true) or severe confusion], antianxiety (a drug that help with feeling calmer and less worried), and antidepressant (a drug that helps with the feeling of sadness and improves an individual's mood) medications. During a review of Resident 10's Order Summary Report (a document containing a summary of all active physician orders) dated 3/25/2026, the order summary report included the following physician orders: -Xanax Oral Tablet 0.25 MG [milligrams - metric unit of measurement, used for medication dosage and/or amount] (Alprazolam) Give 1 tablet by mouth two times a day for Anxiety M/B (manifested by) inability to relax, order date 11/6/2025, start date 11/6/2025. During a concurrent interview and record review on 3/25/2026 at 9:17 a.m., with Registered Nurse Supervisor (RNS) 1, Resident 10's PASARR dated 9/2/2025 was reviewed. RNS 1 stated Resident 10's PASARR Level I screening dated 9/2/2025 did not indicate a diagnosis of anxiety. RNS 1 stated Resident 10 did not have another PASARR Level I screening submitted with the new diagnosis of anxiety. RNS 1 stated the importance of conducting a resident review of the PASARR Level I screening was to ensure the resident was assessed for any new diagnoses to ensure the resident's needs could be met. RNS 1 stated if a review of the PASARR Level I screening was not conducted, the resident might not receive services and treatment that the resident needed. During a concurrent interview and record review on 3/26/2026 at 10:52 a.m., with the Assistant Director of Nursing (ADON) Resident 10's PASARR dated 9/2/2025 was reviewed. The ADON stated Resident 10's PASARR Level I screening dated 9/2/2025 did not indicate a diagnosis of anxiety. The ADON there was no new resident review PASARR Level I screening that was submitted for the Resident 10's diagnosis of anxiety. The ADON stated if a resident review PASARR Level I was not submitted for a new diagnosis, there would be potential that the resident may not receive the treatment and services that he or she needed. (c ) During a review of Resident 12's admission Record, the admission Record indicated the facility admitted Resident 12 on 3/20/2025 and was readmitted on [DATE] with diagnoses including anxiety disorder (constantly feeling worried and nervous), depression (a mental health condition where someone feels very sad, empty, or loses interest in things for a long time), and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 12's H&P dated 1/8/2026, the H&P indicated Resident 10 had the capacity to make decisions. During a review of Resident 12's MDS dated [DATE], the MDS indicated Resident 12 had moderate cognitive impairment. The MDS indicated Resident 12 needed moderate assistance (helper does less than half the effort to complete the activity) with lower body dressing and putting on or taking off footwear and supervision with eating, showering, upper body dressing, toileting, and oral and personal hygiene. The MDS indicated Resident 12 had active diagnoses of anxiety, depression, and schizophrenia. The MDS did not indicate Resident 12 had an active diagnosis of bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). The MDS indicated Resident 12 was taking antipsychotic [a drug that helps reduce symptoms of hallucinations (seeing, hearing, or feeling something that is not actually there), delusions (strong beliefs that are not true) or severe confusion] and antianxiety (a drug that helps with feeling calmer and less worried) medications. During a review of Resident 12's Order Summary Report (a document containing a summary of all active physician orders) dated 3/25/2026, the order summary report included the following: -Depakote Oral Tablet Delayed Release 250 MG [milligrams - metric unit of measurement, used for medication dosage and/or amount] (Divalproex Sodium) Give 2 tablet by mouth two times a day for bipolar disorder manifested by mood changes as evidenced by sudden angry outbursts give 2 tabs = 500 mg) order date 1/6/2026 and start date 1/6/2026. During a concurrent interview and record review on 3/25/2025 at 8:36 a.m., with Registered Nurse Supervisor (RNS) 1 Resident 12's PASARR Level 1 screening dated 8/6/2025 was reviewed. RNS 1 stated PASARR Level I screening dated 8/6/2025 did not indicate a diagnosis of bipolar disorder. RNS 1 stated if a resident review of the PASARR Level I screening was not submitted, the resident might not receive the appropriate treatment or services for the resident's mental illness. During a concurrent interview and record review on 3/26/2026 at 10:59 a.m., with the Assistant Director of Nursing (ADON) Resident 12's PASARR Level I screening dated 8/6/2025 was reviewed. The ADON stated if a resident review PASARR Level I was not submitted for a new diagnosis, there would be potential that the resident may not receive the treatment and services that he or she needed. (d). During a review of Resident 11's admission Record, the admission Record indicated, Resident 11 was initially admitted to the facility on [DATE] and last admission was 3/20/2026 with diagnosis including dementia (a progressive state of decline in mental abilities), anxiety disorder (constantly feeling worried and nervous), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and psychotic disorder (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of Resident 11's H&P, dated 1/22/2026, the H&P indicated, Resident 11 could not make medical decisions, but she could make needs known. During a review of Resident 11's MDS, dated [DATE], the MDS indicated Resident 11 required dependent assistance (Helper does all of the effort) from two or more staff for transfer, shower, dressing, personal hygiene, toilet hygiene, and maximal assistance (Helper does more than half the effort) from one staff for personal hygiene, oral hygiene, bed mobility. During a concurrent interview and record review on 3/25/2026, at 10:15 a.m., with Registered Nurse Supervisor (RNS) 1, Resident 11's PASARR Level I Screening, dated 1/19/2026 was reviewed. The PASARR Level I Screening indicated, Level I was positive for Serious Mental Illness (SMI) which indicates a follow up with a PASARR Level II assessment. RNS 1 stated, PASARR Level II should have been evaluated, but she could not find any document regarding PASARR Level II. RNS 1 stated, if PASARR was not done accurately and followed through for level II, Resident 11 would not receive the mental health related treatment and care he needed. During a concurrent interview and record review on 3/25/2026, at 2:40 p.m., with the Director of Nursing (DON), Resident 11's Notice of Exempted Hospital Discharge, dated 1/19/2026 was reviewed. The Notice of Exempted Hospital Discharge indicated, negative level I screening indicates a level II mental health evaluation is not required. The Notice of Exempted Hospital Discharge indicated, if the individual remains in the nursing facility longer than 30 days, the facility must resubmit a new level I screening as a resident review on the 31st day. The DON stated, new PASARR level I should have submitted on 2/19/2026 (31st day since admission of 1/19/2026) since Resident 11 was planned to stay longer than 30 days. The DON stated, Resident 11 was admitted from General Acute Care Hospital (GACH) Psychiatric unite (provide 24/7 care for acute mental health disorders, focusing on safety, crisis stabilization, and medication management) due to SMI. The DON stated, Resident 11 definitely needed mental health treatment and care. The DON stated, the staff should have followed up with Level II evaluation to provide proper care and treatment. During a review of Resident 11's Care Plan (CP) titled, Resident 11 has behavior problems, revised on 1/22/2026, the CP Goal indicated, Resident 11 would not have evidence of behavior problems by target date of 5/8/2026. The CP Interventions indicated, administer medications as ordered, and monitor/document side effects and effectiveness. During a review of the facility's Policy and Procedure (P&P) titled, PASARR, revised 1/2026, the P&P indicated, 1. b. If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process. c. Upon completion of the Level II evaluation, the State PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate.

Based on observation, interview, and record review, the facility failed to develop and implement an individualized care plan with measurable objectives, timeframes, and interventions for 2 of 3 Residents (Residents 51 and 19) by failing to:Develop a comprehensive care plan and conduct an Interdisciplinary Team (IDT, team of health care professionals that work together with the resident and or resident's representative to prioritize the resident 's needs and goals) meeting for Resident 51 who had a left shoulder and left ankle fracture (broken bone) and refused multiple times to follow up with orthopedic (branch of surgery concerned with conditions involving the muscles and bones) appointments per physicians recommendations.Develop and implement a comprehensive person-centered care plan for Resident 19's dental health status.These failures had the potential to negatively affect the delivery of necessary care and services. For Resident 51, this failure had the potential to lead to contracture (loss of motion of a joint associated with stiffness and joint deformity) development, delayed healing, and a decline in overall physical functioning and activities of daily living (ADL, basic activities such as eating, dressing, toileting).This failure had the potential to result in Resident 19, and Resident 51's needs not being met, affecting the residents' well-being, and poor patient outcomes.Findings: 1. During a review of Resident 51's admission Record, the admission Record indicated Resident 51 was admitted to the facility on [DATE] with diagnoses including systemic involvement of connective tissue (group of disorders where the immune system attacks its own healthy tissues causing widespread inflammation and damage to skin, blood vessels, joints [where two bones meet], and organs), muscle weakness, and polyneuropathy (damage of the nerves that can cause weakness, numbness, and burning pain). During a review of Resident 51's History and Physical (H&P), dated 11/11/2025, the H&P indicated Resident 51 was transferred to the facility from a hospital on [DATE] for rehabilitation after being hit on the left side of the body while crossing the street on 11/3/2025. The H&P indicated Resident 51 sustained multiple fractures, which included a left humerus (upper arm bone) fracture, a left distal fibula fracture (break in the smaller of the two lower leg bones between the knee and the ankle), a left tibia dislocation (knee injury where the shin bone loses contact with the lower part of the thigh bone), and a left medial malleolus fracture (break in the bony bump on the inner side of the ankle). The H&P indicated Resident 51 had surgery to re-align Resident 51's left ankle dislocation on 11/3/2025 and had additional surgeries to repair the bone fractures of the left ankle and left humerus on 11/5/2025. During a review of Resident 51's Orthopedic Consultation note (Ortho Note), dated 12/17/2025, the Ortho Note indicated Resident 51's left arm was to be non-weightbearing (NWB, restriction in which a person is not allowed to put any weight through the operated body part) and Resident 51's left leg was weightbearing as tolerated (WBAT, a person is medically cleared to place as much weight through the affected arm or leg to the point of comfort or tolerance) while wearing a Controlled Ankle Motion boot (CAM boot, orthopedic device used to immobilize the foot, ankle, or lower leg in a fixed position and removing some of the weight off the foot and ankle while walking) boot. The Ortho Note indicated for Resident 51 to follow up with orthopedics on 1/28/2026 at 11 a.m. During a review of Resident 51's Order Summary Report, the Order Summary Report indicated a physician's order, dated 12/17/2025, to follow up with orthopedics on 1/28/2026 at 11 a.m. During a review of Resident 51's Order Summary Report, the Order Summary Report indicated a physician's order, dated 12/23/2025, for Resident 15 to continue with NWB precautions to the left arm. During a review of Resident 51's Order Summary Report, the Order Summary Report indicated a physician's order, dated 12/23/2025, for Resident 51's left leg to be WBAT while wearing a CAM boot. During a review of Resident 51's Interdisciplinary Team (IDT, team of health care professionals that work together with the resident and/or resident's representative to prioritize the resident 's needs and goals) Progress Note, dated 1/22/2026, the IDT Progress Note indicated an IDT meeting was held at Resident 51's bedside due to Resident 51's refusal to wear the left leg CAM boot when walking. The IDT Progress Note indicated Occupational Therapist 1 (OT 1) educated Resident 51 that a front wheeled walker (FWW, mobility device with two wheels in the front used for support when standing or walking) would not be provided if Resident 51 did not wear the left leg CAM boot due to increased risk of re-injury to the left leg. The IDT Progress Note indicated an orthopedic follow up appointment was scheduled for 1/28/2026 at which time Resident 51 would discuss possibly discontinuing the left leg CAM boot with the physician. The IDT Progress Note indicated therapy services would work on transfers only, not walking, until further clarification from the orthopedics physician. During a review of Resident 51's Minimum Data Set (MDS, a resident assessment tool), dated 2/16/2026, the MDS indicated Resident 51 had severe cognitive (mental action or process of acquiring knowledge and understanding) impairment. The MDS indicated Resident 51 required set up/clean up assistance (helper sets up or cleans up) for eating, oral hygiene, and rolling to both sides, supervision or touching assistance (helper provides verbal cues and/or touching and/or contact guard assistance as resident completes the activity) for toileting hygiene, bathing, dressing, and personal hygiene and partial/moderate assistance (helper does less than half the effort) for putting on and taking off footwear. The MDS indicated Resident 51 had functional limitations in range of motion (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in one arm and one leg. During a concurrent observation and interview on 3/23/2026 at 1:26 p.m. with Resident 51 in Resident 51's room, Resident 51 was sitting at the edge of the bed wearing slippers on both feet. Resident 51 stated she broke her left shoulder and left ankle in November 2025 when she was hit by a car while crossing the street. Resident 51 minimally raised the left arm and stated she was unable to move the left arm well because it felt very heavy and her left hand felt numb. Resident 51 removed both slippers, moved both ankles up and down, and stated she needed a massage to the left leg because she had cramps (sudden, involuntary tightening of the muscle) and tightness in the calf muscle (lower part of the leg). Resident 51 stated she walked with a FWW in the room without the CAM boot and puts weight through her left arm. Resident 51 stated she refused the scheduled orthopedics appointment in January 2026 because she did not want to leave her husband (who was also a resident at the facility) unattended. Resident 51 stated was unsure what happened because staff never followed up with scheduling another orthopedics appointment and she had not heard anything regarding the status of her left arm and ankle for over two months. During a concurrent interview and record review on 3/25/2026 at 9:49 a.m. with the Case Manager (CM), the CM stated she was responsible for scheduling follow up consultation appointments for the residents in the facility. The CM stated if a resident missed or refused a follow up consultation appointment, the CM must attempt to re-schedule the appointment, document the reason for missed appointments or refusals in the clinical record, notify the physician, create a care plan, conduct an IDT meeting, and continue to follow up with the resident to investigate the reason for refusal, offer accommodations, and re-schedule the appointment. The CM reviewed Resident 51's clinical record and confirmed Resident 51 was supposed to follow up with orthopedics on 1/28/2026 but did not. The CM stated she scheduled a follow up orthopedic appointment for Resident 51 on 1/28/2026 but Resident 51 refused to attend and the CM did not document the refusal in the clinical record. The CM stated she tried to schedule additional follow up orthopedic appointments multiple times with Resident 51, but Resident 51 refused each time and the CM did not document the re-scheduling attempts. The CM stated she should have followed up and rescheduled Resident 51's orthopedic appointment, investigated the reasons for Resident 51's refusals and offered possible accommodations, notified the physician, developed a care plan, and held an interdisciplinary team meeting, but did not. The CM reviewed Resident 51's clinical record and confirmed the facility did not create a care plan or conduct an IDT for Resident 51's multiple refusals to follow up with orthopedics but should have. The CM stated if the facility developed a care plan and held an IDT meeting as indicated, the physician would have been notified, interventions would have been created to address the issue, and the entire team would have been aware of Resident 51's refusals and lack of follow up with orthopedics. During a concurrent interview and record review on 3/26/2026 at 10:11 a.m. with the Minimum Data Set Nurse (MDSN), the MDSN stated a care plan was developed and used as a guideline to ensure proper care was provided for each resident. The MDSN stated IDTs were conducted upon admission, quarterly, and as needed if any area of concern requiring a formal, interdisciplinary discussion was warranted. The MDSN reviewed Resident 51's clinical record and confirmed the facility did not develop a comprehensive care plan or conduct an IDT meeting to address Resident 51's refusals to follow up with orthopedics as recommended and ordered but should have. The MDSN stated care plan development and IDT conferences were important to ensure the root cause of the issue was properly investigated and appropriate interventions were implemented to address the areas of concern. During an interview on 3/26/2026 at 3:23 p.m., the Director of Nursing (DON) stated comprehensive care plans were used as a guide to ensure the appropriate care and services were provided for each resident. The DON stated care plans were used to ensure problem areas were accurately identified, goals were created, and interventions were implemented to address a resident's areas of concerns. The DON stated it was important care plans were accurate to ensure the staff was aware of the resident's status and the appropriate care and services were provided. The DON stated any resident refusals for follow up appointments should be documented in the clinical record, care planned, reported to the physician, nursing, and the resident's family, and addressed in an IDT meeting to ensure all staff were aware of the resident's refusal and interventions were in place to address the areas of concern. The DON stated if a resident's refusal to follow up with orthopedics as recommended and ordered was not care planned and discussed in an IDT meeting, it could potentially result in missed interventions, delays in necessary care and services, and placement of unnecessary restrictions on a resident which could negatively impact a resident's progress and function. During a review of the facility's Policy and Procedure (P/P) titled, Care Plans, Comprehensive Person-Centered, revised 12/2016, the P/P indicated the IDT, in conjunction with the resident and his/her family or legal representative developed and implemented a comprehensive, person-centered care plan for each resident. The P/P indicated the comprehensive care plan would include measurable objectives and timeframes, describe the services that were to be furnished to attain or maintain the resident's highest practicable, physical, mental, and psychosocial well-being, describe services that would otherwise be provided for the above but were not provided due to the resident exercising his or her rights, including the right to refuse treatment, reflect on the resident's expressed wishes regarding care and treatment goals, and aid in preventing or reducing a decline in the resident's functional status and/or functional levels. The P/P indicated identifying problem areas and their causes and developing interventions that were targeted and meaningful to the resident were the end point of an interdisciplinary process. 2. During a review of Resident 19's admission record, the admission record indicated Resident 19 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (the blood supply to part of the brain is blocked or reduced), dementia (a progressive state of decline in mental abilities), and dysphagia (difficulty swallowing). During a review of Resident 19's H&P, dated 11/11/2025, the H&P indicated, Resident 19 had no capacity (ability) to understand and make decisions. During a review of Resident 19's MDS, dated [DATE], the MDS indicated Resident 19 required maximal assistance (Helper does more than half the effort) from one staff for toileting hygiene, shower, dressing, personal hygiene, transfer, moderate assistance (Helper does less than half the effort) from one staff for bed mobility, and supervision or touching assistance (Helper provide verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) from one staff for oral hygiene and eating. During a concurrent observation and interview on 3/23/2026, at 10:59 a.m., with Resident 19 in his room, Resident 19 was watching television in bed. Resident 19 missing upper front teeth. Resident 19 stated, he lost his partial dentures while he was in a General Acute Care Hospital (GACH) prior to admission. Resident 19 stated, he told the nursing staff, but no one helped him retrieve or replace his dentures. Resident 19 stated, it was painful to chew hard food items like chopped chicken or diced unripe melon. During a concurrent interview and record review on 3/25/2026, at 3:25 p.m., with the Minimum Data Set Nurse (MDSN), Resident 19's Care Plan (CP), dated from 11/10/2025 to 3/25/2026 was reviewed. Resident 19's Care Plans did not address Resident 19's dental health status. The MDSN stated, Resident 19's dental health status such as missing partial denture and broken upper front teeth should have been reflected in CP. The MDSC stated, this would delay the treatment and care to prevent complications such as social isolation, unintended weight loss, and low self-esteem. The MDSC stated, the staff failed to address and develop CP for Resident 19's dental health issues. During an interview on 3/26/2026, at 2:46 p.m., with the Director of Nursing (DON), the DON stated, the resident's care plan is the specific resident's plan of care, and it should be initiated as soon as the staff identified the concerns. The DON stated, if the CP for Resident 19's dental health issues were not developed and implemented, Resident 19 might suffer from unintended weight loss, dental pain related to chewing food, and loss of dignity due to missing denture and broken teeth. During a review of the facility's Policy and Procedure (P&P) titled, Care plans, Comprehensive Person-Centered, revised 1/2026, the P&P indicated, Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: 8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . g. Incorporate identified problem areas; Incorporate risk factors associated with identified problems . 10. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process.

Based on interview and record review, the facility failed to ensure the comprehensive person-centered care plan was revised, updated, and reflected ophthalmologist (a medical professional specializing in comprehensive eye and vision care, including medical and surgical treatment) recommendations for one of seven sampled residents (Resident 45).This failure had the potential to result in Resident 45's vision worsening due to dry eyes and increased Intra Ocular Pressure (IOP- a measurement of the fluid pressure inside the eye). Findings:During a review of Resident 45's admission record, the admission record indicated Resident 45 was admitted to the facility on [DATE] with diagnoses including right eye blindness, muscle weakness, and dysphagia (difficulty swallowing).During a review of Resident 45's History and Physical (H&P), dated 6/24/2025, the H&P indicated, Resident 45 had fluctuating capacity (ability) to understand and make decisions.During a review of Resident 45's Minimum Data Set (MDS-a resident assessment tool), dated 1/23/2026, the MDS indicated Resident 45 required moderate assistance (Helper does less than half the effort) from one staff for transfer, dressing, and supervision or touching assistance (Helper provide verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) from one staff for oral hygiene, shower, personal hygiene, toilet hygiene, eating.During a review of Resident 45's Order Summary Report (OSR), dated 3/25/2026, the OSR indicated, instill one drop of artificial tears in both eyes every four hours as needed for dry eyes was ordered on 3/25/2026. During a concurrent interview and record review on 3/25/2026, at 10:10 a.m., with Registered Nurse Supervisor (RNS) 1, Resident 1's Ophthalmology Exam/Consult and Report, dated 10/14/2025 and 2/12/2026 were reviewed. The Ophthalmology Exam/Consult and Report indicated, artificial tears regimen for dry eye treatment and Monocular Precautions such as control IOP, avoiding eye rubbing, and monitor for medications were recommended. RNS 1 stated, all the recommendations from the ophthalmologist should be carried out and reflected in Resident 45's care plan as interventions.During a concurrent interview and record review on 3/25/2026, at 3:35 p.m., with the Minimum Data Set Nurse (MDSN), Resident 45's Care Plan (CP) titled, Resident 45 has impaired visual function related to blindness on right eye, revised 7/14/2025 was reviewed. The CP goal indicated, Resident 45 will maintain optimal quality of life within limitation imposed by visual function through 4/23/2026. The CP Interventions indicated, identify factors affecting visual function and monitor signs and symptoms of acute eye problems. The CP interventions indicated, there were no interventions for dry eyes and IOP control. The MDSN stated, the staff failed to reflect ophthalmologist's recommendations to CP. The MDSN stated, CP interventions should be revised and updated when there were recommendations from specialists including ophthalmologist to prevent further vision loss.During an interview on 3/26/2026, at 2:53 p.m., with the Director of Nursing (DON), the DON stated, ophthalmologist's recommendations should be carried out as ordered after notifying the Primary Care Physician (PCP) and reflected to care plan as interventions to prevent further vision loss. The DON stated, preserving vision loss was important to maintain Resident 45's quality of life. The DON stated, the staff should have revised and updated care plan on 10/14/2025 and 2/12/2026 after ophthalmologist visits because ophthalmologists emphasized same recommendations twice in a row.During a review of the facility's Policy and Procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 1/2026, the P&P indicated, Policy Interpretation and Implementation: 8. The comprehensive, person-centered care plan will: b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . 13. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. 14. The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition.

Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one of six sampled residents (Residents 51) by failing to follow up with an orthopedic (specialty area in medicine referring to the management of the muscles, bones, and their connective structures) consultation appointment for Resident 51's left humerus (upper arm bone) and left ankle fractures (broken bone) per consulting physician's recommendations.This deficient practice resulted in Resident 51 not receiving necessary treatment and services to improve mobility (ability to move) and activities of daily living (ADL, basic activities such as eating, dressing, toileting) and had the potential to result in a further decline in Resident 51's left arm and left ankle range of motion (ROM, full movement potential of a joint), unnecessary weightbearing (guidance from a physician limiting the amount of weight a person can put through a specific arm and/or leg after surgery) and orthotic device (medical device such as a brace or boot designed to support, realign, protect, prevent and correct deformities and improve function) restrictions, delayed healing, and a decline in overall physical functioning.Findings: During a review of Resident 51's admission Record, the admission Record indicated Resident 51 was admitted to the facility on [DATE] with diagnoses including systemic involvement of connective tissue (group of disorders where the immune system attacks its own healthy tissues causing widespread inflammation and damage to skin, blood vessels, joints [where two bones meet], and organs), muscle weakness, and polyneuropathy (damage of the nerves that can cause weakness, numbness, and burning pain). During a review of Resident 51's History and Physical (H&P), dated 11/11/2025, the H&P indicated Resident 51 was transferred to the facility from a hospital on [DATE] for rehabilitation after being hit on the left side of the body while crossing the street on 11/3/2025. The H&P indicated Resident 51 sustained multiple fractures, which included a left humerus fracture, a left distal fibula fracture (break in the smaller of the two lower leg bones between the knee and the ankle), a left tibia dislocation (knee injury where the shin bone loses contact with the lower part of the thigh bone), and a left medial malleolus fracture (break in the bony bump on the inner side of the ankle). The H&P indicated Resident 51 had surgery to re-align Resident 51's left ankle dislocation on 11/3/2025 and had additional surgeries to repair the bone fractures of the left ankle and left humerus on 11/5/2025.During a review of Resident 51's Minimum Data Set (MDS, a resident assessment tool), dated 2/16/2026, the MDS indicated Resident 51 had severe cognitive (mental action or process of acquiring knowledge and understanding) impairment. The MDS indicated Resident 51 required set up/clean up assistance (helper sets up or cleans up) for eating, oral hygiene, and rolling to both sides, supervision or touching assistance (helper provides verbal cues and/or touching and/or contact guard assistance as resident completes the activity) for toileting hygiene, bathing, dressing, and personal hygiene and partial/moderate assistance (helper does less than half the effort) for putting on and taking off footwear. The MDS indicated Resident 51 had functional limitations in range of motion (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in one arm and one leg.During a review of Resident 51's Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation and Plan of Treatment (PT Eval), dated 11/11/2025, the PT Eval indicated Resident 51's medical precautions included for Resident 51's left leg to be toe-touch weightbearing (TTWB, safety measure after surgery or fractures prescribed by the physician which allows a person to touch the toes of the injured leg on the ground for balance while walking) while wearing a Controlled Ankle Motion boot (CAM boot, orthopedic device used to immobilize the foot, ankle, or lower leg in a fixed position and removing some of the weight off the foot and ankle while walking) for four weeks. During a review of Resident 51's Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Evaluation and Plan of Treatment (OT Eval), dated 11/11/2025, the OT Eval indicated Resident 51's medical precautions included for Resident 51's left leg to be TTWB while wearing a CAM boot for four weeks and for Resident 51's left arm to be non-weightbearing (NWB, restriction in which a person is not allowed to put any weight through the operated body part) and positioned in a sling (flexible material used to support a person during a mechanical lift transfer) when Resident 51 was out of bed. During a review of Resident 51's Orthopedic Consultation note (Ortho Note), dated 12/17/2025, the Ortho Note indicated Resident 51's left arm was to be NWB and Resident 51's left leg was weightbearing as tolerated (WBAT, a person is medically cleared to place as much weight through the affected arm or leg to the point of comfort or tolerance) while wearing a CAM boot. The Ortho Note indicated Resident 51 to follow up with orthopedics on 1/28/2026 at 11 a.m. During a review of Resident 51's Order Summary Report, the Order Summary Report indicated a physician's order, dated 12/17/2025, to follow up with orthopedics on 1/28/2026 at 11 a.m. During a review of Resident 51's Order Summary Report, the Order Summary Report indicated a physician's order, dated 12/23/2025, for Resident 51 to continue with NWB precautions to the left arm. During a review of Resident 51's Order Summary Report, the Order Summary Report indicated a physician's order, dated 12/23/2025, for Resident 51's left leg to be WBAT while wearing a CAM boot.During a review of Resident 51's Interdisciplinary Team (IDT, team of health care professionals that work together with the resident and/or resident's representative to prioritize the resident 's needs and goals) Progress Note, dated 1/22/2026, the IDT Progress Note indicated an IDT meeting was held at Resident 51's bedside due to Resident 51's refusal to wear the left leg CAM boot when walking. The IDT Progress Note indicated Occupational Therapist 1 (OT 1) educated Resident 51 that a front wheeled walker (FWW, mobility device with two wheels in the front used for support when standing or walking) would not be provided if Resident 51 did not wear the left leg CAM boot due to increased risk of re-injury to the left leg. The IDT Progress Note indicated an orthopedic follow up appointment was scheduled for 1/28/2026 at which time Resident 51 would discuss possibly discontinuing the left leg CAM boot with the physician. The IDT Progress Note indicated therapy services would work on transfers only, not walking, until further clarification from the orthopedics physician. During a review of Resident 51's OT Discharge summary, dated [DATE], the OT Discharge Summary indicated Resident 51 was discharged from OT services due to highest practical level achieved.During a review of Resident 51's PT Discharge summary, dated [DATE], the PT Discharge Summary indicated Resident 51 was discharged from OT services due to highest practical level achieved. During a concurrent observation and interview on 3/23/2026 at 1:26 p.m. with Resident 51 in Resident 51's room, Resident 51 was sitting at the edge of the bed wearing slippers on both feet. Resident 51 stated she broke her left shoulder and left ankle in November 2025 when she was hit by a car while crossing the street. Resident 51 minimally raised the left arm and stated she was unable to move the left arm well because it felt very heavy and her left hand felt numb. Resident 51 removed both slippers, moved both ankles up and down, and stated she needed a massage to the left leg because she had cramps (sudden, involuntary tightening of the muscle) and tightness in the calf muscle (lower part of the leg). Resident 51 stated she walked with a FWW in the room without the CAM boot and puts weight through her left arm. Resident 51 stated she refused the scheduled orthopedics appointment in January 2026 because she did not want to leave her husband (who was also a resident at the facility) unattended. Resident 51 stated was unsure what happened because staff never followed up with scheduling another orthopedics appointment and she had not heard anything regarding the status of her left arm and ankle for over two months. During a concurrent interview and record review on 3/25/2026 at 9:27 a.m. with Registered Nurse Supervisor 1 (RNS 1), RNS 1 stated a licensed nurse was responsible for accepting a resident's paperwork and implementing new physician orders and recommendations when a resident returned to the facility from a consultation appointment. RNS 1 stated if follow up appointments were recommended by the consulting physician; the licensed nurse entered the recommended date and time of the follow up appointment in the physician's orders and informed the case manager who then scheduled the follow up appointment based on the physician's instructions. RNS 1 reviewed Resident 51's physician's orders, dated 12/17/2025, and confirmed Resident 51 was supposed to follow up with Orthopedics on 1/28/2026 per physician's orders, but was unable to verify if Resident 51 attended the scheduled appointment because there were no ortho notes or progress notes confirming the visit. RNS 1 stated the lack of orthopedic follow-up as recommended could potentially result in injury due to lack of updated instructions and precautions in how to properly care for the residents and a decline in function. During a concurrent interview and record review on 3/25/2026 at 9:49 a.m. with the Case Manager (CM), the CM stated she was responsible for scheduling follow up consultation appointments for the residents in the facility. The CM stated if a resident missed or refused a follow up consultation appointment, the CM must attempt to re-schedule the appointment, document the reason for missed appointments or refusals in the clinical record, notify the physician, create a care plan, conduct an IDT meeting, and continue to follow up with the resident to investigate the reason for refusal, offer accommodations, and re-schedule the appointment. The CM reviewed Resident 51's clinical record and confirmed Resident 51 was supposed to follow up with orthopedics on 1/28/2026 but did not. The CM stated she scheduled a follow up orthopedic appointment for Resident 51 on 1/28/2026 but Resident 51 refused to attend and the CM did not document the refusal in the clinical record. The CM stated she tried to schedule additional follow up orthopedic appointment's multiple times with Resident 51, but Resident 51 refused each time and the CM did not document the re-scheduling attempts and did not notify nursing or the physician of Resident 51's repeated refusals. The CM stated she should have followed up and rescheduled Resident 51's orthopedic appointment, investigated the reasons for Resident 51's refusals and offered possible accommodation, notified the physician, developed a care plan, and held an interdisciplinary team meeting, but did not. The CM stated it was important for residents to attend follow-up appointments as recommended or ordered to ensure staff provided the appropriate care and services based on the resident's current medical needs. During a concurrent interview and record review on 3/25/2026 at 2:59 p.m. with the Director of Rehabilitation (DOR), the DOR reviewed Resident 51's clinical record. The DOR stated Resident 51 was evaluated by OT services on 11/11/2025 and discharged from OT services on 1/30/2025 due to a functional plateau (state of little of no change). The DOR stated Resident 51 was evaluated by PT on 11/11/2025 and discharged from PT on 2/5/2025 due to a functional plateau. The DOR reviewed Resident 51's IDT Progress Note, dated 1/22/2026, and confirmed PT and OT could not issue Resident 51 a FWW and safely work on walking exercises with Resident 51 until Resident 51 followed up with orthopedics on 1/28/2026. The DOR stated Resident 51 reached her highest practical level in therapy, mobility, and ADLs with the NWB restrictions to the left arm and Resident 51's refusal to wear a CAM boot when walking per physician's orders and needed guidance from the orthopedic physician to safely progress Resident 51 in therapy. The DOR reviewed Resident 51's clinical record and stated he was unsure if Resident 51 attended her scheduled ortho appointment on 1/28/2026 because there were no ortho notes or progress notes in the chart. The DOR stated lack of orthopedic follow up could result in a lack of progress or decline in a resident's function. During an interview on 3/26/2026 at 3:23 p.m. with the Director of Nursing (DON), the DON stated the licensed nurse was responsible for accepting a resident's paperwork and implementing new physician orders and recommendations when a resident returned to the facility from a consultation appointment. The DON stated if follow up appointments were recommended by the physician, the charge nurse contacted the case manager or social worker to schedule the follow up appointment based on the physician recommendations. The DON stated any resident refusals for follow up appointments should be documented in the clinical record, care planned, discussed in an IDT meeting, and reported to the physician, nursing, and the resident's family. The DON stated if residents did not attend follow up appointments as recommended or ordered, it could result in missed interventions, delays in necessary care and services, and placement of unnecessary restrictions on a resident which could negatively impact a resident's progress and function. During a review of the facility's Policy and Procedure (P/P) titled, Referrals, Appointments, Follow-up, Social Services/Case Manager, revised 12/2008, the P/P indicated Social Services or Case Management personnel shall coordinate most resident referrals with outside agencies. The P/P indicated Social Services or Case Management would collaborate with the nursing staff or other pertinent disciplines to arrange for services that have been ordered by the physician such as clinic appointments. The P/P indicated Social Services or Case Management would document the referral in the resident's medical record and collaborate follow up appointments/referrals with the nursing staff or other pertinent disciplines to ensure appropriate follow-up was carried out.

Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 51) who had a left shoulder and a left ankle fracture (broken bone) was:1. Wearing a Controlled Ankle Motion boot (orthopedic device used to immobilize or protect the foot and ankle after an injury or surgery) during transfers (moving from one place to another) and walking and not weightbearing (putting pressure or force through an arm or leg) through the left arm per physician's orders2. Not walking with a front-wheeled walker (FWW, mobility device with two wheels in the front used for support when standing or walking) per Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) and Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) recommendations. This deficient practice placed Resident 51 at risk for fall and injury, worsening fractures, delayed healing, pain, and a decline in overall physical functioning. Findings: During a review of Resident 51's admission Record, the admission Record indicated Resident 51 was admitted to the facility on [DATE] with diagnoses including systemic involvement of connective tissue (group of disorders where the immune system attacks its own healthy tissues causing widespread inflammation and damage to skin, blood vessels, joints [where two bones meet], and organs), muscle weakness, and polyneuropathy (damage of the nerves that can cause weakness, numbness, and burning pain). During a review of Resident 51's History and Physical (H&P), dated 11/11/2025, the H&P indicated Resident 51 was transferred to the facility from a hospital on [DATE] for rehabilitation after being hit on the left side of the body while crossing the street on 11/3/2025. The H&P indicated Resident 51 sustained multiple fractures, which included a left humerus fracture, a left distal fibula fracture (break in the smaller of the two lower leg bones between the knee and the ankle), a left tibia dislocation (knee injury where the shin bone loses contact with the lower part of the thigh bone), and a left medial malleolus fracture (break in the bony bump on the inner side of the ankle). The H&P indicated Resident 51 had surgery to re-align Resident 51's left ankle dislocation on 11/3/2025 and had additional surgeries to repair the bone fractures of the left ankle and left humerus on 11/5/2025.During a review of Resident 51's Minimum Data Set (MDS, a resident assessment tool), dated 2/16/2026, the MDS indicated Resident 51 had severe cognitive (mental action or process of acquiring knowledge and understanding) impairment. The MDS indicated Resident 51 required set up/clean up assistance (helper sets up or cleans up) for eating, oral hygiene, and rolling to both sides, supervision or touching assistance (helper provides verbal cues and/or touching and/or contact guard assistance as resident completes the activity) for toileting hygiene, bathing, dressing, and personal hygiene and partial/moderate assistance (helper does less than half the effort) for putting on and taking off footwear. The MDS indicated Resident 51 had functional limitations in range of motion (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in one arm and one leg.During a review of Resident 51's PT Evaluation and Plan of Treatment (PT Eval), dated 11/11/2025, the PT Eval indicated Resident 51's medical precautions included for Resident 51's left leg to be toe-touch weightbearing (TTWB, safety measure after surgery or fractures prescribed by the physician which allows a person to touch the toes of the injured leg on the ground for balance while walking) while wearing a CAM boot for four weeks. During a review of Resident 51's OT Evaluation and Plan of Treatment (OT Eval), dated 11/11/2025, the OT Eval indicated Resident 51's medical precautions included for Resident 51's left leg to be TTWB while wearing a CAM boot for four weeks and for Resident 51's left arm to be non-weightbearing (NWB, restriction in which a person is not allowed to put any weight through the operated body part) and positioned in a sling (flexible material used to support a person during a mechanical lift transfer) when Resident 51 was out of bed.During a review of Resident 51's Orthopedic Consultation note (Ortho Note), dated 12/17/2025, the Ortho Note indicated Resident 51's left arm was to be NWB and Resident 51's left leg was weightbearing as tolerated (WBAT, a person is medically cleared to place as much weight through the affected arm or leg to the point of comfort or tolerance) while wearing a CAM boot. The Ortho Note indicated Resident 51 to follow up with orthopedics on 1/28/2026 at 11 a.m. During a review of Resident 51's Order Summary Report, the Order Summary Report indicated a physician's order, dated 12/17/2025, to follow up with orthopedics on 1/28/2026 at 11 a.m.During a review of Resident 51's Order Summary Report, the Order Summary Report indicated a physician's order, dated 12/23/2025, for Resident 51 to continue with NWB precautions to the left arm.During a review of Resident 51's Order Summary Report, the Order Summary Report indicated a physician's order, dated 12/23/2025, for Resident 51's left leg to be WBAT while wearing a CAM boot.During a review of Resident 51's Progress Note, dated 1/21/2026, written and signed by Occupational Therapist 2 (OT 2), the Progress Note indicated staff informed OT 2 that Resident 51 was seen walking to the restroom without assistance and without wearing a CAM boot to the left leg. The Progress Note indicated OT 2 informed Resident 51 that he was unable to issue a FWW as she requested because Resident 51 refused to wear the physician ordered CAM boot during transfers and for walking to reduce the risk of re-injury to the left leg. The Progress Not indicated OT 2 instructed Resident 51 to use a bedside commode with assistance as safe alternative due to Resident 51's non-compliance with the CAM boot but Resident 51 refused. During a review of Resident 51's IDT Progress Note, dated 1/22/2026, the IDT Progress Note indicated an IDT meeting was held at Resident 51's bedside due to Resident 51's refusal to wear the left leg CAM boot when walking. The IDT Progress Note indicated Occupational Therapist 1 (OT 1) educated Resident 51 that a FWW would not be provided if Resident 51 did not wear the left leg CAM boot due to increased risk of re-injury to the left leg. The IDT Progress Note indicated an orthopedic follow up appointment was scheduled for 1/28/2026 at which time Resident 51 would discuss possibly discontinuing the left leg CAM boot with the physician. The IDT Progress Note indicated therapy services would work on transfers only, not walking, until further clarification from the orthopedics physician. During a review of Resident 51's OT Discharge summary, dated [DATE], the OT Discharge Summary indicated Resident 51 was discharged from OT services due to highest practical level achieved.During a review of Resident 51's PT Discharge summary, dated [DATE], the PT Discharge Summary indicated Resident 51 was discharged from OT services due to highest practical level achieved. During a concurrent observation and interview on 3/23/2026 at 1:26 p.m. with Resident 51 in Resident 51's room, Resident 51 was sitting at the edge of the bed wearing slippers on both feet. Resident 51 stated she broke her left shoulder and left ankle in November 2025 when she was hit by a car while crossing the street. Resident 51 minimally raised the left arm and stated she was unable to move the left arm well because it felt very heavy and her left hand felt numb. Resident 51 removed both slippers, moved both ankles up and down, and stated she needed a massage to the left leg because she had cramps (sudden, involuntary tightening of the muscle) and tightness in the calf muscle (lower part of the leg). Resident 51 stated she walked with a FWW in the room without the CAM boot and puts weight through her left arm. Resident 51 stated she refused the scheduled orthopedics appointment in January 2026 because she did not want to leave her husband (who was also a resident at the facility) unattended. Resident 51 stated was unsure what happened because staff never followed up with scheduling another orthopedics appointment and she had not heard anything regarding the status of her left arm and ankle for over two months. During a concurrent observation and interview on 3/25/2026 at 4:20 pm with Resident 51 in Resident 51's room, Resident 51 was wearing slippers on both feet and walking in the room using an FWW. Resident 51 was not wearing a CAM boot and was observed pushing through the left arm while walking with an FWW. Resident 51 stated she did not like to wear the CAM boot on her left leg while walking because it was too heavy and the material rubbed against her skin. Resident 51 stated she put weight through her left arm when walking with a FWW and when standing up because her injury was over four months ago and had not heard anything from staff regarding any changes to her weightbearing restrictions. Resident 51 stated a staff member provided her with a FWW a long time ago to help her get to the bathroom, but she did not remember when or which staff member it was. During a concurrent interview and record review on 3/26/2026 at 10:35 a.m. with OT 2, OT 2 reviewed Resident 51's therapy notes and confirmed Resident 51 was evaluated by OT services on 11/11/2025 and discharged from OT services on 1/30/2026. OT 2 stated OT discharged Resident 51 from OT services because she reached her maximal functional level in mobility and activities of daily living (ADL, basic activities such as eating, dressing, and toileting) because of her orthopedic restrictions and refusal to wear the left leg CAM boot per physician's orders. OT 2 stated Resident 51 never used a walker during therapy because she was unsafe to do so due to Resident 51's refusal to wear the left leg CAM boot and inability or refusal to maintain the left arm NWB precautions per physician's orders. OT 2 reviewed Resident 51's Progress Note, dated 1/21/2026, and confirmed staff informed Resident 51 was observed walking unassisted with a FWW and without wearing the left leg CAM boot. OT 2 stated he did not recommend and/or issue Resident 51 a FWW due to safety concerns and risk of injury and recommended Resident 51 perform transfers only, no walking. OT 2 stated Resident 51 was unsafe to walk with a FWW and did not know how Resident 51 obtained an FWW. OT 2 stated if Resident 51 was walking with a FWW without a left leg CAM boot and weightbearing through the left arm, it could result in harm and injury. During a concurrent interview and record review on 3/26/2026 at 11:28 a.m. with Physical Therapist 1 (PT 1), PT 1 reviewed Resident 51's therapy notes and confirmed Resident 51 was evaluated by PT services on 11/11/2025 and discharged from OT services on 2/5/2026. PT 1 stated Resident 51 was discharged from PT services because she reached her maximal functional level in mobility because of her orthopedic restrictions and refusal to wear the left leg CAM boot per physician's orders. PT 1 stated the purpose of a CAM boot was to protect the operated leg by removing pressure or force off the joint when transferring or walking. PT 1 stated PT 1 did not issue Resident 51 a FWW because it was unsafe. PT 1 stated Resident 51 tried walking one to two times during therapy but stopped and could not continue due to safety concerns and Resident 51's continued non-compliance with physician's orders. PT 1 stated Resident 51 was unsafe walking with a FWW without a left leg CAM boot and weightbearing through the left arm because it was against physician's orders and had the potential to disrupt Resident 51's healing process. During a concurrent interview on 3/26/2026 at 3:23 p.m. with the Director of Nursing (DON), the DON stated PT and OT determined the level of assistance and type of device a resident needed to safely transfer and walk in the facility. The DOR stated it was important for residents to follow physician's orders and therapy recommendations to prevent injury and accidents. The DOR stated if Resident 51 was walking with a FWW that was not recommended by therapy without wearing a left leg CAM boot and weightbearing through the left arm against physician's orders, it could result in worsening of the fractures, harm, injury, and accidents. During a review of the facility's Policy and Procedures (P/P) titled, Safety of Residents, revised 1/2026, the P/P indicated resident safety and supervision and assistance to prevent accidents were facility-wide priorities. The P/P indicated the care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices.

Based on observation, interview, and record review, the facility failed to ensure Restorative Nursing Aide 1 (RNA 1) was competent to provide active assistive range of motion (AAROM, use of muscles surrounding the joint to perform the exercise but required some help from a person or equipment) exercises to one of six sampled resident's (Resident 61) both legs in accordance with physician orders.This deficient practice resulted in an inefficient delivery of range of motion (ROM, full movement potential of a joint) services for Resident 61 and had the potential to result in ROM decline, contracture (loss of motion of a joint associated with stiffness and joint deformity) development, and an overall decline in physical functioning for residents receiving Restorative Nursing Aide (RNA, trained nursing staff who help residents gain an improved quality of life by increasing their level of strength and mobility) services. Findings:During a review of Resident 61's admission Record, the admission Record indicated Resident 61 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including cerebral infarction (stroke, blockage of the flow of blood brain, causing or resulting in brain tissue death), muscle weakness, and contractures (loss of motion of a joint associated with stiffness and joint deformity) of the right shoulder, both hips, both knees, and both ankles.During a review of Resident 61's Minimum Data Set (MDS, a resident assessment tool), dated 1/15/2026, the MDS indicated Resident 61 had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 61 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying assistance) for eating, substantial/maximal assistance (helper does more than half the effort) for oral hygiene, personal hygiene, upper body dressing, and rolling to both sides, and was dependent (helper does all the effort) in toileting hygiene, bathing, upper body dressing, and transfers. The MDS indicated Resident 61 had functional limitations in range of motion (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in one arm and one leg.During a review of Resident 61's Order Summary Report, the Order Summary Report indicated a physician's order, dated 3/16/2026, for RNA to provide AAROM exercises to Resident 61's both legs, five times a week.During an observation on 3/24/2026 at 1:44 p.m. of Resident 61's RNA session, in Resident 61's room, Resident 61 was lying in bed. After assisting Resident 61 with right arm ROM exercises, RNA 1 demonstrated the exercises and asked Resident 61 to lift the left leg up and down and inwards and outwards away from the body, 15 times each direction. Resident 61 partially moved the left leg up and down and inwards and outwards towards the body but could not move through the full ROM in all directions. RNA did not assist Resident 61 in moving the left hip through the full ROM. RNA 1 held and supported Resident 61's upper portion of the leg and asked Resident 61 to bend and straighten the left knee, 15 times. Resident 61 was able to partially bend the knee downwards and upwards, but could not move through the full ROM. RNA 1 did not assist Resident 61 in moving the left leg through the full ROM. RNA 1 asked Resident 61 to move the left ankle and all toes of the left foot up and down. Resident 61 tried but was unable. RNA 1 did not assist Resident 61 with left ankle and left toe ROM exercises. RNA 1 moved to the right side of the bed and verbally asked Resident 61 to move the right leg up and down and inwards and outwards away from the body, 15 times in each direction. Resident 61 partially moved the left leg up and down and inwards and outwards towards the body, but could not move through the full ROM. RNA 1 did not assist Resident 61 in moving the right leg through the full ROM. RNA 1 held and supported Resident 61's upper portion of the leg and asked Resident 61 to bend and straighten the right knee and all the toes on the right foot, 15 times in each direction. Resident 61 was able to partially bend the knee downwards and upwards, but could not move through the full ROM. RNA 1 did not assist Resident 61 in moving the right knee through the full ROM. During a concurrent interview and record review on 3/24/2026 at 2:15 p.m. with RNA 1, RNA 1 reviewed Resident 61's physician's order, dated 3/16/2026, and confirmed Resident 61 had an RNA order for RNA to provide AAROM exercises to Resident 61's both legs. RNA 1 stated she did not know what AAROM exercises were and thought the order said AROM exercises which meant Resident 61 performed the ROM exercises on his own with only cueing or demonstration of the exercises and without physical assistance from RNA. RNA 1 stated Resident 61 was unable to fully move both legs independently but did not physically assist with ROM because she thought the order was for AROM and did not know what AAROM exercises were. RNA 1 stated if a resident could not move the arm or leg through the full ROM on his or her own and did not have the proper ROM assistance, it could result in joint stiffness. During a concurrent interview and record review on 3/24/2026 at 2:35 p.m. with the Director of Staff Development (DSD), the DSD stated the RNAs in the facility were Certified Nursing Assistants (CNA) with specialized training in RNA services. The DSD reviewed Resident 61's physician's order, dated 3/16/2026, and confirmed Resident 61 had an RNA order for RNA to provide AAROM exercises to Resident 61's both legs. The DSD stated AAROM meant the resident performed as much ROM as possible on his or her own and the RNA physically assisted the resident through the rest of the ROM. The DSD stated if RNA did not know what AAROM exercises were and did not assist the residents with the appropriate ROM exercises as ordered, it could result in joint stiffness, ROM decline, and contractures. During a concurrent interview and record review on 3/25/2026 at 1:27 p.m. with the Director of Rehabilitation (DOR), the DOR stated Rehab created the RNA programs based on a resident's needs. The DOR stated RNAs were to carry out RNA exercises as ordered. The DOR reviewed Resident 61's physician's orders, dated 3/16/2026, and confirmed Resident 61 had an RNA order for AAROM exercises to Resident 61's both legs. The DOR stated AAROM exercises were typically prescribed to residents who were unable to obtain full ROM on their own and needed the physical assistance of RNA or equipment to help move through the rest of the motion. The DOR stated it was important that RNAs were competent in the different types of ROM exercises as ordered to ensure they were appropriately addressing the resident's needs to prevent ROM decline and contracture development. During an interview on 3/26/2026 at 3:23 p.m. with the Director of Nursing (DON), the DON stated RNAs assisted residents in the facility with activities such as ROM exercises to ensure the residents maintained their current level of function and did not experience a functional decline after discharge from skilled therapy services (services that require specialized training and experience of a licensed therapist or therapy assistant). The DON stated RNAs must understand and demonstrate competency in the different types of range of motion exercises when providing RNA services to help prevent injuries, contracture development, and functional declines.During a review of the facility's Policy and Procedures (P/P), titled, Staffing, Sufficient and Competent Nursing, revised 1/2026, the P/P indicated the facility provided sufficient numbers of nursing staff with the appropriate skills and competency to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment.

Based on interview and record review, the facility failed to complete the performance evaluations (a way to measure how well you are doing a specific job or assignment) at least once every 12 months for Certified Nurse Assistants (CNA) 1, 2 and Restorative Nursing Aide (RNA - nursing aide program that help residents maintain any progress made after therapy intervention to maintain their function) 1.This failure had the potential to result in the inability to identify staff-specific clinical weaknesses, creating potential for nurse aids to perform tasks incorrectly and not meeting residents' needs Findings:During a concurrent interview and record review on 3/25/2026 at 3:06 p.m., with the Director of Staff Development (DSD), CNA 1, 2, and RNA 1's Anniversary Performance Review (APR), for years of 2024 and 2025 were reviewed. The DSD stated performance evaluations were essential to assess staff performance, identify training needs, and communicate facility expectations to meet residents' care needs. The DSD stated the facility did not complete APR's for the following staff and years:a. CNA 1's date of hire (DOH) was 7/18/2023, and missing APR for 2024 and 2025.b. CNA 2's DOH was 1/8/2024, and missing APR for 2025.c. RNA 1's DOH was 3/13/2023, and missing APR for 2024 and 2025. During an interview on 3/26/2026 at 4:06 p.m., with the Director of Nursing (DON), the DON stated performance evaluations should be completed at least annually and as needed to ensure nurse aids are providing appropriate care, meeting expected performance, and identify strengths and areas for improvement.During a review of the facility's Policy and Procedure (P&P) titled, Performance Evaluation, revised January 2026, the P&P indicated a performance evaluation will be completed on each employee at the conclusion of his/her 90-day probationary period, and at least annually thereafter.

Based on observation, interview, and record review, the facility failed to clarify physician orders for two of six sampled residents (Residents 15's and 32's) by failing to:1. Clarify frequency (number of times) for administration of Resident 15's artificial tears eye drops.2. Clarify frequency and ensure that there was no risk of duplicate therapy for Resident 32's multiple acetaminophen (a medication used to treat fever and pain) orders.These deficient practices had the potential to cause medication errors, inadequate treatment or excess dosage for Residents 15 and 32, and placed Resident 32 at risk for acetaminophen toxicity and liver damage. Findings:1. During a review of Resident 15's admission Record (a document containing demographic and diagnostic information), dated 3/23/2026, the admission record indicated the facility admitted Resident 15 on 3/5/2024 with diagnoses including Type 2 Diabetes Mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing) without complications and disorder involving the immune mechanism.During a review of Resident 15's Internal Medicine Note, dated 3/10/2026, the note indicated Resident 15 had capacity for medical decision making.During a review of Resident 15's Minimum Data Set (MDS - a resident assessment tool), dated 3/11/2026, the MDS indicated Resident 15's cognition (mental action or process of acquiring knowledge and understanding through thought and the senses) was moderately impaired. The MDS indicated Resident 15 needed supervision assistance from the facility staff for performing activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as eating, moderate assistance for oral hygiene, upper body dressing and personal hygiene, and maximal assistance for toileting hygiene, showering, lower body dressing and putting on or taking off footwear. During a review of Resident 15's Care Plan, dated 1/13/2025, the care plan indicated, Focus: vision/eyes: resident is at risk for altered peripheral vision, altered experiences, seeing halos, flashes of lights, curtains over eyes, pain, and localized infection, diabetic retinopathy (serious, often asymptomatic, complication of diabetes caused by high blood sugar damaging blood vessels in the retina) due to diabetes, disease process. Goal: will be free from eye discomfort/pain. Interventions/Tasks: monitor eyes for irritation, redness or increased dryness and notify physician.During a review of Resident 15's medication reconciliation on 3/23/2026, Resident 15's Order Summary Report (a document containing a summary of all active physician orders), dated 3/23/2026, the order summary report indicated the following physician orders:Artificial Tears Ophthalmic Solution 0.2-0.2-1% (glycerin [viscous liquid used to provide moisture] - Hypromellose [a product used as a lubricant to treat dry eyes] - polyethylene glycol 400 [a product used as a lubricant to treat dry eyes]), instill 1 drop in both eyes as needed for dry eyes, order date 1/13/2026, start date 1/13/2026.During a review of Resident 15's Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 3/1/2026 to 3/23/2026, the MAR indicated artificial tears ophthalmic solution was administered one time on 3/16/2026.During a review of Resident 15's Order Summary Report, dated 3/23/2026, the order summary report indicated the artificial tears' physician order was modified to indicate a frequency as follows: Artificial Tears Ophthalmic Solution 0.2-0.2-1% (glycerin [viscous liquid used to provide moisture] - Hypromellose [a product used as a lubricant to treat dry eyes] - polyethylene glycol 400 [a product used as a lubricant to treat dry eyes]), instill 1 drop in both eyes every 4 hours as needed for dry eyes, order date 3/23/2026, start date 3/23/2026. During a concurrent interview and record review on 3/23/2026 at 3:07 p.m. with Licensed Vocational Nurse (LVN) 2, Resident 15's active physician orders were reviewed. The physician order for Resident 15's artificial tears eye drops did not indicate a frequency for as needed dosing for dry eyes. LVN 2 stated it was important to have the frequency of as needed dosing for Resident 15's artificial tears eye drops because while one nurse could interpret the order to give the artificial tears eye drops two times a day, another nurse could interpret the same order to give it three times a day as needed. LVN 2 stated there was a risk that medication might not be administered properly. During an interview on 3/24/2026 at 1:52 p.m. with the Director of Nursing (DON), the DON stated the physician orders should include medication name, dosage, strength, frequency, time and any special instructions. The DON stated artificial tears eye drops should have had a frequency and not just as needed. DON stated if the instructions did not include how many times the artificial tears eye drops should be administered, there would be no guidance for the facility staff as to when to give the medication and patient could get it as many times as they requested. DON stated there was a risk for resident to be overmedicated with artificial tears.2. During a review of Resident 32's admission Record, dated 3/23/2026, the admission record indicated the facility admitted Resident 32 on 3/5/2026 with diagnoses including hepatomegaly (abnormal enlargement of the liver [an important organ in human body located in the upper right abdomen that performs over 500 essential functions, including filtering blood, detoxifying chemicals, metabolizing drugs, and producing bile for digestion], not elsewhere classified, uncomplicated alcohol dependence, fatty (change of) liver (a condition that occurs when excess fat [5%-10% or more of liver weight] builds up in liver cells, often linked to obesity, type 2 diabetes, and high cholesterol]) not elsewhere classified and muscle weakness.During a review of Resident 32's History and Physical (H&P) dated 3/8/2026, the H&P indicated Resident 32 did not have capacity for medical decision making due to chronic encephalopathy (a medical term for a disease or dysfunction altering brain function, often causing altered mental state, confusion, personality changes, and seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness].During a review of Resident 32's MDS, dated [DATE], the MDS indicated Resident 32's cognition was moderately impaired. The MDS indicated Resident 32 needed setup or clean-up assistance from the facility staff for performing ADLs such as eating, oral hygiene and personal hygiene, and supervision or touching assistance for toileting hygiene, showering, upper body dressing, lower body dressing and putting on or taking off footwear.During a concurrent observation and interview on 3/23/2026 at 12:20 p.m. with LVN 3, LVN 3 prepared and administered the following three medications to Resident 32. LVN 3 stated Resident 32 requested Tylenol, generic name - acetaminophen (medication used for pain) for right side pain.a. Two tablets of acetaminophen 325 milligrams ([mg] a metric unit of measurement, used for medication dosage and/or amount)b. One capsule of gabapentin (a medication used to treat nerve pain and seizures) 300 mgc. One capsule of Zenpep (a medication used to treat exocrine pancreatic insufficiency [EPI - a condition where the pancreas does not produce enough enzymes to digest food]) 10000 unitsDuring a review of Resident 32's Order Summary Report, dated 3/23/2026, the order summary report indicated but not limited to the following physician orders:Acetaminophen Oral Tablet 500 mg, give 2 tablets by mouth as needed for moderate to severe pain 4-10, Non-Pharmacological Interventions (NPI) as follows: 1. Relaxation 2. Adjust room temp/lighting 3. Reposition 4. Toileting 5. Music/TV 6. Snacks 7. Warm/cold compress 8. Breathing exercise. Not to exceed 3-gram ([gm] a metric unit of measurement, used for medication dosage and/or amount) per 24 hours, to include all acetaminophen (APAP) products, give 2 tablets = 1000 mg, QD (daily), order date 3/5/2026, start date 3/5/2026. 2. Acetaminophen tablet 325 mg, give 2 tablets by mouth every 4 hours as needed for temperature greater than or equal to 100.3 F, *NTE 3 gm/24 hours *to include all APAP products, order date 3/6/2026, start date 3/6/2026. 3. Acetaminophen tablet 325 mg, give 2 tablets by mouth every 6 hours as needed for mild pain 1-3, NPI as follows: 1. Relaxation 2. Adjust room temp/lighting 3. Reposition 4. Toileting 5. Music/TV 6. Snacks 7. Warm/cold compress 8. Breathing exercise. *NTE 3 gm/24 hours, to include all APAP products, give 2 tablets = 650 mg, order date 3/6/2026, start date 3/6/2026. 4. Gabapentin oral capsule 300 mg, give 1 capsule by mouth three times a day for neuropathy, order date 3/5/2026, start date 3/5/2026. 5. Zenpep 10000-32000 unit capsule delayed release particles, give 1 capsule by mouth with meals for EPI, take with food, order date 3/5/2026, start date 3/6/2026.During a concurrent interview and record review on 3/23/2026 at 2:53 p.m. with LVN 3, Resident 32's Order Details for acetaminophen 500 mg was reviewed. The order details dated 3/23/2026 indicated, Order Date: 3/5/2026 7:27 p.m., order summary: Acetaminophen Oral Tablet 500 mg, give 2 tablets by mouth as needed for moderate to severe pain 4-10, NPI as follows: 1. Relaxation 2. Adjust room temp/lighting 3. Reposition 4. Toileting 5. Music/TV 6. Snacks 7.Warm/cold compress 8. Breathing exercise. Not to exceed 3-gram ([gm] a metric unit of measurement, used for medication dosage and/or amount) per 24 hours, to include all acetaminophen (APAP) products, give 2 tablets = 1000 mg, QD (daily). LVN 3 stated Resident 32 complained of mild pain, so she (LVN 3) administered two tablets of acetaminophen 325 mg. LVN 3 stated the order for acetaminophen 500 mg did not clearly indicate a frequency which could increase the risk for acetaminophen overdose. LVN 3 stated the order indicated 2 tabs = 1000 mg, QD at the end of the order, but it was not clear if it was QD (daily) as needed or QD scheduled and first part of the order did not indicate a frequency for as needed dosing.During a review of Resident 32's MAR, dated 3/1/2026 to 3/23/2026, the MAR indicated two tablets each of separate orders of acetaminophen 325 mg and 500 mg which were documented as administered to Resident 32 on the following dates and times:1a. Acetaminophen 500 mg, 2 tablets by mouth as needed for moderate to severe pain 4-10, administered on 3/12/2026 at 5:12 p.m.1b. Acetaminophen 325 mg, 2 tablets by mouth every 6 hours as needed for mild pain 1-3, administered on 3/12/2026 at 8:30 p.m.2a. Acetaminophen 500 mg, 2 tablets by mouth as needed for moderate to severe pain 4-10, administered on 3/13/2026 at 3:08 p.m.2b. Acetaminophen 325 mg, 2 tablets by mouth every 6 hours as needed for mild pain 1-3, administered on 3/13/2026 at 8:30 p.m.3a. Acetaminophen 325 mg, 2 tablets by mouth every 6 hours as needed for mild pain 1-3, administered on 3/23/2026 at 12:24 p.m. 3b. Acetaminophen 500 mg, 2 tablets by mouth every 24 hours as needed for moderate to severe pain 4-10, administered on 3/23/2026 at 4:39 p.m.During an interview on 3/24/2026 at 1:44 p.m. with the DON, the DON stated she (DON) corrected the order for Resident 32's acetaminophen 500 mg on 3/23/2026 so that it indicated instructions with frequency of every 24 hours as needed. DON stated she saw Resident 32's medical diagnoses and medical history of fatty liver disease and alcohol dependance. DON stated Resident 32 would be at risk for liver toxicity if acetaminophen was not administered appropriately.During a review of the facility's policy and procedure (P&P) titled, Medication Orders, dated 2001, the P&P indicated, The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. The P&P indicated, 1. Medication Orders - When recording orders for medication, specify the type, route, dosage, frequency and strength of the medication ordered. A placebo. orders. The P&P indicated, PRN (as needed) Medication Orders - When recording PRN medication orders, specify the type, route, dosage, frequency, strength and the reason for administration. Example: Tylenol 500 mg by mouth 4 hours as needed for mild pain or temp greater than 101-degree Fahrenheit [( F) is a unit of temperature].During a review of the facility's P&P titled Administering Medications, dated 2001, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed. The P&P indicated, Medications are administered in accordance with prescriber orders, including any required time frame.

Based on observation, interview, and record review, the facility failed to ensure proper labeling of medications in one of two inspected medication carts (Station 2 Medication Cart 2) according to manufacturer's specifications and ensure clean medication storage in one of one inspected medication room (Station 1 Medication Room) by failing to: 1. Ensure Resident 52's Lantus Solostar ([generic name - insulin glargine] a type of insulin [a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) pen in Station 2 Medication Cart 2 was labeled with an open date in accordance with manufacturer's specifications.2. Ensure Resident 42's Lantus Solostar pen was labeled with an open date and expired Humalog Kwikpen ([generic name - insulin lispro] a type of insulin [a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) labeled with an open date of [DATE] was removed from Station 2 Medication Cart 2 in accordance with manufacturer's specifications. 3. Remove three contaminated vitamin C liquid bottles from medication storage in Station 1 Medication Room.These deficient practices placed Residents 42, 52 and other facility residents at risk of receiving medications that had become expired, ineffective or toxic due to improper labeling and/or storage and had the potential to cause adverse health effects such as hypoglycemia (low blood glucose level), hyperglycemia (high blood glucose level) and hospitalization.Findings:1. During a review of Resident 52's admission Record (a document containing demographic and diagnostic information), dated [DATE], the admission record indicated the facility admitted Resident 52 on [DATE] with diagnosis that included but not limited to cerebral infarction (a type of ischemic stroke caused by a blockage in brain blood vessels, resulting in a lack of oxygen and brain cell death) due to unspecified occlusion (blockage of blood vessels) or stenosis of unspecified cerebral artery (narrowing of artery inside the brain).During a review of Resident 52's History and Physical (H&P) dated [DATE], the H&P indicated Resident 52 could make medical decisions. The H&P indicated Resident 52 had diagnosis of Type 2 Diabetes Mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing).During a concurrent inspection and interview on [DATE] at 3:17 p.m. with Licensed Vocational Nurse (LVN) 1 of Station 2 Medication Cart 2, the following medication was not labeled with an open date as required by manufacturer's specifications:a. One Lantus Solostar 100 units (a unit of measurement for dose) per milliliters ([mL] a unit of measurement for volume) prefilled pen for Resident 52 with no open date.According to the manufacturer's product labeling, unopened / not in-use Lantus Solostar pen if stored at room temperature below 86-degree Fahrenheit [( F) is a unit of temperature]) [30-degree Celsius [( C) is a unit of temperature]) and opened / in-use Lantus Solostar pen must be used within 28 days. During a review of Resident 52's Order Summary Report (a document containing a summary of all active physician orders), dated [DATE], the order summary report indicated but not limited to the following physician orders: Lantus Solostar 100 units/mL solution pen-injector, inject 16 units subcutaneously (under the skin) one time a day for DM 2, order date [DATE], start date [DATE].2. During a review of Resident 42's admission Record, dated [DATE], the admission record indicated the facility admitted Resident 42 on [DATE] with diagnosis that included but not limited to Type 2 Diabetes Mellitus with hyperglycemia.During a review of Resident 42's H&P, dated [DATE], the H&P indicated Resident 42 could make own medical decisions.During a concurrent inspection and interview on [DATE] at 3:17 p.m. with LVN 1 of Station 2 Medication Cart 2, the following medications for Resident 42 were not labeled with an open date and/or not removed from storage after being expired, as required by manufacturer's specifications:a. One Lantus Solostar 100 units/mL prefilled pen for Resident 42 with no open date.According to the manufacturer's product labeling, unopened / not in-use Lantus Solostar pen if stored at room temperature below 86 F (30 C) and opened / in-use Lantus Solostar pen must be used within 28 days. b. One Humalog Kwikpen prefilled pen for Resident 42 with an open date of [DATE]. The Humalog Kwikpen expired on [DATE].According to the manufacturer's product labeling, once opened / in-use or once stored at room temperature, below 86 F (30 C), insulin lispro pen must be used within 28 days or be discarded. LVN 1 stated the expired insulin for Resident 42 should have been removed from medication cart. LVN 1 stated the insulins for Resident 42 and 52 should have had an open date to determine their (insulin's) expiration date. LVN 1 stated if the residents received an expired medication or insulin, the residents could become sick and if the insulin did not work properly, the residents could become hypo or hyper glycemic.During a review of Resident 42's Order Summary Report, dated [DATE], the order summary report indicated but not limited to the following physician orders:a. Humalog KwikPen 100 units/mL solution pen-injector, inject as per sliding scale: If 70-149 = 0, if blood sugar below 70 and able to swallow give 8 ounce ([oz] a unit of measurement for volume) of orange juice, follow hypoglycemia protocol; 150-199 = 1; 200-249 = 2; 250-299 = 3; 300-349 = 5; 350-399 = 6 if blood sugar >399 milligrams ([mg] metric unit of measurement, used for medication dosage and/or amount) per deciliter ([dL] a unit of measurement for volume) = 7 units and call Medical Doctor (MD), subcutaneously before meals and at bedtime for DM, order date [DATE], start date [DATE].b. Lantus SoloStar 100 units/mL solution pen-injector, inject 10 units subcutaneously one time a day for DM, administer after dinner, hold if blood sugar (BS) <100, order date [DATE], start date [DATE].During an interview on [DATE] at 1:57 p.m. with the Director of Nursing (DON), the DON stated facility nurses should have stored the insulin in the refrigerator when they (insulins) were not open or not in use, and once they (insulins) were opened and/or removed from the refrigerator, the facility nurses should have labeled them with an open date. The DON stated if an insulin did not have an open date and was not stored in refrigerator, then there was a risk that the insulin could have passed its beyond-use date and the facility nurses would not be able track its (insulin's) expiration date. DON stated there would be a risk that insulin could be administered beyond expiration date and pose a risk of not managing blood sugar well and could potentially place residents at risk for hyperglycemia or hypoglycemia.3. During a concurrent inspection and interview on [DATE] at 3:58 p.m. with the Assistant Director of Nursing (ADON) of Station 1 Medication Room, there were three bottles of vitamin C that were leaking, looked contaminated and/or deteriorated with brown colored spillage on and around the bottles on medicine cabinet's shelf. a. Three bottles of vitamin C labeled with sealed clear plastic around their lids.The ADON stated although the vitamin C bottles were not expired, they (vitamin C bottles) did not look good to be administered.During an interview on [DATE] at 1:57 p.m. with the DON, the DON stated the vitamin C bottles looked dirty and they could have been contaminated. The DON stated there was a risk of contamination and would not be safe to administer to facility's residents. The DON stated it was important to replace them (vitamin C bottles) with clean stock and the shelf area needed to be cleaned so that the other medications would not be contaminated.During a review of facility's policy and procedure (P&P) titled, Medication Labeling and Storage, dated 2001, the P&P indicated, The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. The P&P indicated, The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. If the facility has discontinued, outdated or deteriorated medications or biologicals.returning or destroying these items. The P&P indicated, Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. The P&P indicated, Labeling of medications and biologicals. consistent with applicable federal and state requirements and currently accepted pharmaceutical practices.

Based on observation, interview, and record review, the facility failed to replace partial dentures and follow through with a dental visit as requested by the resident and Responsible Party (RP) for one of seven sampled residents (Resident 19).This failure had the potential to result in Resident 19 having discomfort and pain while chewing foods that could lead to unintended weight loss and lower self-esteem.Findings:During a review of Resident 19's admission record, the admission record indicated Resident 19 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (the blood supply to part of the brain is blocked or reduced), dementia (a progressive state of decline in mental abilities), and dysphagia (difficulty swallowing).During a review of Resident 19's History and Physical (H&P), dated 11/11/2025, the H&P indicated, Resident 19 had no capacity (ability) to understand and make decisions.During a review of Resident 19's MDS, dated [DATE], the MDS indicated Resident 19 required maximal assistance (Helper does more than half the effort) from one staff for toileting hygiene, shower, dressing, personal hygiene, transfer, moderate assistance (Helper does less than half the effort) from one staff for bed mobility, and supervision or touching assistance (Helper provide verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) from one staff for oral hygiene and eating.During a concurrent observation and interview on 3/23/2026, at 10:59 a.m., with Resident 19 in his room, Resident 19 was watching television in bed and missing upper front teeth were observed during the interview. Resident 19 stated, he lost his partial denture while he was in a General Acute Care Hospital (GACH) prior to admission to this facility. Resident 19 stated, RP and he told the nursing staff, but no one helped him. Resident 19 stated, it was painful to chew hard food items like chopped chicken or diced unripe melon.During a concurrent interview and record review on 3/25/2026, at 10:27 a.m., with Registered Nurse Supervisor (RNS) 1, Resident 19's Inventory of Personal Items, dated on 11/10/2025 was reviewed. The Inventory of Personal Items indicated, Resident 19 had no personal belongings. RNS 1 stated, she was not aware of Resident 19's missing partial denture during hospitalization and broken upper front teeth. RNS 1 stated, the staff should have notified the Social Service Director (SSD) to get a replacement. RNS 1 stated, if the resident did not have proper fitted dentures or broken teeth, the resident might have discomfort or pain that could lead to unintended weight loss.During a concurrent interview and record review on 3/25/2026, at 1:04 p.m., with the SSD, Resident 19's Dental Progress Note (DPN), dated 1/9/2026 was reviewed. The DPN indicated, Resident 19 had broken teeth, but Resident 19 refused to extract (remove or pull out) the broken teeth. The SSD stated, she did not know that Resident 19 lost his partial upper front denture prior to admission. The SSD stated, she should have followed through with Resident 19 regarding the reason for refusal after last dental visit on 1/9/2026. The SSD stated, having proper fitting dentures and treatment of broken teeth were important because this could lead to weight loss due to discomfort and low self-esteem.During an interview on 3/25/2026, at 1:10 p.m., with Resident 19 and RP at the bedside, Resident 19 stated, he misunderstood when the dentist mentioned extractions. Resident 19 stated, he thought he would pull out all his upper teeth and that was why he refused treatment. Resident 19 stated, he just needed to have partial denture, not full denture. Resident 19's RP stated, Resident 19 and she asked the nursing staff regarding denture replacement but no response so far. Resident 19's RP stated, Resident 19 did not want to show his missing teeth and did not smile anymore among other people and complained about dental pain while eating hard food.During an interview on 3/26/2026, at 2:46 p.m., with the Director of Nursing (DON), the DON stated, the SSD should have followed up with the dental office to get a partial denture replacement immediately. The DON stated, the nursing staff should have communicated with the SSD regarding the missing denture and refusal of treatment. The DON stated, providing denture in timely manner was important because it could affect the ability to eat, and it could lead to social isolation.During a review of Resident 19's Speech Therapy (diagnoses and corrects communication, language, cognitive, voice, and swallowing disorders) Treatment Encounter Note, dated 1/12/2026, the Speech Therapy Treatment Encounter Note indicated, Resident 19 demonstrated stable swallow performance with mildly prolonged bolus breakdown due to his dental status and continue with soft and bite-size food diet.During a review of Resident 19's Order Summary Report (OSR), date 3/25/2026, the OSR indicated, provide fortified (foods that have extra nutrients) and no added salt diet with thin liquid and soft/bite sized texture was ordered on 11/14/2025. The OSR indicated, consult with dental for oral hygiene with follow up and treatment as indicated was ordered on 11/10/2025.During a review of Resident 19's Care Plan (CP), dated from 11/10/2025 to 3/25/2026, the CP indicated, there was no CP for dental issues such as broken teeth or missing partial denture.During a review of the facility's Policy and Procedure (P&P) titled, Dental Services, revised 1/2026, the P&P indicated, Policy Statement: Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. Policy Interpretation and Implementation: 1. Routine and 24-hour emergency dental services are provided to our residents through: a contract agreement with a licensed dentist that comes to the facility monthly . 6. Social services representatives will assist residents with appointments . 10. If dentures are damaged or lost, residents will be referred for dental services within 3 days. If the referral is not made within 3 days, documentation will be provided regarding what is being done to ensure that the resident is able to eat and drink adequately while awaiting the dental services; and the reason for the delay.

Based on interview and record review, the facility failed to ensure two of three sampled residents (Resident 46 and 91) understood the Arbitration Agreement ([AA]-a written contract where you agree to settle disputes out of court with a private, neutral person instead of judge or jury) prior to obtaining their signature.This failure had the potential to affect residents' rights, as residents may sign legally binding agreements without fully understating the terms, including the waiver of the right to pursue claims in a court of law.Findings:a. During a review of Resident 46's admission Record, the admission Record indicated the facility admitted Resident 46 on 3/18/2026 with diagnoses including end stage renal disease (permanent state of kidney failure where kidneys work at less than 10% capacity, failing to filter waste and extra fluid from the blood), heart failure (a chronic condition where the heart is too weak or stiff to pump blood efficiently) and arterial fibrillation (an irregular heartbeat).During a review of Resident 46's History and Physical (H&P), dated 3/20/2026, the H&P indicated, Resident 46 had the ability to understand and make decisions.\During a review of Resident 46's Minimum Data Set (MDS- a resident assessment tool), dated 3/25/2026, The MDS indicated Resident 46's cognitive (functions your brain uses to think, pay attention, process information, and remember things) was moderately impaired.During a review of Resident 46's Arbitration Agreement dated 3/18/2026, the AA indicated Resident 46 signed the agreement.During an interview on 3/25/2026 at 11:54 a.m. with Resident 46, Resident 46 stated he did not know what arbitration was. b. During a review of Resident 91's admission Record, the admission Record indicated the facility admitted Resident 91 on 12/4/2025, and readmitted on [DATE] with normal pressure hydrocephalus (a brain condition where a special fluid builds up inside the brain), respiratory disorders (medical conditions that affect the lungs and airways) and immunodeficiency (a condition where the body's immune system is weakened). During a review of Resident 91's H&P dated 12/5/2025, the H&P indicated whether Resident 91 had the ability to understand and make decisions. During a review of Resident 91's MDS dated [DATE], The MDS indicated Resident 91's cognitive was moderately impaired.During a review of Resident 91's Arbitration Agreement dated 12/7/2025, the AA indicated Resident 91 signed the agreement.During an interview on 3/25/2026 at 11:52 a.m. with Resident 91, Resident 91 stated, the resident did not know what arbitration was. During a concurrent interview and record review on 3/25/2026 at 12:15 p.m. with the admission Coordinator (AC), Resident 46's AA, dated 3/18/2026 and 91's AA, dated 12/7/2025 were reviewed. The AC stated she asked Resident 46 and 91 if they understood the arbitration agreement, upon their response to yes, proceeded with signing without verifying their understanding. The AC stated arbitration affects residents' rights, including waving the right to go to court. During an interview on 3/26/2026 at 2:23 p.m. with the Director of Nursing (DON), the DON stated arbitration is a way to resolve disputes outside of court and singing the agreement gives up the right to proceed in court. The DON stated it is important to ensure the residents or family understand what arbitration means and what the agreement involves before signing, and staff should verify understanding more thoroughly than by asking yes-or no questions. During a review of the facility's Policy & Procedure (P&P) titled Binding Arbitration Agreements, dated November 2023, the P&P indicated after the terms and conditions of the agreement are explained, the resident or representative must acknowledge that he or she understands the agreement before being asked to sign the document:a. A signature alone is not sufficient acknowledgement of understanding.b. The resident (or representative) must verbally acknowledge understanding, and the verbal acknowledgement documented by the staff member who explains the agreement.

Based on interview and record review, the facility failed to implement its abuse reporting and prevention policy and procedure (P&P) by failing to report unusual occurrences to officials which included the Long-Term Care Ombudsman, Law Enforcement, and the California Department of Public Health (CDPH) for one of five sampled residents (Resident 1), when Resident 1 sustained a displaced (bone snaps into two or more pieces and shifts out of alignment) fracture (break) through the left humeral neck (upper portion of the left arm bone just below the shoulder ball) injury of unknown origin.This failure had potential to result in a delay in an onsite inspection by the CDPH to ensure injuries from unknown origins were investigated and lead to a delay in preventing potential unknown injuries.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including polyosteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage [firm, flexible tissue]), dementia (a progressive state of decline in mental abilities), and muscle weakness. During a review of Resident 1's history and physical (H&P) dated 8/29/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 1/28/2026, the MDS indicated Resident 1 had moderate cognitive (judgement, planning, organization to manage average demands in one's environment) impairment. The MDS indicated Resident 1 was dependent on facility staff for all aspects of activities of daily living (ADL: basic activities such as eating, dressing, toileting), roll left and right and had impairments on both sides of the upper (shoulders/arms) and lower (hips/knees) extremities. During a review of Resident 1's change in condition (COC), dated 2/1/2026 at 11:17 p.m., the COC indicated Resident 1 had swelling of the left arm and had ecchymosis (discoloration of the skin resulting from bleeding underneath caused by bruising). During a review of Resident 1's X-Ray (a medical test that enables providers to get pictures of the inside of the body) Report, dated 2/2/2026, the X-Ray report indicated Resident 1 had a displaced fracture at surgical neck of humerus (left). During a review of Resident 1's COC, dated 2/3/2026 at 1:13 p.m., the COC indicated Resident 1 was transferred to a general acute care hospital (GACH) for treatment of Resident 1's left humerus fracture. During an interview on 2/23/2026 at 4:02 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Certified Nursing Assistant 2 (CNA 2) informed her about Resident 1's left arm discoloration. LVN 1 stated Resident 1's arm was discolored in the upper and lower part of the left arm. LVN 1 stated when there was a COC, she should have but did not notify her Director of Nursing (DON). During a concurrent interview and record review on 2/24/2026 at 10:52 a.m., with the DON, the facility's P&P titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated 2001 was reviewed. The DON stated an unusual occurrence included suspected abuse, such as an injury of unknown origin, and the facility's protocol for unusual occurrences was for LVN 1 to report to the DON, the Administrator (ADMN), notify CDPH, the ombudsman (resident advocate) and if needed, law enforcement, and Adult Protective Services (APS: state-mandated program that investigates reports of abuse for ages 60 and above. The DON stated a serious injury such as accidents and fractures are unusual occurrences that must be reported to the appropriate officials and CDPH within two hours. The DON stated if a case of suspected abuse is not reported, the resident may not feel safe. The DON stated when LVN 1 found out about Resident 1's fracture on 2/3/2026, she should have informed her (DON) about it. The DON stated upon reviewing the Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy, which indicated all abuse including injuries of unknown origin now knows that this incident was reportable. During an interview on 2/24/2026 at 12:34 p.m., with the ADMN, the ADMN stated an unusual occurrence is an occurrence that cannot be explained, defined, or identify the root cause. The ADMIN stated for an unusual occurrence, and abuse allegations the facility would report the incident, notify the ombudsman, police, and CDPH within two hours of the initial incident, and follow up within 5 days with an investigation of the incident. The ADMN stated they do not know how Resident 1's left arm got broken. The ADMN stated this incident is an injury of an unknown origin and would have been reportable and indicated it would be reported since it is of an unknown origin. The ADMN stated should have investigated this incident to help them determine whether it was abuse or not. The ADMN stated if no one reported it, it could open the residents up to further harm and injury. During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated 2001, the P&P indicated all reports of resident abuse (including injuries of unknown origin), neglect.are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. If resident abuse or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The administrator of the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: The state licensing/certification agency responsible for surveying/licensing the facility. Immediately is defined as a. within two hours of an allegation involving abuse or result in serous bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Within five (5) business days of the incident, the administrator will provide a follow-up investigation report. During a review of the facility's P&P titled, Unusual Occurrence Reporting, dated 2001, the P&P indicated as required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees or visitors. Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations. A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency (and other appropriate agencies as required by law) within forty-weight (48) hours of reporting the event or as required by federal and state regulations.

Based on interview and record review, the facility failed to ensure the Licensed Vocational Nurse (LVN 1) notified the facility's Medical Director (MD) of the resident's abnormal blood test of [NAME] Blood Count ([WBC] part of the immune system that protects the body from infection, normal range 4,000 - 11,000 cells per microliter [cells/ul] a unit of measurement), laboratory blood test results, in accordance with their policy and procedure (P/P), titled Lab and Diagnostic Test Results- Clinical Protocol, and Emergency and/or Alternative Physician Care, that stipulated, if the attending or covering physician does not respond to immediate notification within an hour, the nursing staff should contact the MD, when the resident's physician did not respond to LVN 1's notification of abnormal laboratory test result, for one of three sampled residents (Resident 1). This deficient practice resulted in a delay of Resident 1's evaluation and treatment, and an increase of Resident 1's WBCs from 15.90 cells/ul on 11/5/2021 to 20.51 cells/ul on 11/11/2021. Resident 1 was subsequently transferred to a General Acute Care Hospital (GACH 1) on 11/12/2021 with an elevated WBC of 45.0 cells/ul, hematuria (blood in the urine), and was diagnosed with severe sepsis (a life-threatening complication of an infection that can lead to the malfunctioning of various organs, shock, and death) and septic shock (a condition sometimes occurring in severe sepsis, in which the blood pressure fails and the organs of the body fail to receive sufficient oxygen), acute cystitis (inflammation of the urinary bladder) with hematuria, and acute renal (kidney) failure. On 12/13/2021 Resident 1 was transferred from GACH 1 to GACH 2 where he was evaluated and treated for acute Klebsiella (a bacteria that causes respiratory, urinary, and wound infections) urinary tract infection [(UTI) occurs when the bacteria enter the urinary tract, there is a higher chance of this infection when there is an indwelling catheter in place [a tube place in your body to drain and collect urine from the bladder], hematuria and cystitis, urinary retention, acute kidney injury with Stage III chronic kidney disease ([CKD] when the kidneys have mild to moderate damage, and are less able to filter waste and fluid out of the blood), leukocytosis (elevated WBCs), and sepsis. Findings: A review of Resident 1's Admission Records (Face Sheet) indicated Resident 1 was admitted to the facility on [DATE], with diagnosis including malignant neoplasm of the brain (a fast growing cancer that spreads to other areas of the brain and spine), chronic kidney disease ([CKD] when kidneys do not function as they should to filter waste from the blood), type two diabetes mellitus ([DM] a chronic (long term) condition affecting the way the body processes blood sugar), and essential primary hypertension ([HTN] high blood pressure that is not due to another medical condition). A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 11/10/2021, indicated Resident 1's cognitive skills for daily decision-making were severely impaired. The MDS indicated Resident 1 had an indwelling urinary catheter (a tube which is inserted into the bladder to drain urine) in place. A review of Resident 1's Physician Order Report (POR) dated 11/5/2021 indicated an order for a Complete Blood Count ([CBC] a set of medical laboratory test that provides information about the cells in a person's blood). A review of Resident 1's Laboratory Report (LR) dated 11/5/2021, and timed at 1:54 p.m., indicated Resident 1's WBC were 15.90 cells/ul. The LR indicated there was a written notation that the laboratory test results were reported to Resident 1's physician's office on 11/5/2021 at 3:30 p.m., and the writer (an unknown person) was waiting for Resident 1's physician's response. The LR indicated Resident 1's LR were sent to the physician again on 11/6/2021 at 12 p.m. A review of Resident 1's Progress Notes (PN) dated 11/6/2021, and timed at 11:59 a.m., indicated Resident 1's physician was notified of Resident 1's CBC test results. The LNPNs indicated there was no documentation indicating Resident 1's physician responded to the notification. A review of Resident 1's physician's Nurse Practitioner's (NP) notes, dated 11/8/2021 and timed at 6:22 p.m., indicated, under the Data Review section, there were no new laboratory tests results. However, per the POR and LR both dated 11/5/2021, a laboratory test for a CBC was ordered, and results were received on 11/5/2021. A review of Resident 1's POR, dated 11/10/2021 (five days after initial out of range test results were received on 11/5/2021 and the physician never responded) indicated an order for a STAT (immediate) urinalysis ([UA] a urine test) used to detect UTIs kidney disease and diabetes) with a culture and sensitivity ([C&S] a test to check for bacteria in a urine sample), a CBC with differential (measures the number of each type of white blood cells) and a Comprehensive Metabolic Panel ([CMP] a blood test that gives doctors information about the body's fluid balance). The POR indicated there was no documentation indicating Resident 1's physician made an order for Resident 1's treatment due to the abnormal WBC test results received on 11/5/2021 and there was no indication that Resident 1's physician received and responded to the abnormal WBC results received on 11/5/2021. A review of Resident 1's LR dated 11/11/2021 and timed at 2:26 p.m., indicated Resident 1's WBCs increased from 15.90 cells/ul on 11/5/2021 to 20.51 cells/ul on11/11/2021. A review of Resident 1's PNs dated 11/11/2021 and timed at 12:51 a.m., indicated after receiving Resident 1's LR on 11/11/2021, Resident 1's physician ordered intravenous ([IV] into the vein) antibiotics for seven days. A review of Resident 1's POR dated 11/11/2021 indicated a physician's order for Ceftriaxone 1.0 gram [(gm) a unit of weight measurement] via IV once a day at 9 a.m. Resident 1 was transferred to GACH 1 on the same day as IV antibiotic was to be started (11/12/2021). A review of Resident 1's PNs dated 11/12/2021 and timed at 5:54 a.m., indicated Resident 1 was found with moderate to severe bleeding from the urethra/penial area, with vital signs ([v/s] measurement of the body's most basic functions) including blood pressure ([BP]) 89/74 millimeters of mercury ([mmHg] a unit of measurement. The reference range is 90/60 - 120/80 mmHg), heart rate (HR) 115 beats per minute ([bpm]- reference range is 60-100 bpm), and a blood sugar (b/s) of 142 milligrams per deciliter ([mg/dl] a unit of measurement. The reference range is of 80-100.) A review of Resident 1's Physician's Order (PO), dated 11/12/2021 and timed at 6:30 a.m., indicated to transfer Resident 1 to GACH 1 for further evaluation. A review of GACH 1's Admission Record, indicated Resident 1 was admitted to GACH 1 on 11/12/2021. A review of GACH 1's LR dated 11/12/2021, indicated Resident 1's WBCs (blood test) were 45.0 cells/ul. The GACH 1's LRs indicated Resident 1's UA result, dated 11/12/2021, was as follows: 1. Protein +1 (reference range is negative). 2. Blood + 3 (reference range is negative). 3. Leukocytes 250 (reference range is negative). 4. Urine color red (reference range is straw yellow. 5. WBCs 10-15 hpf ([high power field] to indicate infections, inflammation, or contamination, reference range is 0-5 hpf). 6. Bacteria 5-10 hpf (reference range is zero, 10 or higher is highly suggestive of a UTI in symptomatic patients). A review of GACH 1's Preliminary Emergency Department Report dated 11/12/2021 indicated Resident 1 had severe sepsis with septic shock and acute cystitis with hematuria, and acute renal failure. A review of GACH 1's Transfer Form, dated 11/12/2021 indicated Resident 1 was transferred to GACH 2, a higher level of care. A review of GACH 2's History and Physical/Admission Notes indicated Resident 1 was admitted to GACH 2 on 11/13/2021. A review of the History of Present Illness (HPI) indicated upon arrival, Resident 1 continued to have persistent hematuria and was seen by a urologist (a doctor who specializes in the study or treatment of the function and disorders of the urinary system) who inserted an indwelling urinary catheter and irrigated (the process of washing out an organ or wound with a continuous flow of water or medication) Resident 1's bladder, which resulted in fresh hematuria. Resident 1 was weaned (stop) off pressors (medications that raise the blood pressure), but Resident 1's BP dropped again. A review of GACH 2's Discharge Summary, dated 12/10/2021 (28 days after admission), indicated Resident 1 was treated for acute Klebsiella UTI orthostatic hypotension, altered mental status with acute agitation/delirium, hematuria and cystitis, urinary retention likely due to BPH, acute blood loss anemia with iron deficiency, acute kidney injury with Stage III CKD, leukocytosis (increase in WBCs) due to steroid (man-made hormones) use and UTI, elevated INR ([International Normalized Ratio] tells how long it takes for the blood to clot) due to sepsis and hematuria. During an interview on 6/20/2023, at 2:40 p.m., LVN 1 stated she did not recall if she notified Resident 1's physician of Resident 1's LR dated 11/5/2021. LVN 1 stated if a physician does not respond within 30 minutes, staff are instructed to contact a resident's physician and/or on-call physician. If neither one of the physicians respond, the staff are instructed to contact the MD so there is no delay in care and treatment. LVN 1 stated when WBCs are high, it can indicate an infection is present and if a resident is not treated timely the infection can lead to sepsis. During an interview with the Assistant Director of Nursing (ADON) on 6/20/2023 at 3:25 p.m., the ADON reviewed Resident 1's LRs dated 11/5/2021 and 11/11/2021 and stated when the physician does not respond within 30 minutes the MD should be called to expedite any order needed to treat the resident. The ADON stated it is important to notify the physician right away so there is no delay in care and treatment that could possibly lead to sepsis and a resident's death. A review of the facility's policy and procedure (P&P), titled, Lab and Diagnostic Test Results- Clinical Protocol, revised 9/2012, the P&P indicated a physician should respond within one hour regarding a laboratory test result requiring immediate notification. If the attending or covering physician does not respond to immediate notification within an hour, the nursing staff should contact the Medical Director for assistance. A review of the facility's P&P, titled Emergency and/or Alternative Physician Care, revised 4/2013, indicated all resident shall be provided with emergency and/or alternative physician care. If a physician and his/her backup coverage do not respond in a timely or appropriate manner to staff's notification of medical issues, the nursing staff will contact the medical director for assistance.

Based on interview and record review, the facility failed to ensure one of six sampled residents (Resident 1), received routine hemodialysis (HD, a treatment to filter wastes, water, and balance essential minerals such as potassium, sodium, and calcium in the blood) three times a week (TTS or Tuesdays, Thursdays, and Saturdays) as ordered by the primary medical doctor (PMD). Resident 1 last received HD from a general acute care hospital (GACH) on [DATE]. The facility failed to: 1. Conduct an Interdisciplinary Team (IDT, (a group of health professionals with various expertise) meeting after Resident 1 refused HD on Saturday, [DATE] per the facility ' s policy and procedure. 2. Notify the dialysis (a treatment process for people whose kidneys are failing) center (DC) that Resident 1 refused HD treatment on [DATE]. 3. Implement the physician ' s order for Resident 1 to receive HD care, treatment, and services on Tuesday, [DATE] from an off-site dialysis center. 4. Notify Resident 1 ' s PMD of the missed HD treatment and services on [DATE]. 5. Implement Resident 1 ' s care plan to receive HD services on [DATE]. 6. Ensure Licensed Vocational Nurse (LVN) 1, the night shift nurse (worked from 11 p.m. to 7 a.m.), notified LVN 2, the day shift nurse (worked from 7 a.m. to 3 p.m.), that Resident 1 missed dialysis on [DATE]. 7. Ensure Resident 1 had pre (before) and post (after) dialysis communication form on [DATE]. These failures resulted in Resident 1 ' s change of condition (COC) and death on [DATE] after not receiving six days of HD (from [DATE] to [DATE]). On [DATE] at 5 p.m., while onsite at the facility, the Administrator (ADM), and Director of Nursing (DON) were verbally notified of an Immediate Jeopardy (IJ, a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) situation regarding HD services. Resident 1 had missed 6 days of hemodialysis (from [DATE] to [DATE]). On [DATE] at 4:58 p.m., the IJ was removed in the presence of the ADM and DON after the facility submitted an acceptable IJ Removal Plan (a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation) and the surveyor verified and confirmed onsite the facility ' s implementation of the IJ Removal Plan. The IJ Removal Plan included: 1. The DON and Assistant DON (ADON) reviewed all 6 dialysis residents ' (Resident 5, 6,7,8,9, and 10)) last 30 days of progress notes, change of conditions (COC), and medication administration records (MAR) for refusals/missed dialysis appointments. 2. The IDT met with Resident 5 and discussed refusal of HD on [DATE], explored possible root cause, provided alternate measures, education, explained risk and benefits. 3. The IDT met with Resident 6, who manages her own appointments and transportation, and discussed missing HD on [DATE] and [DATE], explored possible root cause, provided alternate measures, education, explained risk and benefits. 4. The ADM and DON conducted an in-service to licensed nurses regarding: notifying dialysis center if resident was refusing dialysis appointments, shift-to-shift reporting and start of shift huddles on dialysis refusal, implement care plan interventions related to residents who refuses dialysis, monitor for any changes of condition, utilizing dialysis schedule posting for reference, utilizing appointment book for any scheduling changes, initiating COC, and updating the care plan reflecting interventions of any non-compliance. 5. Registered Nurse (RN) assessments were completed for the remaining 6 HD residents. 6. Reviewed all 6 dialysis residents ' Pre and Post Dialysis Communication forms for the last 30 days. Findings: During a review of Resident 1 ' s Admission Record, dated [DATE], the Admission Record indicated, Resident 1 was initially admitted to the facility on [DATE], and was readmitted on [DATE] with diagnoses including cardiomyopathy (heart failure, when the heart is unable to pump enough blood throughout the body), end stage renal disease (ESRD, when the kidneys are unable to eliminate wastes and excess fluids in the blood), diabetes (abnormal blood sugar) and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). The Admission Record indicated, Resident 1 was discharged to a mortician (a person who prepares the dead for a funeral) on [DATE]. A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated [DATE], indicated the resident ' s cognition (ability to think and understand) was severely impaired. During a review of Resident 1 ' s general acute care hospital (GACH) records, dated [DATE], the GACH records indicated, nephrology (a branch of medicine concerned with the kidneys) made arrangements for HD per the resident ' s TTS routine schedule prior to re-admission to the skilled nursing facility (SNF). During a review of Resident 1 ' s Care Plans (CP) titled Dialysis, dated [DATE], indicated Resident 1 needed hemodialysis related to ESRD. The CP interventions indicated, encourage resident to go for the scheduled dialysis appointments on Tuesday, Thursday, and Saturday. During a review of the facility ' s electronic document titled eINTERACT SBAR (situation, background, assessment, recommendation) SUMMARY for Providers, dated [DATE] at 6:26 a.m., the electronic document indicated pt (patient) refused dialysis 3 times. During a review of Resident 1 ' s Care Plans (CP) titled, The resident is resistive to care related to refusing dialysis three times, dated [DATE], the CP interventions indicated, monitor resident for change in condition and provide resident with opportunities for choice during care provision. During a review of Resident 1 ' s Medical Practitioner Narrative Note (MPNN), dated [DATE] at 1:26 p.m., the MPNN indicated, Resident 1 ' s PMD recommended to continue HD for Resident 1 ' s due to ESRD and heart failure diagnoses. During a review of Resident 1 ' s nurses notes, dated [DATE] at 8:44 p.m., the nurses note indicated, Resident 1 refused some activities of daily living (ADL, daily self-care activities such as eating, bathing, and moving), meals and medications. During a review of Resident 1 ' s Change of Condition (COC), dated [DATE] at 8:02 a.m., the COC indicated, Resident 1 refused ADLs, all meals, vital signs (reflects the essential body functions, including the resident's heartbeat, breathing rate, temperature, and blood pressure [measure of the force that the heart uses to pump blood around the body]), and was yelling at staff. Resident 1 ' s primary doctor recommended a psychiatric evaluation (used to determine a patient's mental state and guide recommendations for the best treatment). During a review of Resident 1 ' s Nurse ' s Alert Note ([NAME]), dated [DATE] at 9:04 a.m., the Nurse ' s Alert Note indicated, Resident 1 refused all care and dialysis. The [NAME] indicated, Resident 1 ' s PMD was aware and recommended to be sent out to GACH. The [NAME] indicated, an ambulance was set up for transportation at 9:02 a.m. During a review of Resident 1 ' s nurses note, dated [DATE] at 10:50 a.m., the nurses note indicated, Code Blue [when a patient requires immediate medical attention, most often as the result of not breathing or heart stopped beating] was called at 9:46 a.m. while a regular Basic Life Support (BLS, non-critical, unable to inject medications) ambulance personnel were at bedside and cardiopulmonary resuscitation (CPR, an emergency lifesaving procedure) was initiated at 9:48 a.m. Between 9:57 a.m. to 10:37 a.m., the Fire Department and Paramedics (a more highly trained emergency medical technician capable of more advanced medical procedures) took over the rescue efforts while a doctor from a GACH was on the phone providing orders and instructions. At 10:38 a.m., lifesaving procedures were halted and Resident 1 was pronounced dead. During a concurrent interview and record review of the nursing notes on [DATE] at 1:20 p.m., with the MDS nurse, the MDS nurse stated, Resident 1 returned to the facility from a general acute care hospital (GACH) on [DATE] at 8:30 p.m. The MDS nurse stated, LVN 1 (nurse who admitted the resident to the facility) had no documentation on the nursing notes of Resident 1 receiving dialysis while outside the facility. The MDS nurse stated, Resident 1 ' s PMD wrote a note on [DATE] at 1:26 p.m. indicating the resident was seen by the PMD. During a concurrent interview and record review on [DATE], at 1:20 p.m., with the MDS nurse, Resident 1 ' s Change of Condition (COC), dated [DATE], was reviewed. The COC indicated, Resident 1 was assessed to have behavioral issues when the resident refused to go to HD and yelled at Certified Nurse Assistant. The COC indicated the Registered Nurse spoke to the resident, but the resident continued to refuse HD. The COC indicated the primary doctor ' s recommendations were to continue to monitor and do a COC. During a concurrent interview and record review of Resident 1 ' s clinical record (IDT notes) on [DATE], at 10:04 a.m., with MDS nurse, MDS nurse stated Resident 1 ' s refusal to treatments of medication and HD should have been brought up in the daily stand-up meetings and the IDT but there was no IDT about his refusals. During an interview on [DATE], at 11:36 a.m., with LVN 2, LVN 2 stated, on [DATE] during the morning shift (7 a.m. to 3 p.m.), Resident 1 was asked if the resident had gone for HD during the night shift (the resident ' s HD appointment starts at 4:45 a.m.). LVN 2 stated, the resident stated he had gone to HD. LVN 2 stated she did not check Resident 1 ' s pre and post dialysis communication forms to verify whether the resident had gone to HD. LVN 2 stated, If a resident comes back from dialysis, there is a post dialysis assessment, the doctor is contacted if there are critical (very low or high) laboratory (blood test) levels. LVN 2 stated, because Resident 1 was still refusing care on [DATE], LVN 2 called the HD center to verify if Resident 1 received HD (on [DATE]). LVN 2 stated, she was notified by the HD center that Resident 1 did not go to dialysis on [DATE]. LVN 2 stated she initiated a COC and notified the doctor (on [DATE]); however, she did not report (to the doctor) that the resident had missed HD on [DATE]. During an interview on [DATE], at 12:20 p.m., with the DON, the DON stated, when a resident refuses dialysis, the nurse ' s responsibility was to let the following nurse (next shift) and dialysis center know about the refusal and do a COC. The DON stated, the facility had an appointment book but was not sure if HD schedules were included. During an interview on [DATE], at 1:16 p.m., with Resident 1 ' s PMD, the PMD stated, she does not recall if the facility notified her about Resident 1 refusing HD on [DATE]. The PMD stated, she was aware Resident 1 refused medications, care, and HD previously. The PMD stated, if a resident missed HD and the doctor was not notified, the possible outcomes were arrhythmia (irregular heartbeat), heart failure, and death. The PMD stated, there were no alternatives to dialysis except temporary medications and stabilizing the laboratory (blood test) levels. The PMD stated, she did not think about ordering laboratory tests because those were usually done at the dialysis center. The PMD stated, she referred Resident 1 for psychiatric evaluation to determine his decision-making capacity to refuse but Resident 1 died on that day ([DATE]). During an interview on [DATE], at 3:58 p.m., with Dialysis Clinical Coordinator (DCC), the DCC stated, Resident 1 ' s last HD at their center was on [DATE]. DCC stated, a call was received from a nurse in Resident 1 ' s facility on [DATE] asking if Resident 1 received HD on [DATE]. DCC stated, their center called (on [DATE]) Resident 1 ' s facility asking why Resident 1 has not returned for HD but was notified Resident 1 died on [DATE]. DCC stated, the facility should have called the dialysis center when a resident refuses dialysis to re-schedule another dialysis. During an interview on [DATE], at 4:36 p.m., with Medical Director (MD), MD stated, if a resident refused dialysis, a doctor must assess for mental capacity to refuse. MD stated, if the resident was alert, oriented with decision-making capacity, the doctor will educate medical care and dialysis compliance whether they are in a skilled nursing facility or hospital about the risks and benefits. The MD stated, collect baseline (first)laboratory tests to monitor (resident ' s condition). During a concurrent interview and record review on [DATE] at 5:23 p.m., with Medical Records (MR), Resident 1 ' s Pre (before) and Post (after) Dialysis Communication Forms (PPDC) from re-admitted on [DATE] to discharge date on [DATE] were reviewed. Medical Records stated, there were no PPDC forms initiated or completed indicating if Resident 1 had HD at an off-site dialysis center. During a concurrent interview and record review on [DATE] at 5:23 p.m., with Medical Records (MR), Resident 1 ' s Interdisciplinary Team (IDT) from re-admitted on [DATE] to discharge date on [DATE] were reviewed. Medical Records stated, there were no IDT forms related to refusal of treatments, medications, and HD. During a record review of the facility ' s policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated ,d+[DATE], the P&P indicated the services that are to be furnished in an attempt to assist the resident attain or maintain that level of physical, mental and psychosocial wellbeing that the resident desires or that is possible, including serviced that would otherwise be provided for the above. During a record review of the facility ' s P&P titled End- Stage Renal Disease, Care of a Resident with dated ,d+[DATE], the P&P indicated residents with ESRD will be cared for according to currently recognized standards of care.

Based on observation, interview, and record review, the facility failed to practice infection control measures to prevent scabies (a contagious skin condition caused by tiny insects called mites that infest and irritate skin causing intense itching, inflammation, and red patches) outbreak for five of 87 residents (Resident 1, Resident 2, Resident 3, Resident 4 and Resident 5). The facility failed to: 1. Recognize a possible scabies outbreak 3/12/2023 when Resident 1 was treated for scabies and Resident 2, who was Resident 1's roommate was suspected to have scabies and provide the necessary care and treatment, including but not limited to conduct skin scraping (a diagnostic test to confirm or rule out scabies), Provide treatment for residents that tested positive) both residents. 2. Implement the local department of health (DPH) Healthcare-Associated-Infections Epidemiologist (HAIE - a health care professional that specializes in the recommendations to conduct Resident 1 and Resident 2's skin scraping rule out scabies. Both residents had symptoms of possible scabies and resided in one room on the Sub-Acute unit. 3. Provide prophylactic treatment (treatment to prevent a disease) with Permethrin (Elimite) cream 5% (a medication applied to the entire body to treat scabies) to 87 of 87 residents and staff in the facility within 24 hours per HAIE recommendation on 3/31/2023 and again on 4/3/2023. On 4/3/2023 the number of infected residents had doubled since 3/31/2023 and there were four identified residents exhibiting signs and symptoms of possible scabies (visible rash). On 4/3/2023, 36 hours after HAIE recommendations to apply prophylactic treatment to the residents within 24 hours from 3/31/2023, 20 residents in the Sub-Acute unit were treated. However, the remaining 65 residents in the skilled nursing unit (SNF) had not yet received prophylactic treatment. 4. Monitor the rash status of affected residents and staff (resolved, nor resolved, new rash) for 86 of 86 facility residents, by implementing an infection control surveillance (close observation or monitoring) and completing a line listing (a table that contains key information about each case, such as potential exposure, symptomatic [showing signs of infection], asymptomatic [not showing signs of infection]). 5. Perform deep terminal cleaning (the thorough manual cleaning of all surfaces, floors, soft furnishings, and re- usable equipment, which is required after every resident with treatment for scabies has used the shower room) in two of two shower rooms (Shower room [ROOM NUMBER] and Shower room [ROOM NUMBER]) after use by residents and staff potentially exposed to scabies or with symptoms of scabies. 6. Ensure staff working on the 7:00 a.m. to 3:00 p.m. shift on 4/3/2023 and 4/4/2023 received a prophylactic treatment to prevent further spread of scabies as recommended by HAIE from DPH. These deficient practices placed Resident 1, Resident 2, Resident 3, Resident 4 and Resident 5 and all facility residents, staff, and visitors to the facility, at risk for spread of undiagnosed and untreated scabies. On 4/6/2023 at 6:33 p.m., an Immediate Jeopardy [(IJ) a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident and the situation created a need for immediate corrective action] situation was called in the presence of the Administrator (ADM), Administrator in Training (AIT), Director of Nursing (DON), and two Regional Consulting Nurses 1 (RCN 1) and RCN 2 due to the facility's failure to implement and maintain a scabies infection control program. The facility was notified to provide IJ removal plan (IJRP) with the immediate actions to be taken to prevent further spread of the scabies infection. On 4/8/2023 at 12:12 p.m., the ADM provided an acceptable IJRP. The IJ removal plan included the following: 1. The first two treatments with Permethrin were provided to Resident 1 and Resident 2 on 4/3/2023 due to a lack of availability of medication. The treatment was completed, and both residents were showered 12 hours later 4/4/2023. 2. All Sub-Acute residents, including Residents 3, Resident 4, and Resident 5 were treated with Permethrin (as it became available) on 4/4/2023 and the rest of remaining 81 residents in the facility on 4/5/2023. 3. 12 residents refused treatment on 4/5/2023. Residents that refused treatment were placed on monitoring of skin issues/rashes daily for six weeks. Infection Prevention Nurse (IPN) will ensure compliance Monday to Friday and Registered Nurse (RN) supervisor/charge nurse on Saturday and Sunday. Those residents will be offered treatment again on 4/10/2023. 4. All residents will receive a second dose of Permethrin treatment on 4/11/2023, 4/12/2023 or 4/13/2023. 5. IPN/DON initiated discussions with individual staff regarding scabies prophylactic treatment on 4/5/2023. Any direct care staff refusing the treatment will need to use gowns and gloves while providing care for six weeks. IP Nurse will ensure compliance Monday to Friday and RN supervisor/charge nurse on Saturday and Sunday for six weeks. 6. An in-service of facility staff will be completed by 4/10/2023, prior to staff returning to work regarding scabies signs and symptoms, treatment, staff treatments, Personal Protective Equipment [(PPE) a disposable specialized clothing or gear that protects from hazards such as infections) needs and infection control practices until all staff have been educated (in-serviced) by the DON or IP nurse. Ongoing in-services of staff and any staff not in-serviced yet will undergo in-service by IP nurse or designee before reporting to a workstation. 7. A facility wide skin sweep (a careful inspection of each residents' skin condition performed by a licensed health care professional) was conducted by the treatment nurses on 4/3/23 for a total of 87 residents on 4/7/23 for a total of 87 residents. No new rashes were identified. 8. Treatment Nurses will perform weekly skin sweeps every Monday for six weeks. Any new skin issues identified will be reported to DON for review. 9. The wound care physician provided an examination of Resident 1, Resident 2, and Resident 4 on 4/4/2203 who were already being seen by the Wound care physician for other skin issues. a. Resident 1 has had a history of reddened skin and rashes with various treatments provided and is currently prescribed A&D ointment (moisturizer to treat or prevent dry, rough, scaly, itchy skin and minor skin irritations), Betamethasone cream (used to treat skin inflammation and itchiness) and was treated with Permethrin on 4/3/2023. b. Resident 2 has a history of eczema (a group of skin conditions characterized by itchy, scaly, red skin), Clobetasol (medication used to treat, itching, swelling and redness) prescribed and a Permethrin treatment was given on 4/3/2023. Resident 3 did not have a rash or skin issues and received Permethrin treatment on 4/4/2023. c. Resident 4 had a diagnosis of moisture associated skin damage (MASD) diagnosis according to the previous physician's examination. Resident 4 received Permethrin prophylactically on 4/4/2023. d. Resident 5 was treated with Permethrin on 4/4/2023 and scheduled to be seen by a dermatologist (branch of medicine concerned with the diagnosis and treatment of skin disorders) on 4/7/2023. e. The facility Medical Director reviewed details of skin issues and conducted examinations for Resident 1, Resident 2, Resident 3, Resident 4, and Resident 5 on 4/7/2023. Medical Director is aware and in agreement with the dermatologist follow-up. f. A Dermatologist is scheduled to examine Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, and any residents with a new rash, itching or reddened skin on 4/9/2023. g. Facility Wound Care Physicians will be conducting ongoing skin assessments on Tuesdays for any resident with new skin issues as needed for six weeks or greater. Any resident with a new skin issue will be identified and receive physician follow up as needed. A physician visit and exam will be done at least weekly for six weeks or until no new skin issues are identified. h. A Line listing for subacute residents and staff, who worked in the subacute unit was initiated on 3/31/2023. The line listing was updated to include SNF residents and all staff on 3/31/2023. IP was instructed to utilize a line list form provided by DPH on 4/3/2023, (by DPH). The Line listing was updated daily and reviewed by DON as of 4/4/2023.The Line Listing will be completed daily by the IP or designee until advised by PH to discontinue. i. Shower sheets or skin sheets (assessment of residents' skin) will be done daily and reviewed by the licensed nurses for follow-up as needed. IP nurse will audit process five days a week for six weeks. Residents shower chairs, wheelchairs and equipment were terminally cleaned (deep cleaning) on 4/6/2023. j. In-service for housekeeping/laundry staff was provided on 4/6/2023 regarding PPE, terminal cleaning, and scabies procedures by the IP Nurse. There will be ongoing in-services of staff and any staff not in-serviced yet will attend an in-service by IP nurse/designee before reporting to their workstations. Additional in-services will be provided by DON to housekeeping/laundry staff on 4/8/2023, 4/9/2023 and 4/10/2023. On 4/8/2023 at 4:24 p.m. after onsite validation through observation, interviews, and record review the IJRP implementation, the IJ situation was removed in the presence of Administrator, AIT, DON, IP, and Regional Clinical Director. Findings: 1. During a review of Resident 1's Admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure (narrowing of airway limiting air movement), tracheostomy (surgical incision to manage airway to enable resident to breathe), gastrostomy (a surgical incision made into stomach for placement of soft tube for the administration of food, nutrition, and medications). During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 2/6/2023, the MDS indicated Resident 1 had severe cognitive (ability to make decisions of daily living) impairment and could not make daily decisions for self. Resident 1 was totally dependent on staff in all aspects of activities of daily living (ADL activities related to personal care such as toileting, personal hygiene, and getting dressed). During an interview on 3/31/2023 at 4:27 p.m. with the licensed vocational nurse (LVN 3), LVN 3 stated the facility had to put all the residents in the Sub-Acute unit on contact isolation due to a possible exposure to scabies. LVN 3 stated for contact isolation; a gown, gloves, and mask would be worn as well as performing hand hygiene. LVN 3 stated it was important to wear proper PPE as not wearing PPE can spread scabies around and put other residents on the Sub-Acute unit as well as the SNF side at risk. During an observation of the SNF side of the facility on 3/31/2023 at 8:32 a.m., there were no contact precautions (a series of procedures designed to protect from infection through direct or indirect contact, such as PPE carts outside the rooms, signs informing anyone entering the rooms they need contact precautions due to a possible scabies outbred) implemented. The subacute unit had orange signs posted outside residents' rooms indicating enhanced precautions (infection control interventions designed to reduce transmission of resistant organisms) as there were residents who had Candida Auris (C-Auris: a fungus that causes serious infections that can spread in healthcare settings through contact with contaminated environmental surfaces or equipment, or from person to person), but no contact precautions signs were observed warning staff of possible scabies. A review of the facility's Census (list of how many residents are in the facility) for 3/31/2023 indicated there were 23 residents in the Sub-Acute unit and 64 residents on the SNF unit with a total of 87 residents combined. During an observation on 3/31/2023 at 10:18 a.m., outside of Resident 1's room in the Sub-Acute unit, there was no signage or PPE cart for contact precautions. Upon further observation, Resident 1's left arm and hand had a rash with red spots, resembling a burrowing (tiny raised serpentine lines that are grayish or skin-colored and can be a centimeter [a unit of measure of length] or more in length) scabies mites and red dots that included a circular rash on Resident 1's forearm and small rashes on the hand. During review of Resident 1's Order Summary Report (OSR), dated 4/8/2023 indicated there was a physician's order dated 4/4/2023, the OSR indicated to apply Permethrin Cream 5% from neck to toe topically (applied to the skin), one time a day every Monday for Scabies prophylaxis until 4/10/2023. During a concurrent observation and interview on 3/31/2023 at 10:25 a.m. with Certified Nursing Assistant (CNA 2), CNA 2 entered Resident 1 and Resident 2's room without having PPE on and was preparing to take Resident 1 to the shower. CNA 2 indicated Resident 1's arm did not look like it had a rash (to her). CNA 2 stated Resident 1's arm looked more like Resident 1 had dry skin. CNA 2 stated Resident 1's roommate Resident 2 had the same dry skin. CNA 2 stated if she was informed by the IPN that Resident 1 had been identified as contagious, she would wear the appropriate PPE but Resident 1 and Resident 2 were not contagious. During an interview on 3/31/2023 at 11:26 a.m. with the treatment nurse (TXN 1), TXN 1 stated that the facility's protocol for scabies included the dermatologist to come every Tuesday to examine the residents' skin and do the skin scraping test as required for scabies diagnosis. The facility's dermatologist would scrape the skin, treat the resident with Permethrin Cream 5% and apply from neck to toe. After 12 hours the residents are showered and given Ivermectin (a medication to treat certain parasitic infections) two to four doses once a week. The residents are placed on contact isolation and residents' primary care physician and families are notified of potential or actual scabies diagnosis. TXN 1 stated it was important to treat the resident as soon as possible to prevent the spread of scabies or it can lead to an outbreak. During a concurrent interview and Resident 1's electronic record review on 3/31/2023 at 4:00p.m. with IPN, the physicians' orders indicated a physician's order dated 3/31/2023 for a skin scraping and to monitor for itchiness, red skin lesions, and to place the resident on contact isolation. During an interview on 4/5/2023 at 3:13p.m. with MDS Nurse 2 (MDSN 2), MDSN 2 stated there were no infection control measures implemented to prevent the spread of scabies, such as isolating any residents with suspected scabies on the SNF side of the facility. MDSN 1 stated the facility did not prophylactically treat any residents. MDSN 2 stated she did not get any treatment either. A record review of Resident 1's Medication Administration Record (MAR), for April 2023 indicated Resident 1 received Permethrin Cream 5% on 4/3/2023, however another record review of Resident 1's MAR for April 2023 indicated Resident 1 received Permethrin Cream 5% on 4/4/23. The ADL documentation in the Bathing-Showering section indicated Resident 1 did not receive a shower on 4/4/23 or 4/5/23. According to the Permethrin Cream manufacturer guideline, leaving the Permethrin Cream 5% on for longer than intended may more likely develop to adverse reactions like itching, burning or stinging sensation on the skin. 2. During a review of Resident 2's Admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including tracheostomy, gastrostomy, chronic respiratory failure with hypoxia (low levels of oxygen [element in air necessary to sustain human life]), and multiple fractures (breaks) of ribs, base of skull, facial bones, and right shoulder with routine healing. A review of Resident 2's MDS dated [DATE] indicated Resident 2 had severe cognitive impairment and could not make decisions for self. Resident 2 was totally dependent on staff in all aspects of activities of daily living. During an observation on 3/31/2023 at 10:24 a.m., Resident 2's right arm had crusted rash on the upper arm and under the arm extending to the elbow. During a concurrent interview and record review on 3/31/2023 at 11:16 a.m. with TXN 1, TXN 1 stated Resident 2 was admitted on [DATE] with a recurring history of chronic rash and dermatitis (a condition of the skin in which it becomes red, swollen, and sore, sometimes with small blisters resulting from direct irritation of the skin be an external agent or an allergic reaction). Resident 2's skin assessment on 12/2/2022 indicated the resident had a right flank (the side of a person between the ribs and the hip) resolving rash and no elevated red bumps. During a record review of Resident 2's medical record, on 3/31/2023 at 3:56 p.m. with IPN, there was a physician's order to place Resident 2 on contact isolation and to do a skin scraping one time on 4/4/23 to rule out scabies. A review of Resident 2's progress notes dated 3/10/2023 indicated Resident 2 was noted with increased generalized body rash and a new physician's order was received for Permethrin cream for two weeks for unspecified dermatitis prophylaxis to apply over generalized body every evening on Sunday and Wednesday until 3/22/2023 and to be showered 14 to 16 hours after application. During a review of Resident 2's MAR for March, 2023 the MAR indicated Resident 2 had a physician's order dated 3/10/2023 for Permethrin cream 5% to apply to generalized body topically one time a day every Wednesday, Sunday for unspecified dermatitis prophylaxis and to be showered 12 hours after application. During an interview on 4/5/2023 at 2:10 p.m. with TXN 1, TXN 1 stated Permethrin is a medication that helps eliminate mites (scabies). TXN 1 stated he was unsure how many staff had been treated with Permethrin, since nursing staff have direct contact with residents. TXN 1 stated he had not been treated yet. TXN 1 stated it was important to treat the residents for scabies because it is a highly infectious disease. 3. During a review of Resident 4's Admission Record (AR), the AR indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including tracheostomy, gastrostomy, hemiplegia (severe weakness) and hemiparesis (relatively mild weakness of one side of the body) affecting left non-dominant side, and aphasia (inability to communicate). During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4 had severe cognitive impairment and could not make decisions for self. Resident 4 was totally dependent on staff in all aspects of activities of daily living. During an observation on 3/31/2023 at 9:18 a.m., Resident 4 had a rash on the right arm with redness and burrowing. During a concurrent interview and record review on 3/31/2023 at 4:03 p.m. with IPN, the IPN confirmed there was a physician's order to place Resident 4 on contact isolation, to do the skin scraping, and to monitor the resident for itching. During an interview on 3/31/2023 at 9:37 a.m., with HAIE, HAIE stated there were three residents identified with skin burrowing on 3/31/2023, which were Resident 1, Resident 2, and Resident 4. HAIE stated she recommended the facility do the skin scraping of Residents 1, 2 and 3. During an interview on 3/31/2023 at 2:24 p.m. with the IPN, the IPN stated that if the facility finds out there is one or more residents with scabies, the DPH, the resident's physician, and each resident's family should be notified. The resident's skin must be scraped to rule out scabies infection and the residents should be treated with Permethrin. The affected residents would be placed on contact isolation, the residents' belongings should be cleaned, and a bed linen placed in a plastic bag and then washed with hot water. IPN stated once the residents were placed on contact isolation, the facility should provide the prophylactic treatment to the resident and the residents roommate, and any staff members who has been in contact with the resident. IPN stated if a resident is admitted with a rash, the facility should observe (monitor) the resident, and if the rash was spreading throughout the body, the physician should be notified an order for scraping should be obtained along with the prophylaxis treatment. IPN stated there was CNA 10 complaining about itching and was treated for scabies by her primary physician, IPN indicated CNA 10 got it (scabies) from an outside source. IPN stated when a resident tested positive for scabies it should be reported to DPH to prevent having an outbreak that could spread to other residents, staff, visitors, and the local community. During an interview on 3/31/2023 at 2:50 p.m. with ADM, the ADM stated CNA 10 reported to the DSD on 3/27/2023 about having positive scabies result. The ADM stated that if the CNA's diagnosis was verified, facility would make sure the exposed residents would have screening for scabies. The ADM stated the facility would notify the family that there was a staff member who tested positive for scabies. The ADM stated based on communication with DPH, the facility was to do a skin sweep, monitor everyone (residents and staff), and to not do the prophylaxis until they have the positive results. The ADM stated the plan was for everyone (residents and staff) to get treatment within 24 hours. The ADM stated, if there were any skin issues, the facility would test for it and treat it, or the resident's wellbeing would be compromised, however the facility does not have a specific Scabies policy. During an interview on 3/31/2023 at 3:39 p.m. with IPN, the IPN stated she was not informed that CNA 10 had reported testing positive for scabies on 3/27/2023. The IPN stated she was not aware of it until 3/30/2023 when DPH called the facility regarding scabies infection control. The IPN stated the facility did not have any skin scraping kits as they have never had any scabies cases before. During an interview on 4/5/2023 at 9:15 a.m. with the HAIE, the HAIE stated CNA 10 notified the facility on 3/27/2023 but, it seemed as if the facility did not believe CNA 10. The HAIE stated on 3/31/2023, she provided the facility (ADM, DON and IPN) with recommendations to do a skin scraping for all residents, but the facility notified the HAIE the dermatologist, who could do the skin scraping, was not available. The HAIE stated that on 4/3/2023 she guided the facility to skip scraping and to provide prophylactic treatment to all the residents and staff since the facility did not do scraping as recommended on 3/31/23 and it was important to act fast. The HAIE guided the facility to conduct terminal environmental cleaning and bagging of resident's belongings while the residents were receiving prophylactic treatment. The HAIE indicated the facility did not provide the prophylactic treatment to all staff and residents from 3/31/23 until the night of 4/4/23 due to not having enough Permethrin Cream 5%, and the treatment was provided to residents on the Sub-Acute unit only. During a record review of the DPH's email with guidance provided to the facility on [DATE] at 4:53 p.m., a review of DPH's email indicated the following: treating all staff and residents at the same time within a 24 hours period to prevent reinfestation and place individuals on contact isolation for the duration of the treatment period, obtain skin scrapings when possible prior to treatment, all non-washable items should be stored in a sealed plastic bag for at least 72 hours prior to being dry cleaned, perform enhanced environmental cleaning of the facility (vacuum mattresses, upholstered furniture) and to complete the line list for all residents and staff. During an interview on 4/3/2023 at 9:05 a.m. with IPN, the IPN stated she still did not have a line list. IPN stated the DPH recommended the facility provide prophylactic treatment to all the residents and staff at the facility tonight (4/3/2023). The IPN stated the facility would also do environmental cleaning including the bedding and bag all the residents belonging that were not washable (on 4/3/2023). During an interview on 4/3/2023 at 9:22 a.m. with the DON, the DON denied any prior knowledge of a potential scabies outbreak and stated all the staff and residents would receive the prophylactic treatment on 4/3/2023 at 7:00 p.m. and will receive a shower at 7:00 a.m. on 4/4/2023. All residents' belongings would be bagged today (4/3/2023). During an interview on 4/5/2023 at 1:42 p.m. with the DON and the ADM, the DON stated that only 20 residents, who were from the Sub-Acute unit, were treated on 4/4/2023 with Permethrin Cream 5%. The DON stated that not all the residents, including the residents on the Sub-Acute unit, were treated prophylactically with Permethrin Cream 5% as HAIE recommended on 3/31/23. The Administrator and the DON stated the plan was to prophylactically treat all staff and the remaining 65 (since Resident1 and Resident 2 were already treated) residents in the facility the night of 4/5/2023. During a telephone interview 4/6/2023 at 5:39 p.m. with the Pharmacist (Pharm D), Pharm D stated the pharmacy did not have the requested amount of Permethrin Cream 5% in stock. During an interview on 4/5/2023 at 1:49 p.m. with Licensed Vocational Nurse (LVN 3), LVN 3 stated none of the residents assigned to her were on contact isolation for possible exposure to scabies. LVN 3 stated she had roughly 22 residents assigned to her. During an interview on 4/5/2023 at 1:56 p.m. with IPN, the IPN indicated the HAIE guidance to bag resident's non-washable items in Resident 4's room was not carried out. The IPN confirmed no residents in the SNF side were put on isolation for possible exposure to scabies. IPN stated no Permethrin Cream 5% was provided to the SNF unit and no deep cleaning was done, so far. During an interview on 4/5/2023 at 2:00 p.m. with Director of Maintenance Director (DM), DM stated none of the residents' rooms with suspected scabies had been deep cleaned. During an interview on 4/5/2023 at 1:51 p.m. with Housekeeper (HK 1), HK1 stated there were no rooms scheduled for deep (terminal) cleaning as recommended by the HAIE. During an interview on 4/5/2023 at 3:24 p.m. with the IPN, the IPN stated there was a new case of a rash identified on Sunday 4/2/2023 and it was Resident 5. Resident 5 had a rash on a shoulder and the abdomen (area of the body that contains internal organs) area. Resident 5 was placed on contact isolation. The IPN stated all residents on the Sub-Acute unit should have been placed on contact isolation and staff should have been wearing gowns when they had direct contact with the symptomatic (with rashes) residents. The IPN stated she was not sure how many staff had received prophylactic treatment. During a telephone interview 4/6/2023 at 5:42 p.m. with the Pharmacist (Pharm D), Pharm D stated if the pharmacy does not have the requested medication in stock, the pharmacy can obtain the medications from other pharmacies and borrow medications. Pharm D stated any medication is important as it could help treat and help recover individuals from any illness. Pharm D stated it is important to have a backup pharmacy as they (the facility) will encounter a situation where medication is not readily available from their supply. Pharm D stated if the pharmacy only has one medication in stock in a single quantity, they will call another pharmacy or place an order. Pharm D. stated the Permethrin Cream 5% should be washed off after 8 hours to 12 hours because it is a strong cream and is nephrotoxic (damaging or destructive to the kidneys) especially with the elderly. Pharm D stated that if the Permethrin Cream 5% was not washed off after certain hours, it defeats the purpose of the medication. Pharm D stated the facility ordered Permethrin cream on 4/3/2023 and not on 3/31/2023. Pharm D confirmed that Resident 2 had a recent order placed for Permethrin 5% Cream on 4/3/2023 and had a previous order on 3/10/2023. During a review of the facility's policy and procedure (P&P) titled Scabies Identification, treatment and Environmental Cleaning dated 08/2016, the P&P indicated failure to identify scrapings as positive does not necessarily exclude the diagnosis. It is difficult to obtain a positive scraping because only one or two mites may cause multiple lesions. Often diagnosis is made from signs and symptoms and treatment followed without scrapings. Affected residents should remain on Contact Precautions until 24 hours after the treatment. Staff members who may been exposed should report any rashes developing on their bodies to the IPN or DON. The P&P indicated bed linens, towels, and clothing used by the affected persons during the 4 days prior to initiation of treatment should be placed in a plastic bags inside the resident's room, handled by gloved and gowned laundry staff without sorting and laundered in hot water for at least 10 minutes. Discard all creams, lotions or ointments used prior to effective treatment. Upholstered furniture containing any cloth fabric should be removed from the room and if necessary, replaced with plastic or vinyl furniture, Mattresses must be covered with plastic or vinyl. The room should be terminally cleaned upon discharge or transfer of the resident from the room. The purpose of the P&P is to treat residents infected with and sensitized to Sacroptes scabies (the official name of the mite that causes scabies) and to prevent the spread of scabies to other residents and staff. A review of the facility's P&P titled Surveillance for Infections dated 09/2017, indicated the IPN will conduct ongoing surveillance for healthcare- associated infection (HAI) and other epidemiology significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions. For residents with infections that meet the criteria for definition of infection for surveillance, collect the following data as appropriate, identifying information, diagnosis admitted , infection site, pathogens, invasive procedure or risk factors, pertinent remarks, treatment measures and precautions. According to the Centers for Disease Control [(CDC) the nation's leading science-based, data-driven, service organization that protects the public's health] when a person is infested with scabies mites the first time, symptoms typically take 4-8 weeks to develop after being infected. However, an infected person can transmit scabies, even if they do not have symptoms. Scabies usually is passed by a direct, prolonged skin-to-skin contact with an infected person. However, a person with crusted scabies can spread the infestation by brief skin-to-skin contact or by exposure to bedding, clothing, or even furniture that he/she has used. CDC - Scabies - Prevention & Control

Based on observation, interview, and record review, the facility failed to ensure the resident, who was admitted with a Stage I pressure sore (a localized injury to the skin and or underlying tissue usually over a bony prominence) to a sacro-coccyx area did not have a sacro-coccyx pressure sore progressed to a Stage III pressure sore for one of two residents with pressure sores (Resident 43) in a total of 36 sampled residents. The facility failed to ensure: 1. The licensed nurses assessed Resident 43's sacro-coccyx pressure sore consistently. 2. The licensed nurses reported to Resident 43's physician of the resident's sacro-coccyx pressure sore condition based on its assessment. 3. The licensed nurses obtained treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. Nursing staff turned, and repositioned Resident 43 every two hours as indicated in the facility's policy and procedure (P/P) titled Prevention of Pressure Injuries and Resident 43's plan of care for the Potential for Impaired Skin Integrity. This deficient practice resulted in Resident 43's Stage I pressure ulcer to the sacro-coccyx area progressing to a Stage III pressure sore (involves the full thickness of the skin and may extend into the innermost layer of the skin) within 29 days of admission to the facility resulting in the need for the resident to be seen by a wound care physician. The wound care physician accessed Resident 43's pressure sore to the sacro-coccyx area as a non-healing Stage III pressure sore measured 4.0-centimeter ([cm] unit of measurement) in length by 3.0 cm in width and by 0.2 cm in depth which required a debridement (the removal of damaged tissue or foreign objects from a wound). Findings: During a review of Resident 43's Admission Record (Face Sheet), the Face Sheet indicated Resident 43 was admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 43's History and Physical (H/P) dated 12/8/2021, the H/P indicated the resident did not have the capacity to understand and make decisions. The H/P record indicated Resident 43's skin was warm. The H/P did not indicate Resident 43 had any other skin issues. During a review of Resident 43's Minimum Data Set (MDS) a standardized assessment and care planning tool, dated 12/13/2021, the MDS indicated Resident 43 had severely impaired cognitive skills (process of acquiring knowledge and understanding through thought, experience, and senses) for daily decision-making and was totally dependent (full staff performance) on staff for transfer, dressing, toilet use, and personal hygiene. The MDS indicated Resident 43 required two or more persons physical assistance with bed mobility. A review of Resident 43's care plan for the Potential for Impaired Skin Integrity, dated 12/7/2021, indicated the resident was identified to be at risk for a skin breakdown due to [CONDITION(S)]. Under this care plan the goal for Resident 43 was to minimize skin breakdown with the target date of 3/7/2022. The care plan approaches included to assess skin daily and as needed, and to report impaired skin integrity to Resident 43's physician, reposition the resident every two hours or more often as needed. On 12/9/2021, this care plan was updated to include additional intervention for Resident 43 to have a low-air-low ([LAL] a mattress designed to prevent and treat pressure wounds) mattress with setting of 80-160 per comfort. During a review of Resident 43's Braden Scale (assessment tool for predicting the risk of pressure sore development) record, dated 12/6/2021, the Braden Scale indicated the resident was scored 7. A score of 7 indicated Resident 43 was at very high risk for developing a pressure sore. In the Braden Scale assessment form was documented the following regarding Resident 43: 1. Sensory perception (ability to physically feel) was very limited. 2. Was constantly moist. 3. Activity was bedfast (confined to bed). 4. Completely immobile. 5. Nutrition very poor. 6. Had friction and shear (wounds occur when forces moving in opposite directions are applied to tissues in the body) problem. During a review of Resident 43's Skin Integrity Conditions (SIC) record, dated 12/6/2021, the SIC record indicated Resident 43 had a pressure sore to a sacro-coccyx area and was described as blanchable (skin color pales or changes; color; non-blanchable (pressure ulcer); If no loss of skin color or pale) redness with granulation tissue (pink or red tissue with shiny, moist, granular appearance) and clear exudate (fluid that leaks out of blood vessels into nearby tissues). The SIC indicated there were no documented measurement of Resident 43's pressure sore to sacro-coccyx area, and no documented pressure sore stage. During a review of Resident 43's physician orders, dated 12/6/2021, indicated there were no orders for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 43's medical record indicated there was no documented evidence the physician was notified of the resident's skin condition upon admission. During an observation on 1/10/2022 at 12 p.m., Resident 43 was observed laying facing the window, on the left side with the head facing the left side of the bed and the same day at 2:50 p.m., Resident 43 was observed laying in the same position as observed at 12 p.m. During an observation on 1/11/2021 at 12:43 p.m., Resident 43 was observed laying in supine position (flat on back) and at 3:13 p.m., Resident 43 was observed laying in the same position as observed at 12:43 p.m., laying in supine position. During a concurrent observation and interview on 1/11/2021 at 8:57 a.m., with a Licensed Vocational Nurse (LVN 3), LVN 3 was observed providing treatment to Resident 43's sacro-coccyx area pressure sore with [MEDICATION(S)] (medical-grade honey-based product line for the management of wounds and [CONDITION(S)]). LVN 3 stated, Resident 43 was admitted with a non-blanchable (skin redness that does not turn white when pressed) redness on the sacrum (the triangular bone just below the lumbar vertebrae at the lowest portion of the spinal column and connected to the pelvis) that rapidly progressed to a Stage III and identified as such by the consulting wound care physician on 1/4/2022. LVN 3 stated Resident 43 was laying on a regular mattress upon admission and the LAL mattress was not ordered until 12/30/2021. LVN 3 stated Resident 43 developed a Stage II pressure ulcer on 12/30/2021, prior to the LAL mattress being ordered. LVN 3 stated the wound care physician was called for consult. LVN 3 stated she was not sure of the date the physician was notified of the resident's Stage II (skin breaks open, wears away or forms an ulcer, which expands into deeper layers of the skin) pressure ulcer to sacro-coccyx area. LVN 3 stated Resident 43's pressure sore Stage I to a sacro-coccyx area from the admitted progressed to a Stage III pressure ulcer because of the resident's frequent incontinence (inability to control bowel and bladder elimination), staff not changing incontinence brief frequent enough, and the delay in ordering a LAL mattress. A review of Resident 43's Physician Orders, indicated there was an order dated 12/30/2021 and timed at 9 a.m., for Resident 43 to have a LAL mattress for the pressure sore management and to clean sacro-coccyx pressure sore Stage II [sic] with Normal Saline (salt water), pat dry, and apply [MEDICATION(S)] daily x 30 days. During a review of Resident 43's Daily Skilled Nursing Notes (DSNN), dated December 7, 9, 11, 12, 13, 14, 15, 16, 18, 19, 20, 21, 22 and 24, 2021, the DSNN indicated Resident 43's skin assessment and wound management area were blank and not completed as indicated in the facility's P/P for Prevention of Pressure Injuries and the resident's care plan, dated 12/7/2021 for the Potential for Impaired Skin Integrity. During an interview on 1/13/2022 at 12:27 p.m., with a Certified Nursing Assistant (CNA 2), CNA 2 stated, CNAs are to inform the charge nurses if residents had any skin changes. We do not document in the chart when a resident has any skin condition changes or when a resident was repositioned. There was no turning schedule implemented, but I know residents were to be repositioned every 2 hours. During an interview on 1/18/2022 at 11:15 a.m., with the Director of Nursing (DON), the DON stated according to the standard nursing practice the residents who were bedridden and at risk for developing a pressure injury should be repositioned every two hours. The DON stated some staff have laminated (plastic) cards with turning and positioning times for residents, that should be on all nursing staff's badges. During a concurrent interview and record review on 1/18/2022 at 11:17 a.m., with the DON, a review of the facility's policy titled, Repositioning, revised 5/2013 was reviewed. The policy and procedure (P/P) indicated residents who are in bed should be on at least every two-hour (q2h) repositioning schedule. The P/P also indicated if ineffective, the turning and repositioning frequency would be increased. The DON stated, I was not aware of the policy. During a concurrent interview and review of Resident 43's past Physician Orders, on 1/18/2002 at 12:55 p.m., with a Registered Nurse (RN 1), RN 1 confirmed there were no physician's orders for treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN 1 stated, 1 did not notify the resident's primary physician for orders relating to any skin problem and did not receive any treatment orders for the residents pressure sore upon admission. RN 1 stated she was the one who assessed Resident 43 upon admission and documented the resident had only redness on the sacro- coccyx area. RN 1 stated the nursing interventions included keeping the site dry as possible and to reposition the resident every two (2) hours. RN 1 stated We do not document when repositioning is done, and the LAL mattress was not ordered for Resident 43 until 12/30/2021. I do not have an explanation why there was a delay in ordering the LAL mattress. I admit the LAL mattress should have been ordered sooner. RN 1 stated nursing staff was not aware Resident 43's pressure ulcer to the sacro-coccyx area progressed to a Stage III until it was determined by the wound care physician on 1/4/2022. RN 1 stated that the nursing staff thought Resident 43's pressure sore to a sacro-coccyx area was a Stage II. RN 1 stated it was the responsibility of the CNAs and LVNs to reposition the residents and it was her responsibility to validate that it is being done. Upon review of Resident 43's medical records, RN 1 was not able to provide documentation to validate Resident 43 was repositioned every 2 hours as indicated in the care plan and facility's policy. RN 1 stated Resident 43 sacro-coccyx pressure sore progressed to a Stage III pressure sore was the result of delay in treatment and lack of communication between staff members. The delay in treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 1/18/2022 at 1:21 p.m., with the DON, the DON stated the LAL mattress was ordered for Resident 43 on 12/30/2021. The DON could not verify why the LAL mattress was not ordered sooner for Resident 43 and stated a LAL mattress should have been ordered for Resident 43 sooner to prevent pressure sore from deterioration. The DON could explain why Resident 43's physician was not notified timely regarding worsening of Resident 43's sacro-coccyx pressure sore and obtain treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated it was the DON's responsibility to oversee staff providing the appropriate nursing care and interventions to prevent pressure sore development and deterioration. The DON could not provide documentation or oversight of Resident 43's pressure sore nor documentation of verifying Resident 43 was turned and repositioned every two hours and as needed (PRN). During a review of Resident 43's Licensed Nurses Progress Notes (LNPN), the LNPN indicated the first time a physician was notified of Resident 43's pressure sore to the sacro-coccyx area was on 12/25/2021, 19 days after the resident was admitted . During a review of Resident 43's Situation, Background, Assessment, Recommendation ([SBAR] an internal change of condition [COC] document) Communication Form for the Licensed Nurses, dated 12/25/2021 and timed at 6:39 a.m., indicated Resident 43 had a right buttock [sic] (referencing to sacro-coccyx area) non-blanchable redness area and the primary physician was notified. On 1/11/2021 at 8:57 a.m., LVN 3 was observed providing treatment to Resident 43's sacro-coccyx area pressure sore. It was observed Resident 43 had only one pressure sore which was to a sacro-coccyx area. During an observation there were no other pressure sores present. During a review of Resident 43's care plan for the Potential for Impaired Skin Integrity, dated 12/25/2021 and timed at 7:13 a.m., the care plan indicated the resident had a non-blanchable redness to right buttock [sic] (referencing to a sacro-coccyx area) and will have no further decline for 21 days. The care plan indicated the staff's approaches included the following: 1. Treatment as ordered 2. Keep clean and dry 3. Reposition every 2 hours and as needed 4. Monitor for pain 5. Monitor for any changes and notify the physician During a review of Resident 43's SBAR Form and Progress Note (for Registered Nurses and LVNs) dated 12/30/2021 and timed at 3:15 p.m., the SBAR form and Progress Note indicated Resident 43 had a pressure sore on the right buttock [sic] (referencing to a sacro-coccyx area) classified as a pressure injury Stage II measuring 2.0 cm (length) by 0.2 cm (in width). During a review of Resident 43's Wound Care Consultant (WCC) physician note, dated 1/4/2022, the Consultant note indicated Resident 43 had a Stage III pressure sore to a sacral-coccyx pressure sore. The WCC physician documented the pressure sore was a non-healing pressure sore that was measured 4.0 cm by 3.0 cm by 0.2 cm. The WCC physician documented a debridement of the sacro-coccyx pressure sore into subcutaneous (the innermost layer of the skin) tissue layer was done. A review of the facility's P/P titled, Prevention of Pressure Injuries, revised 4/2010 indicated the following: 1. Risk Assessment: assess the resident on admission (within eight hours) for existing pressure injury risk factors and repeat the risk assessment weekly and upon any changes in condition. 2. Skin Assessment: inspect the skin daily when performing or assessing with personal care or activities of daily living (ADLs). Identify any signs of developing pressure injuries. 3. Prevention: clean skin promptly after episodes of incontinence. 4. Mobility/Reposition: reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary team and choose a frequency for repositioning based on the resident's risk factors and current clinical practice guidelines. 5. Support Surfaces and Pressure Redistribution: select appropriate support surfaces based on the resident's risk factors, in accordance with current clinical practice. 6. Monitoring: evaluate, report and document potential changes in the skin and review the interventions and strategies for effectiveness on an ongoing basis. During a review of the facility's P/P titled, Wound Care, revised in 10/2010, indicated the following: 1. Any changes in the resident's condition should be recorded in the resident's medical record. 2. Report other information in accordance with professional standards of practice.

Based on interview and record review, the facility's nursing staff failed to provide the necessary care and services for an indwelling urinary catheter (a tube placed in the bladder to drain urine), as per the resident's plan of care, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1, who had an indwelling urinary catheter for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 was transferred to a general acute care hospital (GACH) Emergency Department (ED) after having an elevated body temperature of 103.7 Fahrenheit [F] (normal reference rate [NRR] is from 97° F to 99 °F ) and was diagnosed with an UTI. The ED's notes indicated upon admission, Resident 1's urinary catheter was plugged, dirty and old. This deficient practice of not assessing the catheter as prescribed by the physician, resulted in Resident 1 sustaining a penile shaft (extends from the tip of the penis to the lower part of the belly) wound (injury to living tissue caused by a cut in which the skin is broken), serosanguinous (discharge that contains both blood and clear yellow liquid) drainage (means of removing), white/yellow purulent (containing pus) drainage at catheter insertion site and amber color urine (orange-brown-red colors [abnormal]) with cloudy sediment (refers to abnormal gritty particles or [MEDICATION(S)] in the urine) from the urinary catheter. Findings: During a review Resident 1's Face Sheet (Admission Record), the face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Minimum Data Set (MDS), a standardized care screening and assessment tool, dated 2/23/2021, the MDS indicated Resident 1 was comatose (state of deep unconsciousness for indefinite time) and was not able to make himself understood and understand others and cognition (thought process) was severely impaired. The MDS indicated Resident 1 was totally dependent of a two or three-person physical assist for bed mobility, eating, and personal hygiene. The MDS indicated Resident 1 had an indwelling urinary catheter in place. During a review of Resident 1's Readmission Skin Assessment, dated 1/13/2021, the skin assessment indicated Resident 1 was admitted with an indwelling urinary catheter in place, without documentation of any wounds or skin problems to the penial area. During a review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's care plans, there was no documented evidence a care plan was created to address the care of Resident 1's indwelling urinary catheter. During a review of Resident 1's care plan titled, Bladder (sac in which urine is collected for excretion), dated 2/11/2021, the care plan indicated Resident 1 would not have complaints of pain, increased frequency, and increased odor daily. The staffs' interventions included to assess the bladder at least quarterly, intake and output (I/O) monitor as per protocol, observe for signs and symptoms of UTI (urinary tract infection), such as cloudiness, malodor ( unpleasant smell), sediment, dysuria (painful or difficulty urinating) and chills (a feeling of being cold without an apparent cause and can occur with a fever). During a review of Resident 1's Treatment Assessment Sheets (TAR), dated 2/1/2021 to 2/23/2021, the TAR indicated care was provided to Resident 1's indwelling urinary catheter every shift, but no documented wound in penile was noted, assessed and treated. During a review of Resident 1's physician telephone order (T/O), dated 2/23/2021, the T/O indicated to transfer Resident 1 to the GACH for further evaluation secondary to episode of vomiting (eject matter from the stomach through the mouth) with fever (an abnormally high body temperature). During a review of Resident 1's GACH Emergency Department (ED) Encounter ([NAME]) sheet, dated 2/23/2021, the [NAME] sheet indicated Resident 1 presented to the ED with complaint of fever and vomiting. The [NAME] sheet indicated Resident 1 was in severe septic shock (widespread infection causing organ failure and dangerously low blood pressure) with an elevated temperature of 103.7 F, pulse of 119 bpm (NRR is 60-100 bpm), blood pressure (BP) of 107/58 (NRR is 90/60-139/79), and respirations of 30 breath per minute (NRR is 12-16 bpm). The [NAME] note indicated Resident 1's urinary catheter was old, dirty, and draining amber color urine with white/cloudy sediment with white/yellow purulent (consisting of pus [thick yellowish or greenish opaque liquid produced in infected tissue]) drainage at the insertion site of the urethra (canal that carries urine from the bladder), and a small wound at the resident's penile shaft (from the tip of the penis to where it connects to the lower belly). According to the ED note, Resident 1's urinary catheter was removed and was replaced with a new urinary catheter and bag due to being dirty and old. During a review of Resident 1's GACH urinalysis report ([UA] examinations of the physical and chemical properties of urine and its microscopic appearance to aid in medical diagnosis), dated 2/23/2021 and timed at 2:25 p.m., the UA indicated a large amount greater than 180 of white blood cells ([WBC] colorless cell that circulates in the blood and body fluids involved in counteracting foreign substances and disease) in the urine WBCs NRR is 4.5 to 11 per microliter [units of measurement]), an abnormal Leukoesterate (test conducted to identify white blood cells in the urine), with moderate bacteria, appearance was turbid (freshly harvested urine with an unclear dirty and cloudy appearance), and with moderate blood in the urine. During an interview on 3/1/2021 at 11:35 a.m., Resident 1's family member (FM 1) stated the facility's staff did not inform him regarding Resident 1's urinary catheter's condition. FM 1 stated not being informed of the cut to Resident 1's penis and UTI and was not informed until Resident 1 arrived to the GACH's ED. FM 1 stated the facility neglected Resident 1 and did not care for him as they should have.FM 1 stated the facility neglected Resident 1. During an interview on 3/1/2021 at 2:13 p.m., Resident 1's family member (FM 2) stated feeling sad and angry of the care Resident 1 received in the facility. FM 2 was heard crying as he was explaining the neglect Resident 1 suffered at the facility and asked for a few minutes to compose himself. FM 2 stated the facility needed to held liable for not caring for Resident 1. During an interview on 3/16/2021 at 3:03 p.m., the GACH physician stated Resident 1 arrived to the ED in septic shock, G-tube displacement, abdominal abscess (collection of pus or infected fluid that is surrounded by inflamed tissue inside the belly), fever and vomiting. The GACH physician stated Resident 1 had a urinary tract infection with sediment, blood, and a laceration to the penis with discharge at the insertion site. During an interview on 3/31/2021 at 1:46 p.m., Licensed Vocational Nurse 4 (LVN 4) stated he was not aware of Resident 1 had a wound to the penile shaft. LVN 4 stated the Certified Nurse Assistants (CNAs) should notify him when there was changes in the resident's skin and/or urinary catheter. During a concurrent interview and review of Resident 1's TARs and Nurses Progress Notes (NPN) on 4/19/2021 at 11:44 a.m., Registered Nurse 1 (RN 1) stated the TARs and NPNs indicated the urinary catheter was change every day. RN 1 stated not being aware of Resident 1's catheter being dirty and with blood. RN 1 stated there were no documentation of Resident 1 having a penial injury. While reviewing the records, RN 1 stated there was no care plan to address the care of Resident 1's catheter care created. RN 1 stated the staff should have noted the changes of the urine color, consistency and smell and notify the physician. During a concurrent interview and review of Resident 1's TARs on 3/31/2021 at 2:10 p.m., RN 1 stated there were no documented concerns identified with Resident 1's indwelling catheter. During an interview on 3/31/2021 at 6:10 p.m., RN 4 stated he did not assessed Resident 1's urinary catheter and was not aware Resident 1 had problems with the catheter. During a review of the facility's policy and procedures (P/P), dated 11/2014, the P/P indicated the purpose of the procedure was to prevent catheter-associated urinary tract infections. The P/P indicated the staff would review the resident's care plan for any special needs, check catheter tubbing frequently to ensure resident is not lying on the catheter, change indwelling catheter or drainage bag routinely, check the urine color for unusual appearance such as color, blood and notify physician or supervisor immediately.

Based on interview and record review, the facility failed to provide assistive devices (mechanical lift) for transfer (being moved between surfaces including to or from bed, chair, wheelchair and standing position) to prevent falls for one of four sampled residents (Resident 1), per Resident 1's care plan, the Interdisciplinary Team notes ([IDT] group of different disciplines working together towards a common goal of a resident), and staff interviews. Resident 1, who had a high risk for falls and required a two-person physical assist for transfer, was transferred with a one-person physical assist. This deficient practice resulted in Resident 1 falling to the floor twice during a one-person assisted transfer resulting in severe pain. Resident 1 had generalized body pain and was receiving pain medications whenever necessary (PRN). The pain intensified to 9 on a pain scale (0-10 [10 being the worst pain]). Resident 1's pain intensified to the back, left hip/thigh, and right shoulder, which made the resident cry and required more pain medication [MEDICATION(S)] (a narcotic pain medication combination used to relieve moderate to severe pain]), 5-325 milligram ([mg] unit of measurement) tablet of [MEDICATION(S)]-acetaminophen). A review of Resident 1's Medication Administration Reviews (MARs) for the month of 12/2020 and 1/2021, indicated Resident 1 received [MEDICATION(S)] twenty-one times for pain from 12/30/20 through 1/31/2021. Findings: During a review of Resident 1's admission record, the admission record indicated Resident 1 was admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's diagnoses included chronic [CONDITION(S)] (condition when lungs cannot provide enough oxygen), hypertension (high blood pressure), [CONDITION(S)] [CONDITION(S)] (lack of oxygen to the brain resulting in death of brain cells), and pneumonia (lung infection in which the air sacs fill with pus [thick yellow liquid produced in infected tissue]). During a review of Resident 1's Minimum Data Set (MDS), a resident assessment and care-planning tool, dated 12/26/2020, the MDS indicated Resident 1 was able to follow cues with recall intact on interview and usually had the ability to understand and be understood. The MDS indicated Resident 1 required extensive assistance (resident involve and staff provides weight bearing support) and required a two-person physical assist when being moved between surfaces including to or from bed, chair, wheelchair and standing position. During a review of Resident 1's Fall Risk assessment, dated 9/18/2020, the assessment indicated Resident 1 was assessed as a high risk for falls by evidence of incontinence (lack of voluntary control of urination or bowel movements), high risk fall drugs, mobility that requires supervision or assistance, lack of understanding of physical and mental limitations, and altered awareness of immediate physical environment. During a review of Resident 1's Medication Administration Record (MAR) dated, 12/1/2020 through 1/31/2021, the MAR indicated [MEDICATION(S)] was administered to Resident 1 twenty-one times for pain from 12/31/2020 through 1/31/2021. During a review of Resident 1's care plan dated, 9/18/2020 and titled, Falls, the care plan indicated Resident 1 should be handled gently and carefully and the staff should utilize safety devices (unspecified) as ordered. During a review of Resident 1's care plan, dated 9/18/2020 and titled, Activities of Daily Living (ADL) Functional/ Rehabilitation Potential, the care plan indicated Resident 1 should be handled gently and carefully, and the staff should utilize safety devices (unspecified) as ordered. During a review of Resident 1's care plan, dated 10/29/2020 and titled, Health Status, the care plan indicated Resident 1 was at risk for falls and injury due to the use of blood pressure and pain medications, generalized muscle weakness, unsteady gait (walk), and poor safety awareness. The goal was to keep the resident free of falls. During a review of an Event Report, dated 12/30/2020 and timed at 6:13 p.m., the report indicated Resident 1 had a fall in her room while being transferred from the wheelchair to bed by Certified Nurse Assistant 2 (CNA 2). Resident 1 was unable to stand and was assisted to the floor by CNA 2. CNA 2 called Registered Nurse Supervisor (RNS) and Licensed Vocational Nurse 1 (LVN 1) to notify them of the incident. The RNS entered the room and found Resident 1 sitting on the floor on the left side of the bed. The RNS notified the physician and an x-ray of Resident 1's lower back, left hip, and left thigh was ordered. The Event Report indicated Resident 1 had sharp new pain of 8 out of 10 to the lower back, left thigh, and left hip. The Event Report indicated interventions prior to the fall included to place the resident's bed in the lowest position, call light within reach, and use of mechanical lift ([Hoyer lift] a device used to transfer a resident from one place to another). The Event Report indicated there was no assistive device used at the time of Resident 1's fall. The Event Report indicated the Interdisciplinary Team ([IDT] a team of various discipline working together for a common goal for the resident) recommendations included use of a lift when transferring resident from the wheelchair to the bed. During a review of Resident 1's physician's orders, dated 12/30/2020, the physician's orders indicated an order for a STAT (immediate) x-ray of Resident 1's left hip, right hip, and lumbar (lower) spine for hip and back pain. The physician's order also indicated to apply ice to affected area of injury post fall for 20 minutes four times a day and as needed for three days, monitor for significant injury, and monitor 72 hours for bruising, change in mental status, pain, or other injuries related to the fall. During a review of Resident 1's Nursing Progress Note (NPN), dated 12/30/2020 and timed at 4:30 p.m., the NPN indicated Resident 1 had a fall in her room while being transferred from the wheelchair to bed by CNA 2. Resident 1 was unable to stand and was assisted to the floor by CNA 2. CNA 2 called RNS and LVN 1 to notify them of the incident. RNS entered the room and found Resident 1 sitting on the floor on the left side of the bed. Resident 1 complained of sharp pain in the lower back, left hip, and left thigh. The physician was notified and ordered STAT x-ray of lower spine, left hip and right hip. Ice pack applied per protocol. During an interview, on 2/9/2021 at 11:45 a.m., CNA 1 stated, Resident 1 is a two-person assist and I don't move her to the chair without using the sling (the part the resident sits on that is attached to a mechanical lift). The sling requires a two-person assist. The resident has never stood with me and I wouldn't try because she's not there yet and it would not be safe for someone to try to move or transfer her alone because she has no strength. The resident told me she fell when the CNA (CNA 2) was trying to transfer her to the bed by himself. During an interview, on 2/9/2021 at 12:10 p.m., Resident 1's family member (FM 1) stated, They dropped her (Resident 1) twice as per the CNA (CNA 2). She has always been handled by two nurses and they used a sling to move her. I was told the CNA (CNA 2) handled her on his own, dropped her once then tried to put her back on the bed and then dropped her again. She (Resident 1) asked the CNA (CNA 2) to use the sling because she is heavy, the CNA (CNA 2) told her no and tried to pick her up twice. During an interview, on 2/9/2021 at 1 p.m., Resident 1 stated, Only one CNA tried to move me from my wheelchair to my bed. I told him to use the Hoyer lift and he said no. He tried to pick me up two times and he dropped me two times. I hit my arm and my back on the side of the bed, and I now have pain in my back. I still have pain in my back and right shoulder. Resident 1 was asked what her pain level was, and she stated it was 9. Resident 1 stated, The nurses give me pain medications, but sometimes the pain was so bad it makes me cry. This was the first time the CNA (CNA 2) tried to move me. They always use the sling now. During an interview, on 2/9/2021 at 1:15 p.m., the RNS stated, The CNA (CNA 2) informed us the resident (Resident 1) was assisted to the floor. I, the Director of Nursing (DON), and the LVN (LVN 1) went to Resident 1's room and found her sitting on the floor at the bedside. She complained of pain in the lower back and butt. We gave her pain medications, but she still complains of back pain. The CNA (CNA 2) was in the room alone with the resident (Resident 1). The resident (Resident 1) is a two-person assist with a Hoyer lift. The CNA (CNA 2) should not have tried to move the resident from the chair to bed without using the lift. The RNS stated Resident 1 stated she fell twice, and CNA 2 said he did not use the lift because he did not notice the sling on the chair. The RNS stated the staff should look for a sling and call for assistance. During a telephone interview, on 2/9/2020 at 2:15 p.m., LVN 1 stated, I was called by the CNA (CNA 2) to help assist the resident (Resident 1) back to bed. The CNA (CNA 2) was transferring the resident back to bed from the wheelchair and he could not get her up, so he assisted the resident to the floor. When I got there the resident was sitting on the floor at bedside. The resident was in pain at her lower back. I gave her [MEDICATION(S)] for pain. During an interview, on 2/9/2021 at 2:20 p.m., CNA 3 stated she used the lift to transfer Resident 1, because she had no support in her legs. CNA 3 stated she would not try to lift the resident and she would always ask for assistance to lift Resident 1. CNA 3 stated if she entered the room and there was no sling, she would not move Resident 1 alone, but would look for a sling or ask someone to provide a sling. During an interview, on 2/9/2021 at 3:10 p.m., LVN 2 stated, The resident (Resident 1) is a two-person assist to move from wheelchair to bed. We use the lift for her. The resident (Resident 1) still complains pain 7-8 out of 10. During an interview, on 2/9/2021 at 4 p.m., the Administrator (ADMIN) stated, The CNA (CNA 2) did not use the Hoyer lift because he did not see it and he's a big guy so he could lift the resident (Resident 1) alone. During a review of the facility's In Service Attendance Sheet, dated 10/1/2020, subject as Transferring Residents the attendance sheet indicated CNA 2 was present for this training. The training lesson plan included objectives that indicated the staff will be able to show understanding of proper technique of transferring resident from bed to wheelchair and vice versa, show understanding when to do one or two-person assist with resident's transfers, identify the difference between Hoyer lift and sit to stand lift, and identify which residents require mechanical lift for transfer after this in service. During a review of the facility's P/P, revised in March 2018 and titled, Activities of Daily Living / Supporting, the P/P indicated staff would provide appropriate care and services for residents who are unable to carry out ADLs independently in accordance with the plan of care, including appropriate support and assistance with mobility (transfer and ambulation), including walking. According to the P/P, a resident's ability to perform ADLs will be measured using clinical tools, including the MDS.

Based on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 1), who had respiratory problems was free of unnecessary drugs, such as excessive amounts, in duplicated dosages and medications given that were not prescribed by the physician. Resident 1 was receiving excessive amounts of narcotic and [MEDICAL CONDITION] (any medication capable of affecting the mind, emotions, and behavior) medications without adequate monitoring and in the presence of adverse consequences. This deficient practice resulted in Resident 1 receiving unnecessary drugs in excessive doses and being given medications without a physician's orders [REDACTED]. Findings: A review of Resident 1's Admission Face sheet, indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Sheet (MDS), a standardized assessment and care screening tool, dated June 18, 2017, indicated Resident 1's cognition (thought process) was intact, he was independent in decision-making skills and did not have any memory problems. A review of Resident 1's Clinical Health Status Admission Assessment, indicated the resident was admitted to the facility for pain management and was awake and alert. The assessment indicated Resident 1 had a history of [REDACTED]. A review of Resident 1 physician's telephone orders, dated June 16, 2017, and timed at 11:30 p.m., indicated the following medications were prescribed: A. [MEDICATION NAME] (a strong control narcotic medication used to relieve pain) 15 milligrams (mg) every six hours as needed for pain. B. [MEDICATION NAME] ((benzodiazepine) a medication used to prevent and treat [MEDICAL CONDITION], panic disorder as an anti-anxiety, and akathisia (feeling of restlessness and urge to move)) 1 mg three times a day as needed (PRN (whenever needed)) for akathisia. C. [MEDICATION NAME] (a muscle relaxing medication that is used to treat muscle spasms) 10 mg three times a day as needed for muscle spasms. D. [MEDICATION NAME] 20 mg at bedtime for muscle spasms. E. [MEDICATION NAME] (a medication used to treat [MEDICAL CONDITION] and nerve pain) 1200 mg twice a day for nerve pain. A review of Resident 1's Controlled Drug Record indicated Resident 1 received [MEDICATION NAME] 1 mg on the following dates and times for a total of three doses on June 17, 2017 at 5 p.m., and at 9 p.m., and on June 18, 2017 at 9 a.m. A review of Resident 1's Medication Administration Record (MAR) for the month of June 2017 indicated the resident received [MEDICATION NAME] 1 mg on the following dates and times: June 17, 2017 at 2 p.m. and June 18, 2017 at 9 a.m., for a total of two times, which did not coincide with the controlled drug record of three doses. A review of Resident 1's Controlled Drug Record indicated Resident 1 received [MEDICATION NAME] 15 mg on the following dates and time June 17, 2017 at 5 a.m., 11 a.m., 5 p.m., and at 11 p.m. and June 18, 2017 at 5 a.m., and 3 p.m., for a total of six doses. A review of Resident 1's MAR for the month of June 2017 indicated the resident received [MEDICATION NAME] 15 mg a total of five times on the following dates and times: June 16, 2017 at 5 a.m. and 11 p.m., June 17, 2017 at 11 a.m., June 18, 2017 at 5 a.m., and 3 p.m. The nurse's initials on the MAR indicated the medication was administered a total of four times. A review of Resident 1's June 2017 MAR, indicated the resident received [MEDICATION NAME] 1200 mg on the following dates and times: June 17, 2017 at 9 a.m., and 5 p.m., and on June 18, 2017 at 9 a.m., and 5 p.m. for a total of four times. A review of Resident 1's June 2017 MAR, indicated the resident received [MEDICATION NAME] 20 mg on the following dates and times: June 17, 2017 at 9 a.m., and on June 18, 2017 at 8:15 a.m., and 11:30 a.m. for a total of three times. The nurse's initials on the MAR indicated the medication was administered a total of two times. A review of Resident 1's Mood/Behavior/Psychosocial Wellbeing Care Plan, dated June 16, 2017, indicated that diversional activities would be used to redirect the behavior and the resident would be monitored for side effects of the anti-anxiety medication [MEDICATION NAME]. A review of Resident 1's Alteration in Comfort Care Plan, dated June 16, 2017, indicated the resident would be monitored for side effects of pain medications. A review of Resident 1's Fall/Injury Potential Care Plan, dated June 16, 2017, indicated the resident would be monitored for changes in level of alertness and/or increasing lethargy (drowsiness). A review of a Nursing Note, dated June 17, 2017, and timed at 5 a.m., indicated the resident was alert and verbally responsive and [MEDICATION NAME] 10 mg was administered to the resident at 4 a.m. A review of Resident 1's Nursing Note, dated June 17, 2017, and timed at 2:30 p.m., indicated the resident was administered [MEDICATION NAME] 10 mg at 2 p.m. A review of Resident 1's Nursing Notes, dated June 17, 2017, and timed at 6:30 p.m., indicated the resident was administered [MEDICATION NAME] and there was no vital signs (body temperature, pulse rate (heart rate), respiration rate, blood pressure; measurements of the body's most basic functions) documented. A review of Resident 1's Nursing Notes, dated June 17, 2017, and timed at 9 p.m., indicated the resident requested and was administered another [MEDICATION NAME] 1 mg, two and a half hours (not three times a day as ordered) after the prior administration of [MEDICATION NAME] without vital signs assessed and/or documented. A review of Resident 1's Nursing Note, dated June 18, 2017, and timed at 2 p.m., indicated the resident's pain was assessed as being 1 out of 10 pain (1 being the least and 10 being the worst pain) after receiving [MEDICATION NAME] (combination prescription drug [MEDICATION NAME]/[MEDICATION NAME] used to treat moderate to severe pain) at 11:30 a.m. A review of Resident 1's physician's orders [REDACTED]. A review of Resident 1's Nursing Note, dated June 18, 2017, and timed at 8 p.m., indicated the resident was alert and able to verbalize needs. The note indicated that all medications were given as ordered on June 18, 2017, which included: 1. [MEDICATION NAME] 1 mg at 9 a.m. 2. [MEDICATION NAME] (no strength indicated) at 11:30 a.m. 3. [MEDICATION NAME] 15 mg at 5 a.m. and 3 p.m. 4. [MEDICATION NAME] 10 mg at 8:15 a.m. and 11:30 a.m. 5. [MEDICATION NAME] 1200 mg at 9 a.m. and 5 p.m. According to the online site Lexicomp (provider of drug information and clinical content for the healthcare industry) the black box warnings for [MEDICATION NAME] indicated that concomitant use of benzodiazepines and opioids may result in profound sedation, respiratory depression, coma, and death. The online drug information indicated to limit dosages and durations to the minimum required and follow residents for signs and symptoms of respiratory depression and sedation at https://online.lexi.com/crlsql/servlet/crlonline. A review of Resident 1's Nursing Notes, dated June 18, 2017, and timed at 8:30 p.m., indicated the resident had a decreased level of consciousness and appeared to be very sleepy. The resident attempted to talk, but was unable. The note indicated the physician was notified and the paramedics were called. There was no documented evidence the resident's vital signs were assessed. A review of Resident 1's Nursing Notes, dated June 18, 2017, and timed at 9 p.m., indicated the paramedics arrived and took over care of the resident. A review of Resident 1's Nursing Notes, dated June 18, 2017, and timed at 10 p.m., indicated the resident was taken by paramedics to the hospital. A review of Resident 1's Resident Transfer Record, dated June 18, 2017 and untimed, indicated the resident was not verbally responsive and had a change in condition. The record indicated the resident's respirations ((respiratory rate) the action of breathing) was listed as 18 (normal reference range (NRR) is 12-20) and the resident was transferred to the hospital. A review of the Paramedic's Emergency Medical Report, dated June 18, 2017, indicated the paramedics were dispatched at 2125 (9:25 p.m.). The report indicated the resident was observed with an altered level of consciousness (AL(NAME)) with pinpoint pupils (abnormally small pupils resulting from a reaction to certain drugs). According to the report Resident 1's respiratory rate was six and she was lethargic (state of sleepiness or deep unresponsiveness). Resident 1's Glasgow Coma Scale ((GCS) means of recording the conscious state of a person) indicated that the resident did not have any motor or verbal responses and only opened her eyes to pain. The Paramedics administered 2 mg of [MEDICATION NAME] (a medication used to treat and reverse narcotic/opioid drug overdose) which resulted in Resident 1 returning to her baseline mental status. After the [MEDICATION NAME] administration, Resident 1's GCS improved and the resident was able to spontaneously open her eyes, obey commands to move her body, but had some confusion. A review of Resident 1's Emergency Department (ER) Records, dated June 18, 2017, and timed at 10:06 p.m., indicated the resident arrived to the emergency department via ambulance and presented with an accidental narcotic overdose. According to the ER note, Resident 1 denied taking any medications on her own. A review of Resident 1's ER Notes, dated June 19, 2017, and timed at 12:07 p.m., indicated the resident refused to transfer back to the facility and stated that she did not feel safe at the facility. On September 6, 2017 at 2:40 p.m., during a concurrent interview and record review, a Licensed Vocational Nurse 3 (LVN 3) stated the MAR and the Controlled Medication Record should match. LVN 3 stated she was not sure if [MEDICATION NAME] affected one's respirations and she was unaware of any contraindications of administering [MEDICATION NAME] and [MEDICATION NAME] together. On September 6, 2017 at 3:20 p.m., during a concurrent interview and record review, the Director of Nursing (DON) stated LVN 4 probably forgot to document her administrations of the medication [MEDICATION NAME]. The DON stated LVN 4 should have initialed the front of the MAR and documented the administrations of the medication on the back of the MAR. The DON stated the MAR and Controlled Medication Sheets should match with the amount of medications given. The DON stated when giving [MEDICATION NAME] and [MEDICATION NAME] together she would be concerned about the resident's liver and kidney function. The DON stated she was not aware of any black box warning for administering pain medications with benzodiazepines. The DON verified that there was no order for Resident 1 to receive [MEDICATION NAME] pain medication. On September 6, 2017 at 3:38 p.m., during a telephone interview, the facility's Pharmacist Consultant (PC) stated that when giving [MEDICATION NAME], and [MEDICATION NAME] to a resident with [MEDICAL CONDITION], the resident should be carefully monitored for level of sedation and respirations. At 3:55 p.m., on September 6, 2017, during a telephone interview, LVN 2 stated Resident 1 had increased sedation on the day of the incident (June 18, 2017) and would only open her eyes, but was unable to talk. LVN 2 stated, I called another nurse over and we assessed (Resident 1) and then called the paramedics. According to an online site Lexicomp (provider of drug information and clinical content for the healthcare industry) the black box warnings for [MEDICATION NAME] indicated users were exposed to the risks of opioid addiction, abuse, and misuse, which could lead to overdose and death. It also indicated concomitant use of opioids with benzodiazepines or other CNS depressants, could result in profound sedation, respiratory depression, coma, and death. Concomitant prescribing of [MEDICATION NAME] and benzodiazepines or other CNS depressants was to be reserved for use in patients for whom alternative treatment options are inadequate. The online drug information indicated to limit dosages and durations to the minimum required and follow residents for signs and symptoms of respiratory depression and sedation at https://online.lexi.com/crlsql/servlet/crlonline. A review of the facility's policy and procedures titled, Medication Administration-General Guidelines, and dated April 2008, indicated that if a dose seemed excessive for the resident's age or condition, the nurse was to call the prescriber or the pharmacy for clarification. The policy indicated that the nurse was to record the administration on the residents MAR directly after a medication was given by initialing on the line specific to the dose given. As needed medications required additional documentation such as the reason the med was given and the results that were achieved after the dose was given. A review of the facility's policy and procedures titled, Pain-Clinical Protocol, with a revision date of April 2009, indicated that staff would monitor residents for adverse effects of pain medications, which the facility failed to follow.