Every finding on record at Pacific Care Nursing Center

Based on interview and record review, the facility failed to ensure three of four Restorative Nursing Aides ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) (RNA 1, RNA 2, and RNA 3) were competent in RNA skills when:1. RNA 2 and RNA 3 did not complete annual RNA skills competency evaluations.2. RNA 1 did not complete annual competency skills evaluation for application and removal of splints (a rigid material or apparatus used to support and immobilize a broken bone or impaired joint). These deficient practices had the potential to result in injury, worsening contractures (a permanent tightening of muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) and skin breakdown for residents who required an RNA program and residents who required splints.Findings:1. During an interview on 8/19/2026 at 10:28 a.m., with RNA 2, RNA 2 stated he was a full-time RNA and performed RNA treatments such as range of motion (ROM, full movement potential of a joint) exercises, ambulation, positioning, exercises like the arm bicycle, and applying and removing splints.During an interview on 8/19/2026 at 12:29 p.m., with Occupational Therapist (OT 1), OT 1 stated the therapy department only started to assist with completing RNA annual competencies last week and was in the process of completing the RNA annual competencies, but had not completed them yet.During a concurrent interview and record review on 8/19/2026 at 1:03 p.m., with the Director of Staff Development (DSD), DSD reviewed the employee files of RNA 1, RNA 2, and RNA 3. DSD reviewed RNA 2's employee file and stated RNA 2 did not have an RNA annual competency completed since the date of hire on 10/24/2023. DSD stated RNA 2 completed a general nursing skills performance evaluation on 10/24/2023 and had never completed an RNA-specific skills competency evaluation while RNA 2 was employed at the facility.During a concurrent interview and record review on 8/19/2026 at 1:03 p.m., with DSD, reviewed RNA 3's employee files and stated RNA 3 completed an annual general nursing skills performance evaluation on 9/19/2024 and did not complete an RNA-specific annual competency evaluation. DSD stated all staff required an annual competency evaluation to ensure that staff had the proper skills for resident safety and to identify if staff needed more training in any areas. DSD stated RNA staff performed different skills and tasks than Certified Nursing Assistants such as range of motion exercises, ambulation, and splinting. DSD stated the facility needed to evaluate the skills that staff were performing every day, and RNA staff required an RNA-specific annual competency.During an interview on 8/19/2026 at 3:19 PM with the Director of Nursing (DON), the DON stated the RNA program was a nursing program to help residents maintain their function and joint mobility and prevent any or further decline. The DON stated there were designated staff that performed the RNA program and RNA staff were required to complete an RNA-specific competency evaluation every year. The DON stated it was necessary to complete an annual competency based on each staff's position and title, because the facility needed to make sure each staff member was skilled and competent in their skills of caring for the residents. The DON stated if RNA staff competencies were not completed annually, then it was possible that RNA treatment was not completed properly and residents could be injured.During a review of the facility's policies and procedures (P&P) revised 10/2017, titled Staff Competencies, the P&P indicated performance evaluations review the work each employee performs, knowledge of their job and are to ensure that staff has the appropriate competencies and skills to assure resident safety and to provide care and responding to resident needs. The P&P also indicated RNAs will have annual performance evaluations.2. During an interview on 8/18/2026 at 9:59 a.m., with RNA 1, RNA 1 stated she completed RNA tasks such as assisting with eating, hygiene, applying and removing splints, and ROM exercises.During a concurrent interview and record review on 8/19/2026 at 1:03 p.m., with the DSD, RNA 1's RNA competency evaluation dated 2/24/2026 was reviewed. DSD stated RNA 1's RNA competency evaluation did not include a skills assessment of applying and removing splints. DSD stated a revised version of the RNA competency evaluation was provided by the corporate office in March 2026 that added a competency skills check for splinting, but the facility did not complete the revised RNA competency checklist to include assessing RNA 1's skills with applying and removing splints. DSD stated it was important to assess a RNA's skill with applying and removing splints because the facility needed to ensure RNA staff applied and removed splints correctly. DSD stated if RNA staff did not apply and remove splints correctly, then splints could cause wounds on residents and could cause injuries to residents. DSD stated the facility needed to evaluate the skills that staff were performing every day.During an interview on 8/19/2026 at 3:19 p.m., with the DON, DON stated the RNA program was a nursing program to help residents maintain their function and joint mobility and prevent any further decline. The DON stated there were designated staff that performed the RNA program and RNA staff completed RNA-specific competency evaluations every year. The DON stated the previous RNA competency evaluation did not include splinting and it was important for RNA staff to be evaluated in their competency to apply and remove splints. The DON stated if RNA staff competencies were not completed annually, then it was possible that RNA treatment was not completed properly and residents could be injured.During a review of the facility's policies and procedures (P&P) revised 10/2017, titled Staff Competencies, the P&P indicated performance evaluations review the work each employee performs, knowledge of their job and are to ensure that staff has the appropriate competencies and skills to assure resident safety and to provide care and responding to resident needs. The P&P also indicated RNAs will have annual performance evaluations.During a review of the facility's P&P revised 5/2017, titled, Splint Application, the P&P indicated it is the policy of the facility that splints be applied correctly to maintain the resident's range of motion and prevent contractures and further loss of range of motion.

Based on observation, interview, and record review, the facility failed to ensure the ice machine was maintained in a clean condition each month and free of brown grime, green slime, hard water deposits, and buildup.This failure had the potential to cause residents to experience foodborne illness (illness cause by food contaminated with bacteria, viruses, parasites, or toxins ) and other microbial infections.Findings:During a concurrent observation and interview on 8/17/2026 at 8:17 a.m. with Dietary Aide (DA) 1, the inside of the ice machine had brown grime, slime and hard water build up. The DA 1 stated the Maintenance Supervisor (MS) 1 was responsible for cleaning the ice machine.During an observation on 8/17/2026 at 1:42 p.m. signs were posted on the ice machine indicating a warning that the ice machine equipment was under repair, do not operate and do not use until further notice.During a concurrent interview and record review on 8/20/2026 at 1:14 p.m., with MS 1, reviewed the facility's Ice Machine Maintenance Schedule dated 2026. The schedule indicated the ice machine was cleaned and sanitized on 7/2/2026 and again on 8/17/2026 during the survey. MS 1 stated the ice machine needed to be cleaned monthly to prevent hard water buildup and slime. MS 1 stated it was very important to keep the ice machine clean because residents could get sick.During a review of the facility P&P titled Cleaning Instructions for Ice Machines, dated 11/2017, the P&P indicated descaling should be scheduled at a minimum of twice per year but no more than once per month. Descaling dissolves the mineral deposits on the evaporator and other surfaces. It removes scale, calcium, lime scale and other mineral buildup.sanitizing should be performed after each descaling but no more than once per month. Sanitizing disinfects the machine and removes microbial growth including mold and slime.

Based on interview and record review, the facility failed to complete occupational therapy (OT, rehabilitative profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities), physical therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function), and speech and language pathology (SLP, profession that identifies, assesses, and treats speech, language, cognitive communication and swallowing disorders) evaluations and discharge summaries in a timely manner for one of nine sampled residents (Resident 78). This deficient practice had the potential for inaccurate and incomplete therapy documentation and to delay provision of care for Resident 78.Findings:During a review of Resident 78's admission Record, the admission Record indicated Resident 78 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following cerebral infarction (blockage of the flow of blood brain, causing or resulting in brain tissue death) affecting right dominant side, chronic respiratory failure (any condition that affects breathing function and result in lungs not functioning properly) with hypoxia (low oxygen level in tissues).During a review of Resident 78's Minimum Data Set (MDS, resident assessment tool) dated 8/10/2026, the MDS indicated Resident 78 was independent with daily decision making. The MDS indicated Resident 78 was dependent on staff with oral hygiene, toileting, dressing, and bed to chair transfers and did not walk.During a review of Resident 78's PT Evaluation and Plan of Treatment dated 11/24/2025, the PT Evaluation indicated Resident 78 required skilled PT treatment five times a week for four weeks. The PT Evaluation dated 11/24/2025 was completed and signed on 12/2/2025 (about one week after the PT Evaluation date).During a review of Resident 78's PT Discharge Summary (DC) dated 12/2/2025, the PT DC was completed and signed on 12/7/2025 (five days after the PT DC date).During a review of Resident 78's SLP Evaluation and Plan of Treatment dated 7/4/2026, the SLP Evaluation indicated Resident 78 was at risk for aspiration (accidentally inhaling food or liquid into your lungs) and recommended SLP treatment three times a week for four weeks. The SLP Evaluation was dated 7/4/2026 completed and signed on 7/21/2026 (more than two weeks after the SLP evaluation date).During a review of Resident 78's SLP DC dated 7/25/2026, the SLP DC was completed and signed on 8/3/2026 (more than one week after the SLP DC date).During a review of Resident 78's OT DC dated 12/2/2025, the OT DC was completed and signed on 12/15/2025 (almost two weeks after the OT DC date).During an observation and interview on 8/17/2026 at 9:57 a.m., in Resident 78's room, Resident 78 was sitting up in bed. Resident 78 was able to use both arms to move items around the bed and write on a notepad to communicate. Resident 78 wrote she was waiting to receive her therapy.During a concurrent interview and record review on 8/19/2026 at 11:35 a.m., with Physical Therapist (PT 1), Resident 78's PT and SLP records were reviewed. PT 1 reviewed Resident 78's PT Evaluation dated 11/24/2025 and stated the PT Evaluation was not completed until 12/2/2025. PT 1 stated the PT Evaluation was completed late. PT 1 reviewed Resident 78's PT DC dated 12/2/2025 and stated the PT DC was not completed until 12/2/2025. PT 1 stated the PT DC was completed late. PT 1 reviewed Resident 78's SLP Evaluation dated 7/4/2026 and PT 1 stated the SLP Evaluation was not completed until 7/21/2026. PT 1 stated the SLP Evaluation was completed late. PT 1 reviewed Resident 78's SLP DC dated 7/25/2026 and PT 1 stated the SLP was not completed until 8/3/2026. PT 1 stated the SLP DC was completed late. PT 1 stated therapy staff should complete therapy evaluation and treatment documentation on the same day of service and within 48 hours for discharge summaries. PT 1 stated it was important to complete therapy documentation timely, because a therapist needed to see what evaluation or treatment was completed that day to inform the next therapy treatment. PT 1 stated staff should not complete documentation late, because it could affect the accuracy of the documentation and continuity of care.During a concurrent interview and record review on 8/19/2026 at 12:29 p.m., with Occupational Therapist (OT ) 1, Resident 78's OT records were reviewed. OT 1 reviewed Resident 78's OT DC dated 12/2/2025 and stated the OT DC was completed on 12/15/2025. OT 1 stated the OT DC was completed late. OT 1 stated the expectation for therapy documentation was to complete evaluations and treatment documentation within 24-48 hours and discharge summaries within 72 hours. OT 1 stated it was important to document therapy evaluation, treatment, and DC timely, because the documentation provided information for other staff and professionals to see how the resident was doing in therapy and helped inform the OT assistants in what treatments to perform.During an interview on 8/19/2026 at 3:19 p.m., with the Director of Nursing (DON), the DON stated documentation should be completed the day the service was completed. The DON stated documentation should be completed timely and right away when staff could still remember what happened. The DON stated documentation allowed others to know what was going on with the resident and the resident's progress.During a review of the facility's undated OT Job Description, the OT Job Description indicated job responsibilities included providing comprehensive evaluations, document results, and complete resident's daily documentation and discharge accurately and contemporaneously utilizing designated timelines and state/federal guidelines in a timely fashion.During a review of the facility's undated PT Job Description, the PT Job Description indicated job responsibilities included provide comprehensive evaluations, document results, and complete resident's daily documentation and discharge accurately and contemporaneously utilizing designated timelines and state/federal guidelines in a timely fashion.During a review of the facility's undated SLP Job Description, the SLP Job Description indicated job responsibilities included provide comprehensive evaluations, document results, and complete resident's daily documentation and discharge accurately and contemporaneously utilizing designated timelines and state/federal guidelines in a timely fashion.

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 49) had an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for the use of restraints, failed to implement and document alternative measures before applying restraints, and failed to specify a time period for restraint use.This failure had the potential to cause physical injury and psychological harm.Findings:During a review of Resident 49's admission Record, the admission Record indicated Resident 49 was admitted to the facility on [DATE] with diagnosis including gastrostomy tube (GT- a medical device placed through the abdominal wall directly into the stomach to deliver nutrition, fluids, and medication), encephalopathy (disease or damage affecting the brain), chronic respiratory failure (a long-term condition where the respiratory system fails to properly exchange oxygen and carbon dioxide, causing low blood oxygen), and dysphagia (difficulty swallowing).During a review of Resident 49's History and Physical (H&P), the H&P dated 8/29/2025, the H&P indicated Resident 49 did not have the capacity to understand and make decisions. The H&P indicated resident 49 had a tracheostomy(a surgically created opening made through the front of the neck into the windpipe to provide an alternative airway for breathing).During a review of Resident 49's Minimum Data Set (MDS-a resident assessment tool), dated 6/9/2026, the MDS indicated Resident 49 was dependent (helper does all the effort. Resident does none of the effort to complete activity) on nursing staff for oral hygiene, toileting, showering, dressing, personal hygiene and transferring. The MDS indicated Resident 49 used a physical restraint daily on the limb (arms or legs).During a review of Resident 49's Order Summary Report, dated 9/15/2025, the Order Summary Report indicated Resident 49 had an order to apply left to prevent Resident 49 from scratching and removing the tracheostomy ( tube placed through a surgical opening in the neck directly into the windpipe to help a person breathe) dressing.During a review of Resident 49's Physician Order, dated 8/20/2026 at 7:50 a.m. the Physician Orders indicated an order to apply a left-hand mitten to prevent Resident 49 from scratching himself and pulling on the GT and to release the left hand mitten for 15 to 20 minutes every two hours for circulation, skin integrity and comfort. The Physician Order indicated an informed consent was obtained from Resident 49's resident representative.During a interview on 8/20/2026 at 11:26 a.m., with Registered Nurse Supervisor (RNS) 1, RNS 1 stated Resident 49 had an order for a left hand mitten (padded, soft gloves placed over a patient's hands to prevent them from pulling on medical tubing, scratching wounds, or disrupting treatment) to prevent him from scratching and pulling his gastrostomy tube (GT). RNS 1 stated there was no documented consent for the restraint in Resident 49's medical record. RNS 1 stated consent should have been obtained before carrying out the restraint order. RNS 1 stated Resident 49 should not have been wearing the left hand mitten without a signed consent, so the responsible party would be informed of the risks and benefits of the restraint.During a concurrent interview and record review on 8/20/2026 at 1:55 p.m., with the Assistant Director of Nursing (ADON), Resident 49's Physician Order dated 8/20/2026 was reviewed. The ADON stated the order had been clarified on 8/20/2026 because Resident 49 no longer had a tracheostomy dressing. The ADON stated the physician's order did not specify the period the restraint should be used. She stated she frequently checked the residents .as an alternative measure but failed to attempt least restrictive alternatives. The ADON stated Resident 49 did not have a documented consent for the restraint and admitted she assumed the consent was in the chart. She stated consent was necessary to ensure the party responsible agreed with the plan of care. The ADON stated that if the duration of restraint use was not specified in the order, the resident could develop skin issues and increased restlessness.During a review of the facility's Policy and Procedure (P&P), titled Physical Restraint, dated 9/2017, the P&P indicated it is the policy of the facility that restraints will only be used after other alternatives have been tried unsuccessfully and only thorough assessment, informed consent from the resident or their responsible party, a physician's order and a plan of care to address the use of the restraints.Least restrictive measures shall be assessed prior to the use of an actual restraint.Written orders for the use of restraints should specify the use of the restraint and clearly include the following: Orders indicating the specific reason, type and period of time for their use .

Based on observation, interview, and record review, the facility failed to provide appropriate services and treatments to maintain or prevent further decline in joint range of motion (ROM, full movement potential in a joint) for two of nine sampled residents (Residents 38 and 48) when the facility failed to:1a. Provide a safe wear time parameter for application and removal of Resident 38's left elbow splint (rigid material or apparatus used to support and immobilize an impaired joint) and left knee splint.1b. Document the application and removal of Resident 38's left elbow splint and left knee splint.1c. Objectively measure Resident 38's ROM impairments in the upper extremities during an Occupational Therapy (OT, rehabilitative profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Evaluation dated 9/30/2025.2. Objectively measure Resident 48's ROM impairments in the upper extremities during an OT Evaluation dated 8/12/2026.These deficient practices had the potential to prevent accurate monitoring of ROM impairments and cause worsening of contracture (a permanent tightening of muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) and a decline in joint mobility in Residents 38 and 48. The deficient practice also had the potential for injury, pain, and skin integrity issues to Resident 38 when wearing splints. Findings:1. During a review of Resident 38's admission Record, the admission Record indicated Resident 38 initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following cerebrovascular disease (disease of the blood vessels, especially blood vessels to the brain) affecting left dominant side and type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 38's Minimum Data Set (MDS, resident assessment tool) dated 7/13/2026, the MDS indicated Resident 38 had moderate cognitive impairment (ability to think, understand, learn, and remember). The MDS indicated Resident 38 had functional limitations in ROM on both sides of the upper extremities (UE, shoulder, elbow, wrist, hand) and both sides of the lower extremities (LE, hip, knee, ankle, foot). The MDS indicated Resident 38 required substantial assistance with oral hygiene, dressing, sit to lying and required dependent assistance on staff with bed to chair transfers.During an observation and interview on 8/17/2026 at 9:30 a.m., in Resident 38's room, Resident 38 was lying in bed. Resident 38's left elbow was bent more than halfway and the left wrist and fingers were straight. Resident 38 stated she could not move her left arm and leg and used the right arm to try to straighten the left elbow a little.1a. During a review of Resident 38's Occupational Therapy Evaluation and Plan of Treatment (OT Evaluation) dated 9/30/2025, the OT Evaluation indicated a goal for Resident 38 to safely wear an elbow extension splint on the left elbow for up to six hours with minimal signs and symptoms of redness, swelling, discomfort or pain. During a review of Resident 38's OT Treatment Encounter Note (TEN) dated 11/24/2025, the OT TEN indicated Resident 38 tolerated wearing a left elbow extension splint for about two hours with no complaints of pain and no signs of skin redness or skin breakdown noted.During a review of Resident 38's OT Discharge Summary (DC) dated 11/24/2025, the OT DC indicated Resident 38 tolerated and safely wore an elbow extension splint on the left elbow for two hours and was not able to meet the OT goal to safely wear an elbow extension splint on the left elbow for up to six hours.During a review of Resident 38's Physical Therapy Evaluation and Plan of Treatment (PT Evaluation) dated 10/2/2025, the PT Evaluation indicated a goal for Resident 38 to safely wear a knee extension splint on left knee for up to five hours and minimal signs and symptoms of redness, swelling, discomfort or pain.During a review of Resident 38's PT TEN dated 11/24/2025, the PT TEN indicated Resident 38's left knee splint tolerance was three hours without skin breakdown and redness noted.During a review of Resident 38's PT DC dated 11/24/2025, the PT DC indicated Resident 38 safely wore a knee extension splint on the left knee for three hours and did not meet the PT goal to safely wear a left knee extension splint for up to five hours with minimal signs and symptoms of redness, swelling, discomfort or pain.During a review of Resident 38's Order Summary Report dated 8/1/2026, the Order Summary Report indicated the following orders:-order dated 12/1/2025 for Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) to apply left knee extension splint four to six hours a day, once a day, five times a week as tolerated.-order dated 1/29/2026 for RNA program to apply left elbow extension splint five days a week two to five hours as tolerated, check for and signs of skin intolerance/redness.During a review of Resident 38's Care Plan titled Risk for Contracture dated 7/13/2026, the Care Plan indicated Resident 38 was at risk for joint contracture and further joint contracture. The Care Plan approach plan indicated RNA to apply left knee extension splint four to six hours a day as tolerated, RNA to apply left elbow extension splint five times a week two to five hours as tolerated.During a concurrent interview and record review on 8/19/2026 at 11:35 a.m., with Physical Therapist (PT 1), Resident 38's PT records were reviewed. PT 1 stated Resident 38 was seen for PT to establish a safe wearing tolerance for a left knee splint. PT 1 stated upon PT DC on 11/24/2025, Resident 38's maximum tolerance for a left knee splint was three hours. PT 1 reviewed Resident 38's RNA orders and stated the RNA order indicated for RNA to apply the left knee splint for four to six hours. PT 1 stated the RNA order should have indicated for RNA to apply the left knee splint for a maximum of three hours, because three hours was the maximum time PT assessed Resident 38 could safely tolerate the left knee splint. PT 1 stated four to six hours could be too much time to wear the splint and could cause pain or skin breakdown. PT 1 stated if PT did not assess Resident 38 wearing the splint for more than three hours, then PT could not know if Resident 38 could wear the splint longer than three hours without complications.During a concurrent interview and record review on 8/19/2026 at 12:29 p.m., with Occupational Therapist (OT 1), Resident 38's OT records were reviewed. OT 1 reviewed Resident 38's OT DC dated 11/24/2025 and stated Resident 38 tolerated the left elbow splint for only two hours. OT 1 reviewed Resident 38's current RNA orders and stated the RNA order indicated for RNA to apply the left elbow splint for two to five hours. OT 1 stated the RNA order should be for RNA to apply the left elbow splint for a maximum of two hours, because the RNA order should only include the maximum safe wearing time OT established for Resident 38. OT 1 stated during OT treatment, OT staff assessed the proper fit for a splint and slowly increased a resident's tolerance to the splint and monitored the skin, because a splint could cause skin irritation, redness, and wounds if it was not properly assessed and monitored for tolerance.During a review of the facility's policies and procedures (P&P) dated 1/2014, titled, Restorative Nursing and Documentation, the P&P indicated the facility shall provide residents with appropriate treatment and attention to maintain or improve his/her abilities and ROM will not deteriorate.During a review of the facility's P&P revised 5/2017, titled, Splint Application, the P&P indicated It is the policy of the facility that splints be applied correctly to maintain the resident's range of motion and prevent contractures and further loss of range of motion.1b. During a review of Resident 38's August 2026 RNA flowsheet, the RNA flowsheet indicated an RNA staff initial for completion of the RNA order to apply left knee extension splint four to six hours a day, five times a week as tolerated. The RNA flowsheet did not document application and removal of Resident 38's left knee extension splint. During a review of Resident 38's August 2026 RNA flowsheet, the RNA flowsheet indicated an initial for completion of the RNA order to apply left elbow extension splint two to five hours a day, five times a week as tolerated. The RNA flowsheet did not document application and removal of Resident 38's left elbow extension splint. During a concurrent interview and record review on 8/19/2026 at 10:28 a.m., with Restorative Nursing Aide (RNA 2), Resident 38's August 2026 RNA flowsheet was reviewed. RNA 2 stated RNA staff only initialed on the date the RNA treatment was performed. RNA 2 stated there was nowhere on the flowsheet for RNAs to document when a splint was applied and removed every day. RNA 2 stated the RNA weekly summary only included the RNA orders and general splint wear time, but did not document how many specific hours a resident wore each splint each day. RNA 2 stated sometimes Resident 38 wore the left elbow splint for two or three hours and the left knee splint for usually three hours, but the RNA documentation did not reflect the hours Resident 38 wore each splint. RNA 2 stated the application and removal of a splint was important to monitor because the time informed us if a resident could tolerate the splint so that we can report any changes to our supervisor and therapy.During an interview and record review on 8/19/2026 at 12:29 p.m., with OT 1, OT 1 stated splints could cause skin irritation, redness, and wounds to develop if the splint could not be tolerated and worn for too long.During a concurrent interview and record review on 8/19/2026 at 3:19 p.m., with the Director of Nursing (DON), Resident 38's August 2026 RNA flowsheet was reviewed. The DON stated Resident 38's RNA flowsheet did not monitor and document each splint was applied and removed. The DON stated it was important to monitor when each splint was applied and removed, because staff needed to know how long Resident 38 tolerated wearing each splint each day.During a review of the facility's policies and procedures (P&P) dated 1/2014, titled, Restorative Nursing and Documentation, the P&P indicated the staff providing the program shall document the date, the modality, length in minutes when applicable and initial or sign each time the service/treatment is provided.1c. During a review of Resident 38's Occupational Therapy Evaluation and Plan of Treatment dated 9/30/2025, the OT Evaluation indicated Resident 38 had impaired ROM in the left shoulder, left elbow, left wrist, left hand, left thumb, left index finger, left middle finger, left ring finger and left little finger. The OT Evaluation did not indicate objective measurements of the impaired ROM in the left upper extremity joints.During an interview and record review on 8/19/2026 at 12:29 PM with OT 1, Resident 38's OT records were reviewed. OT 1 reviewed Resident 38's OT Evaluation dated 9/30/2025 and stated the OT Evaluation did not indicate the severity of Resident 38's joint impairments and degrees of movement on the left shoulder, elbow, wrist, and fingers. OT 1 stated anyone reading the OT evaluation could not know what the joint impairments were at the left upper extremity joints. OT 1 stated during OT evaluations, OTs should use a goniometer (an instrument used to measure precise angles in joint range of motion) and measure the joint limitations in degrees of movement, because it provided a baseline of joint movement for the resident and helped to create any goals to increase joint ROM or prevent any more declines in ROM. OT 1 stated the objective degrees of ROM also provided information on participation limitations in OT.During a review of the facility's policies and procedures (P&P) revised 10/2017, titled, Limitations in Range of Motion and Mobility and Referrals for Therapy, the P&P indicated the resident's comprehensive assessment should include and measure a resident's current extent of movement and identification of any limitations and opportunity for improvement.During a review of the facility's undated OT Job Description, the OT Job Description indicated job responsibilities included provide comprehensive evaluations using standardized or non-standardized test, document results, and interpret findings.2. During a review of Resident 48's admission Record, the admission Record indicated Resident 48 was admitted to the facility on [DATE] with diagnoses including, but not limited to contracture of muscle, chronic respiratory failure (any condition that affects breathing function and result in lungs not functioning properly) with hypoxia (low oxygen level in tissues). During a review of Resident 48's MDS dated [DATE], the MDS dated indicated Resident 48 rarely made herself understood and rarely had the ability to understand others. The MDS indicated Resident 48 had functional limitations in ROM on both sides of the upper extremities and both sides of the lower extremities. The MDS indicated Resident 48 required dependent assistance on staff with oral hygiene, dressing, bathing, and bed to chair transfers.During a review of Resident 48's Resident Therapy CP dated 8/12/2026, the CP indicated Resident 48 was receiving OT for orthotic (custom-designed or over-the-counter devices-such as shoe inserts, heels, or braces-used to support, align, or improve the function of the foot and lower skeletal system) management, therapeutic exercises and activities.During a review of Resident 48's Occupational Therapy Evaluation and Plan of Treatment dated 8/12/2026, the OT Evaluation indicated Resident 48 had impaired ROM in the right wrist, right hand, left wrist and left hand and recommended wrist hand finger orthoses for both wrists/hands/fingers. The OT Evaluation did not indicate objective measurements of the impaired ROM in both wrists and hands. During an observation on 8/17/2026 at 9:54 AM in Resident 48's room, Resident 48 was lying asleep in bed. Resident 48's elbows were bent and both knees were bent. During an interview and record review on 8/19/2026 at 12:29 PM with OT 1, Resident 48's OT records were reviewed. OT 1 reviewed Resident 48's OT Evaluation dated 8/12/2026 and stated the OT Evaluation did not indicate the severity of Resident 48's joint impairments and degrees of movement in both wrists and fingers. OT 1 stated anyone reading the OT evaluation could not know what the joint impairments were at the wrist and finger joints. OT 1 stated during OT evaluations, OTs should use a goniometer ( an instrument used to measure the range of motion and angles of joints in the human body) and measure the joint limitations in degrees of movement, because it provided a baseline of joint movement for the resident and helped to create any goals to increase joint ROM or prevent any more declines in ROM. OT 1 stated the objective degrees of ROM also provide information on participation limitations in OT.During a review of the facility's P&P revised 10/2017, titled, Limitations in Range of Motion and Mobility and Referrals for Therapy, the P&P indicated the resident's comprehensive assessment should include and measure a resident's current extent of movement and identification of any limitations and opportunity for improvement.During a review of the facility's undated OT Job Description, the OT Job Description indicated job responsibilities included provide comprehensive evaluations using standardized or non-standardized test, document results, and interpret findings.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 40) was not administered expired long acting insulin (medication that lowers blood sugar). This failure had the potential to result in uncontrolled blood sugar levels for Resident 40 due to the use of expired insulin.Findings:During a review of Resident 40's admission Record, the admission Record indicated, Resident 40 was admitted to the facility on [DATE] and readmitted on [DATE] with the diagnosis including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (high blood pressure) and muscle weakness.During a review of Resident 40's History and Physical (H&P) dated [DATE], the H&P indicated, Resident 40 had fluctuating (changes) capacity to understand and make decisions.During a review of Resident 40's Minimum Data Set (MDS - a resident assessment tool) dated [DATE], the MDS indicated, Resident 40 had moderate cognitive (ability to think, understand, learn, and remember) impairment. The MDS indicated, Resident 40 was dependent (helper does all the work) with activities of daily living (ADLs activities such as bathing, dressing, and toileting a person performs daily). The MDS indicated that Resident 40 had a diagnosis of DM. The MDS indicated that Resident 40 was receiving insulin.During a review of Resident 40's Order Summary Report dated [DATE], the Order Summary report indicated, Resident 40 had orders for Lantus insulin to inject (to push a liquid, gas, or substance into a body, tissue, or object using a sharp tool like a needle and syringe) 10 units (unit of measure) subcutaneously (under the skin) at bedtime for DM.During a review of Resident 40's Medication Administration Record (MAR) dated [DATE], the MAR indicated, Resident 40 was administered Lantus insulin on [DATE], [DATE], [DATE] and [DATE] at 9:00 p.m.During a review of Resident 40's Care Plan titled At Risk For Hypoglycemia (low blood sugar) or Hyperglycemia (high blood sugar) related to (r/t) DM dated [DATE] and revised [DATE]. The care plan indicated, Resident 40 was prescribed Lantus insulin and to give as ordered.During a concurrent observation and interview on [DATE] at 3:53 p.m. with Licensed Vocational Nurse 1 (LVN 1), at medication cart 2, Resident 40's Lantus insulin was observed to have an open date of [DATE] and an expiration date of 28 days after opened. LVN 1 stated Resident 40's insulin expired four days ago and should not have been given to Resident 40. LVN 1 stated there was a potential for Resident 40 to have an adverse reaction (any unexpected, harmful, or unwanted effect caused by a medication) when administered expired insulin.During an interview on [DATE] at 4:20 p.m. with the Director of Nurses (DON), the DON stated insulin should be discarded 28 days after it was opened. The DON stated the medication would no longer be effective and there was a potential for Resident 40's DM to not be managed and Resident 40 could become hyperglycemic (high blood sugar).During a review of the facilities Policy and Procedures (P&P) titled Medication Storage in the Facility dated 4/2008, the P&P indicated, medications and biologicals (medication) are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The P&P indicated, 28 days after injectable insulin is opened it expires.

Based on interview and record review, the facility failed to ensure residents, at high risk for falls and injuries, received fall prevention interventions for one of three sampled residents (Resident 1).The facility failed to:1.Ensure Certified Nursing Assistant (CNA) 1 was aware of Resident 1's high fall-risk status.2. Ensure Resident 1's physician (MD) orders dated 2/12/2026 for fall prevention devices including floor mats (cushioned pads placed on the floor besides a resident's bed to decrease the impact of a fall) and bilateral bolsters (firm, padded foam cushions placed along the sides of a bed to act as soft, safe bumpers to prevent residents from rolling out of bed) were not discontinued on 2/13/2026, despite Resident 1 continuing to be assessed as high risk for falls and injuries.3. Implemented Resident 1's care plan titled High Risk for Injury, initiated 2/12/2026, which indicated staff will provide a safe environment for the resident to prevent injuries.4. Follow its policy and procedure (P&P) titled Fall Risk & Prevention of Injury to Include Pathological Fractures (broken bone that occurs in an area weakened by an underlying disease or condition), revised 3/2019, which indicated the facility will provide floor mats at residents' bedside to prevent falls and/or fractures (broken bone).As a result of these failures Resident 1 fell from the bed to the floor on 5/2/2026, sustained multiple injuries, including a left parietal (part of the brain) subdural hematoma (a serious medical condition where blood pools between the brain and the skull, specifically in the upper-middle section of the head), right transverse process fracture (broken bone in one of the tiny, wing-like bumps on the side of spine's bones), of Cervical (C1-neck) and right humeral head (upper arm bone) dislocation (when bones are pulled out of the normal position like the shoulder or finger) and fracture (broken bone at the top of the upper arm), a left seventh (7th) rib fracture, and a right femoral neck fracture, (a broken bone in the hip, right at the narrow neck of the thigh bone), right periorbital ( eyelid and the soft skin around eye ) swelling, and bruising (skin discoloration) with acute skin tears (a sudden accidental scrape or cut where the top layers of your skin peel back) to the upper extremity (arms and hands), and with bilateral pleural effusions (when extra fluid is trapped in the lining around both lungs). Resident 1 was transferred to two general acute care hospitals (GACH 1 and 2) for evaluation and treatment. 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 re-admitted to the facility on [DATE]. Resident 1's diagnoses included encephalopathy (any disease, damage, or malfunction that affects the brain's structure or function), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), chronic respiratory failure (develops when the lungs cannot get enough oxygen into the blood) dependent on respirator (a medical device to help support or replace breathing), tracheostomy (a surgically created hole in the neck leading directly into the windpipe, to help a resident breathe), and contracture (a permanent tightening of muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) of both lower leg.During a review of Resident 1's Care Plan titled High Risk for Injury, initiated on 2/12/2026, the Care Plan indicated Resident 1 was identified to be a high risk for injury related to poor safety awareness, dementia (a progressive state of decline in mental abilities), and encephalopathy. The Care Plan goal indicated Resident 1 would have no injury for three months. The Care Plan interventions included implementing fall precautions and provided a safe environment for the resident.During a review of Resident 1's Care Plan titled At Risk for Falls and Injuries initiated on 2/12/2026, the Care Plan indicated Resident 1 was a high risk for falls related to general weakness, encephalopathy, cognitive decline (inability to think, understand, learn, and remember) and restlessness. The Care Plan goal indicated the facility will minimize the risk of falls. The Care Plan interventions indicated the facility will provide fall precaution interventions for Resident 1.During a review of Resident 1's Care Plan titled At Risk for Fracture, initiated on 2/12/2026, the Care Plan indicated Resident 1 was high risk for fracture related to contractures (a permanent tightening of muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) poor safety awareness, and cognitive impairment. The Care Plan goal indicated the facility will minimize the risk of fracture. The Care Plan interventions included to always handle Resident 1 gently and carefully, maintain his bed in lowest position, and provide one to two-person assist with Activities of Daily Living (ADLs- activities such as bathing, dressing, toileting a person performs daily).During a review of Resident 1's Order Details dated 2/12/2026, the Order Details indicated bilateral floor mats and bilateral bolsters for added safety.During a review of Resident 1's Order Details 2/13/2026, the Order Details indicated the bilateral floor mats and bilateral bolster were discontinued.During a review of Resident 1's Licensed Personnel Progress Notes dated 2/13/2026, Progress Notes indicated Resident 1 did not require the use of bolster and floor mats because the resident did not move and was dependent (helper does all the effort and assistance of two or more helpers was required) on staff for mobility.During a review of Resident 1's Fall Risk Evaluation dated 3/2/2026, the Fall Risk Evaluation indicated Resident 1 was at high fall risk.During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 3/2/2026, the MDS indicated Resident 1's cognition was severely impaired. The MDS indicated Resident 1 was dependent (helper does all the effort. Assistance of two or more helpers is required to complete the activity) with ADLs and roll left and right (ability to roll from lying on back to left and right side, and return to lying on back on the bed)During a review of Resident 1's Emergency Medical Services (EMS- team of trained professionals who provide immediate medical care and transport to a hospital when 911 is called) Run Sheet dated 5/2/2026 at 6:01 p.m., the Paramedic Run Sheet indicated Resident 1 was observed sitting in hospital bed. EMS Run Sheet indicated facility staff were changing Resident 1's incontinent brief (diaper) when Resident 1 rolled out of the bed onto the floor. The Paramedic Run Sheet indicated Resident 1 had an abrasion (superficial wound), and a hematoma (localized collection of blood) to the top of his head, swelling and bruising to his right eye.During a review of Resident 1's GACH 1 Emergency Documentation (ED) Physician Note dated 5/2/2026 at 6:51 p.m., the note indicated upon EMS arrival to Resident 1's room, Resident 1 was back in bed and it was unknown how Resident 1 fell given that he did not have a range of mobility (the ability to move freely and independently) at baseline. The Note indicated contrary to nursing home report to EMS, staff informed MD 1 that the resident was accidentally dropped during cleaning.During a review of Resident 1's GACH 1 Emergency Documentation dated 5/3/2026 at 12:14 a.m., the Note indicated Resident 1 had a left subdural hematoma, fracture of the right transverse process of cervical neck which was immobilized (held in place to restrict movement) with a cervical collar (a device used to support the head, immobilize the neck, and limit movement ), right shoulder fracture and dislocation, supported in sling (device used to immobilize, and protect an injured arm and shoulder) and left seventh rib fracture. The note indicated attempts to reduce Resident 1's shoulder dislocation were unsuccessful, and the resident was transferred to GACH 2 for higher level of care (more intensive medical treatment).During a review of Resident 1's GACH 2's History of Present Illness report dated 5/3/2026, the report indicated Resident 1 was transferred from GACH 1 for higher level of care following a fall which resulted in injuries at a facility, where the resident resided. The report indicated Resident 1 had a left parietal subdural hematoma, right transverse process fracture of cervical neck and right humeral head dislocation and fracture, a left 7th rib fracture, and a right femoral neck fracture, right periorbital swelling, and bruising, with acute skin tears to his upper extremity, and bilateral pleural effusions. Resident 1 was hypotensive (low blood pressure), on two vasopressors (lifesaving medications used when patient's blood pressure drops to dangerous or fatal levels). The report indicated Resident 1 was admitted to the intensive care unit ([ICU- specialized hospital department that provides round-the-clock monitoring and life support for patients with life-threatening injuries). The report indicated neurosurgery (medical specialty that focuses on diagnosing and treating conditions that affect the brain, spine, and nervous system) and orthopedic surgery (medical specialty that focuses on the diagnosis, treatment of injuries of the bones) were consulted and both determined Resident 1 was not a candidate for any surgical intervention. Resident 1's right upper extremity was stabilized with a sling.During a phone interview on 5/7/2026 at 3:54 p.m., with CNA 1, CNA 1 stated Resident 1 did not roll from side to side on his own. CNA 1 stated on 5/2/2026, after she finished changing Resident 1's incontinent brief (diaper), she centered Resident 1 in the middle of the bed, turned him onto his left side, placed a wedge (a triangular, firm foam cushion used to support the body in bed) behind his back, and positioned a pillow between his legs to keep him in place. CNA 1 stated she lowered the bed to the lowest position and, when she turned her back to dump the dirty linens into the cart at the entrance of the room, she heard a thump ( dull sound made by something falling or hit something with a heavy blow), turned around, and saw Resident 1 on the floor, lying face down on his stomach. CNA 1 stated no floor mats or bolsters were in place at the time of the fall and that Resident 1 should have had floor mats because he was frail (physically weak; delicate, or not very healthy).During an interview on 5/7/2026 at 4:06 p.m., with CNA 2, CNA 2 stated Resident 1 was unable to move on his own and required assistance to move from side to side because he was contracted. CNA 2 stated Resident 1 did not have a floor mat or side rails. CNA 2 stated Resident 1 should have had side rails and floor mats in place for his safety, to prevent falls or injuries, and because he wiggled in bed.During a phone interview on 5/8/2026 at 3:59 p.m., with Registered Nurse (RN) 1, RN 1 stated when she entered Resident 1's room after the fall, she found him lying face down on his stomach. RN 1 stated he did not show signs of pain or discomfort and was not agitated or restless. RN 1 stated Resident 1 was a high fall risk and his interventions included keeping his bed low and performing visual checks. RN 1 stated if floor mats had been in place, that would have reduced the impact of the fall and the severity of Resident 1's injuries.During an interview on 5/8/2026 at 4:47 p.m. with CNA 1 in Resident 1's room, CNA 1 stated she was not aware Resident 1 was a high fall risk. CNA 1 stated not knowing this information could lead staff to fail to implement appropriate fall prevention interventions such as ensuring floor mats were in place and calling for help during care. CNA 1 stated Resident 1 was at risk for falls and injuries.During a concurrent interview and record review on 5/11/2026 at 10:46 a.m., with the Director of Nursing (DON), Resident 1's Progress Notes dated 2/12/2026 was reviewed. The note indicated Resident 1 did not require the use of bolsters and floor mats because the resident did not move and was dependent on staff for mobility. The DON stated Resident 1 had contractures in both lower legs, limited movement in his right arm, and weakness in his left arm. The DON stated Resident 1 was unable to move or turn himself and required maximum assistance for moving, turning, and rolling. The DON stated Resident 1's fall risk score from 3/2026 was 16, indicating a high fall risk.During a review of the facility's P&P titled, Safety and Supervision of Residents, revised 2/2019, the P&P indicated, It is the policy of the facility to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.During a review of the facility's P&P titled, Fall Risk & Prevention of Injury to Include Pathological Fractures, revised 3/2019, the P&P indicated, Approaches to prevent falls and/or fractures may include providing floor mats at the bedside.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was not moved following a fall from the bed to the floor. The facility failed to:1.Ensure Certified Nursing Assistant (CNA) 1 and facility staff safely cared for Resident 1 by leaving him in place on the floor until paramedics arrived, as required for suspected head, neck, or spinal injuries after a fall on 5/2/2026.2.Ensure staff followed Resident 1's Care Plan titled At Risk for Fractures initiated 2/12/2026, which indicated, the facility must minimize the risk for fracture (broken bone) by assessing for possible risks sustain a fracture such as unsafe transfers.3.Ensure staff followed the facility's policy and procedure (P&P) titled Falls by a Resident, revised 7/2017, which directed staff not to move a resident after a fall until assessed by a licensed nurse.These failures resulted in improper movement of Resident 1after falling from the bed to the floor on 5/2/2026 at approximately 5:30 p.m., Resident 1 sustained right periorbital ( eyelid and the soft skin around eye ) swelling, and bruising (skin discoloration) with acute skin tears (a sudden accidental scrape or cut where the top layers of your skin peel back) to the upper extremity (arms and hands). Resident 1 was transferred to a general acute care hospital (GACH) for evaluation and treatment via 911 on 5/2/2026 at approximately 6:15 p.m. Resident 1 sustained multiple injuries, including a left parietal (part of the brain) subdural hematoma (a serious medical condition where blood pools between the brain and the skull, specifically in the upper-middle section of the head), right transverse process fracture (broken bone in one of the tiny, wing-like bumps on the side of spine's bones), of Cervical neck (C1) and right humeral head (upper arm bone) dislocation (when bones are pulled out of the normal position like the shoulder or finger) and fracture (broken bone at the top of the upper arm), a left seventh (7th) rib fracture, and a right femoral neck fracture, (a broken bone in the hip, right at the narrow neck of the thigh bone). 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 re-admitted to the facility on [DATE]. Resident 1's diagnoses included encephalopathy (any disease, damage, or malfunction that affects the brain's structure or function), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), chronic respiratory failure (develops when the lungs cannot get enough oxygen into the blood) dependent on respirator (a medical device to help support or replace breathing), tracheostomy (a surgically created hole in the neck leading directly into the windpipe, to help a resident breathe), and contracture (a permanent tightening of muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) of both lower leg.During a review of Resident 1's Care Plan titled At Risk for Fracture, initiated on 2/12/2026, the Care Plan indicated Resident 1 was high risk for fracture related to contractures poor safety awareness, and cognitive impairment. The Care Plan goal indicated the facility will minimize the risk of fracture. The Care Plan interventions included to always handle Resident 1 gently and carefully, maintain his bed in lowest position, and provide one to two-person assist with Activities of Daily Living (ADLs- activities such as bathing, dressing, toileting a person performs daily).During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 3/2/2026, the MDS indicated Resident 1's cognition was severely impaired. The MDS indicated Resident 1 was dependent with ADLs and roll left and right (ability to roll from lying on back to left and right side, and return to lying on back on the bed)During a review of Resident 1's Emergency Medical Services (EMS- team of trained professionals who provide immediate medical care and transport to a hospital when 911 is called) Run Sheet dated 5/2/2026 at 6:01 p.m., the Paramedic Run Sheet indicated Resident 1 was observed sitting in hospital bed. EMS Run Sheet indicated facility staff were changing Resident 1's incontinent brief (diaper) when Resident 1 rolled out of the bed onto the floor. The Paramedic Run Sheet indicated Resident 1 had an abrasion (superficial wound), and a hematoma (localized collection of blood) to the top of his head, swelling and bruising to his right eye.During a review of Resident 1's GACH 1 Emergency Documentation (ED) Physician Note dated 5/2/2026 at 6:51 p.m., the note indicated upon EMS arrival to Resident 1's room, Resident 1 was back in bed and it was unknown how Resident 1 fell given that he did not have a range of mobility (the ability to move freely and independently) at baseline. The Note indicated contrary to nursing home report to EMS, staff informed MD 1 that the resident was accidentally dropped during cleaning.During a review of Resident 1's GACH 1 Emergency Documentation dated 5/3/2026 at 12:14 a.m., the Note indicated Resident 1 had a left subdural hematoma, fracture of the right transverse process of cervical neck which was immobilized (held in place to restrict movement) with a cervical collar (a device used to support the head, immobilize the neck, and limit movement ), right shoulder fracture and dislocation, supported in sling (device used to immobilize, and protect an injured arm and shoulder) and left seventh rib fracture. The note indicated attempts to reduce Resident 1's shoulder dislocation was unsuccessful, and the resident was transferred to GACH 2 for higher level of care (more intensive medical treatment).During an interview on 5/8/2026 at 11:48 a.m., with Respiratory Therapist (RT) 1, RT 1 stated when he walked into Resident 1's room after the fall on 5/2/2026, he saw Resident 1 lying on his side while CNA 1 held his head and applied pressure to his forehead. RT 1 stated after RN 1 assessed Resident 1, they rolled him from side to side to place a sheet underneath him and then used the sheet to lift him and return him to the bed.During an interview on 5/8/2026 at 12:48 p.m., with Registered Nurse (RN) 2, RN 2 stated when Resident 1 fell from the bed to the floor, staff should have left him on the floor until the paramedics arrived. RN 2 stated Resident 1 could have had fractures or internal bleeding and moving him could have caused further harm. RN 2 stated Resident 1 had bruising around his eye and a forehead laceration (a rough, tear or cut in the skin and underlying soft tissues, usually caused by blunt trauma [forceful impact]) , which could have resulted from blunt force trauma and required evaluation at the GACH to rule out internal injuries. RN 2 stated it was a common nursing practice not to move a resident when a neck or head injury was suspected.During an interview on 5/8/2026 at 2:06 p.m., with the Director of Staff Development (DSD), the DSD stated CNAs were trained not to move residents after a fall and to wait for the nurse. The DSD stated it was important for CNAs to avoid moving residents after a fall because they did not know whether the resident had injuries, and moving the resident could worsen those injuries and cause further harm.During a phone interview on 5/8/2026 at 3:59 p.m., with Registered Nurse (RN) 1, RN 1 stated when she entered Resident 1's room after he fell, she found him lying face down on his stomach while CNA 1 applied pressure to his forehead. RN 1 stated staff rolled Resident 1 onto his left side to assess him. She stated he had swelling and discoloration around his right eye and an open cut on his forehead which could be a serious head injury. RN 1 stated she believed it was safe to move Resident 1 from the floor back into bed because she completed a neurological assessment (a painless brain and body checkup used to see how well a person's brain, and body are working) and felt he was okay. RN 1 stated Resident 1 remained calm and did not show any signs of pain, discomfort, or restlessness (inability to sit still or relax).During a follow-up interview on 5/8/2026 at 4:47 p.m., with CNA 1. CNA 1 stated she moved Resident 1 from lying on his stomach so she could place her hand under his head and apply pressure with a towel to his bleeding forehead. CNA 1 stated after RN 1 assessed Resident 1, she and three other staff members rolled him from side to side to place a linen sheet underneath him. CNA 1 stated once the linen sheet was in place, each staff member grabbed a corner of the linen sheet and lifted Resident 1 back into the bed. CNA 1 stated RN 1 told them it was safe to move Resident 1 back into bed, which was why they lifted him.During a review of the facility's policy and procedure (P&P) titled, Falls by a Resident, revised 7/2017, the P&P indicated, When a resident sustains a fall, the licensed nurse is to be notified immediately and the resident is not to be moved until assessed by the licensed nurse.Cross Reference F689

Based on observation, interview, and record review, the facility failed to ensure the nursing staff had specific competencies and skills sets necessary to care for one of three sampled residents (Resident 1) needs by failing to:1.Ensure Certified Nurse Assistant (CNA) 1 did not move Resident 1 onto his left side after he fell from the bed to the floor.2.Ensure the nursing staff did not move Resident 1 from the floor back to the bed after Resident 1 fell and sustained a forehead laceration (a rough, tear or cut in the skin and underlying soft tissues, usually caused by blunt trauma [forceful impact]) and bruising his face.3.Ensure CNA 1 was aware of Resident 1's high fall risk status.This failure had the potential to place Resident 1 and other residents at risk for increased harm of unknown internal injuries from the fall.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 re-admitted to the facility on [DATE]. Resident 1's diagnoses included encephalopathy (any disease, damage, or malfunction that affects the brain's structure or function), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), chronic respiratory failure (develops when the lungs cannot get enough oxygen into the blood) dependent on respirator (a medical device to help support or replace breathing), tracheostomy (a surgically created hole in the neck leading directly into the windpipe, to help a resident breathe), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and contracture (a permanent tightening of muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) of both lower leg.During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 3/2/2026, the MDS indicated Resident 1's cognition (ability to think, understand, learn, and remember) was severely impaired. The MDS indicated Resident 1 was dependent (helper does all the effort) with activities of daily living (ADLs- routine tasks such as bathing, dressing, and toileting a person performs daily to care for themselves) and roll left and right (ability to roll from lying on back to left and right side, and return to lying on back on the bed).During a review of Resident 1's Fall Risk Evaluation dated 3/2/2026, the Fall Risk Evaluation indicated Resident 1 was at high fall risk.During a review of Resident 1's Emergency Medical Services (EMS- team of trained professionals who provide immediate medical care and transport to a hospital when 911 is called) Run Sheet dated 5/2/2026 at 6:01 p.m., the Paramedic Run Sheet indicated Resident 1 was observed sitting in hospital bed. EMS Run Sheet indicated facility staff were changing Resident 1's incontinent brief (diaper) when Resident 1 rolled out of the bed onto the floor. The Paramedic Run Sheet indicated Resident 1 had an abrasion (superficial wound), and a hematoma (localized collection of blood) to the top of his head, swelling and bruising to his right eye.During a review of Resident 1's GACH 1 Emergency Documentation (ED) Physician Note dated 5/2/2026 at 6:51 p.m., the note indicated upon EMS arrival to Resident 1's room, Resident 1 was back in bed and it was unknown how Resident 1 fell given that he did not have a range of mobility (the ability to move freely and independently) at baseline. The Note indicated contrary to nursing home report to EMS, staff informed MD 1 that the resident was accidentally dropped during cleaning.During a review of Resident 1's GACH 1 Emergency Documentation dated 5/3/2026 at 12:14 a.m., the Note indicated Resident 1 had a left subdural hematoma (a serious medical condition where blood pools between the brain and the skull, specifically in the upper-middle section of the head), fracture of the right transverse process (broken bone in one of the tiny, wing-like bumps on the side of spine's bones) of cervical neck which was immobilized (held in place to restrict movement) with a cervical collar (a device used to support the head, immobilize the neck, and limit movement ), right shoulder fracture and dislocation (when bones are pulled out of the normal position like the shoulder or finger), supported in sling (device used to immobilize, and protect an injured arm and shoulder) and left seventh rib fracture. The note indicated attempts to reduce Resident 1's shoulder dislocation was unsuccessful, and the resident was transferred to GACH 2 for higher level of care (more intensive medical treatment).During a phone interview on 5/7/2026 at 3:54 p.m., with CNA 1, CNA 1 stated Resident 1 did not roll from side to side on his own. CNA 1 stated on 5/2/2026, after she finished changing Resident 1's incontinent brief (diaper), she centered Resident 1 in the middle of the bed, turned him onto his left side, placed a wedge (a triangular, firm foam cushion used to support the body in bed) behind his back, and positioned a pillow between his legs to keep him in place. CNA 1 stated she lowered the bed to the lowest position and, when she turned her back to dump the dirty linens into the cart at the entrance of the room, she heard a thump ( dull sound made by something falling or hit something with a heavy blow), turned around, and saw Resident 1 on the floor, lying face down on his stomach. CNA 1 stated no floor mats or bolsters were in place at the time of the fall and that Resident 1 should have had floor mats because he was frail (physically weak; delicate, or not very healthy).During an interview on 5/8/2026 at 11:48 a.m. with Respiratory Therapist (RT) 1, RT 1 stated when he entered Resident 1's room after the fall on 5/2/2026, Resident 1 was lying on his side, and CNA 1 was supporting the resident's head with one hand while applying pressure to his forehead with the other. RT 1 stated after Registered Nurse Supervisor (RNS) 1 assessed Resident 1, they rolled the resident from side to side to place a sheet underneath him and then used the sheet to lift Resident 1 back onto the bed.During an interview on 5/8/2026 at 12:48 p.m. with Registered Nurse Supervisor (RNS) 2, RNS 2 stated when Resident 1 fell from the bed to the floor, the resident should have been left on the floor until paramedics arrived. RNS 2 stated Resident 1 could have had fractures or internal bleeding, and moving him could have caused further harm. RNS 2 stated Resident 1 had bruising around his eye and a laceration on his forehead, which could indicate blunt force trauma ( physical injury caused by a forceful impact) and required evaluation at the general acute care hospital (GACH) to rule out internal injuries. RNS 2 stated it was common nursing practice not to move a resident when a head or neck injury was suspected.During an interview on 5/8/2026 at 2:06 p.m. with the Director of Staff Development (DSD), the DSD stated CNAs were trained not to move a resident after a fall and to wait for the nurse to assess the situation. The DSD stated it was important CNAs do not move residents after a fall because they do not know whether injuries were present, and moving a resident could worsen potential injuries and cause further harm.During a phone interview on 5/8/2026 at 3:59 p.m. with Registered Nurse Supervisor (RNS) 1, RNS 1 stated when she entered Resident 1's room after the fall, Resident 1 was lying face down on his stomach, and CNA 1 was applying pressure to the resident's forehead. RNS 1 stated staff moved Resident 1 onto his left side so she could assess him. RNS 1 stated the resident had swelling and discoloration around his right eye and an open cut on his forehead. RNS 1 stated Resident 1 appeared calm and did not show signs of pain or discomfort. She stated she authorized moving Resident 1 because he did not appear to be in distress.During a follow up interview on 5/8/2026 at 4:47 p.m. with CNA 1, CNA 1 stated she moved Resident 1 from lying on his stomach so she could place her hand under his head and apply pressure with a towel to his bleeding forehead. CNA 1 stated after RNS 1 assessed Resident 1, she and three other staff members rolled the resident from side to side to place a sheet underneath him. CNA 1 stated that once the sheet was in place, each staff member held a corner of the sheet and lifted Resident 1 back into the bed. CNA 1 stated RNS 1 told them it was safe to move the resident back to the bed, which was why they proceeded. CNA 1 stated she could not recall whether she had ever received training on moving a resident after a fall.During a review of the facility's policy and procedure (P&P) titled, Falls by a Resident, revised 7/2017, the P&P indicated, When a resident sustains a fall, the licensed nurse is to be notified immediately, and the resident is not to be moved until assessed by the licensed nurse.Cross Reference F684.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had an existing pressure ulcer ([PU] localized damage to the skin and/or underlying tissue usually over a bony prominence) was turned and repositioned at least every two hours. This deficient practice resulted in Resident 2 being left in the same position on his left side for over four hours and had the potential for new PUs to develop and a delay in healing for Resident 1's existing PU.Findings: During a review of Resident 2's admission Record (Face Sheet) the Face Sheet indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including type 2 diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing) without complications, unspecified (a condition where symptoms match a general category, but there is insufficient information or documentation to classify it more specifically) severe protein-calorie malnutrition (inadequate intake of protein and calories causing muscle weakness), and a stage 4 PU (a full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) in the sacral region (area above the buttocks). During a review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool) dated 6/27/2025, the MDS indicated Resident 2 was dependent (resident does none of the effort to complete the activity) on staff to roll from left to right. During a review of Resident 2's Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE] and 12/25/2026, the Braden Scale for Predicting Pressure Sore Risk assessment indicated Resident 2 scored nine (a score of 12 or below represent a high risk of developing PUs, placing Resident 2 at high risk for PUs. During a review of Resident 2's Weekly Pressure Injury Record dated 1/27/2026, the Weekly Pressure Injury Record indicated Resident 2 had a PU to the sacrococcyx measuring 5.7 centimeters ([cm] a unit of measurement) x 3.6 cm x 2.5 cm. During a review of Resident 2's Care Plan dated 2/4/2026, the Care Plan indicated Resident 1 had an alteration in skin integrity with an actual stage 4 pressure injury to the sacrococcyx (area above the buttock) related to immobility. The Care Plan's interventions indicated to turn and reposition Resident 2 at least every two hours and to utilize pillows as repositioning devices. During an observation of Resident 2 on 2/3/2026 at 10:25 a.m., 12:30 p.m., 1:30 p.m., 2:30 p.m., and 2:45 p.m., Resident 2 was observed lying on a low air loss mattress (a specialized therapeutic support surface often featuring alternating, inflating, and deflating air cells, designed to prevent and treat pressure ulcers) positioned on his left side and a wedge under his right buttock. During an interview on 2/3/2026 at 2:45 p.m., Certified Nursing Assistant (CNA) 1 stated Resident 1 could not turn himself and relied on him (CNA 1) to assist him to turn and reposition at least every two hours to prevent skin breakdown. During an interview on 2/3/2026 at 3:30 p.m., Licensed Vocational Nurse (LVN) 1 stated the Treatment Nurse (TN) and the Charge Nurses (CN) were responsible to make sure the residents were turned and repositioned every two hours and as needed. During an interview on 2/4/2026 at 4:12 p.m., the Director of Nursing (DON) stated licensed nurses were responsible for making sure CNAs turn residents every two hours. The DON stated turning was important to prevent pressure ulcers from getting worse and preventing new ones from occurring. During a review of the facility's Policy and Procedure (P&P) dated 5/2019, titled Prevention of Pressures Ulcers the P&P indicated for a resident in bed: a. Change position at least every 2 hours or more frequently as needed:

Based on observation, interview and record review, the facility failed to implement infection control measures for one of two sampled residents (Resident 2) by failing to:1. Ensure Certified Nursing Assistant (CNA)1 and Registered Nurse (RN)1 wore required personal protective equipment (PPE- clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) before entering Resident 2's room who was on contact isolation ( a set of safety steps used in the facility to stop the spread of germs that are passed by touching a patient or contaminated items in the resident's room).This failure had the potential to spread and transmit infections to all residents, staff and visitors.Findings:During an observation and interview on 2/4/2026 in Resident 2's room with CNA1, CNA 1 and RN 1 were inside the room without wearing an isolation gown, and gloves. Resident 2 was observed sitting on his wheelchair while CNA1 and RN 1 held the wheelchair with their bare hands. A sign for Contact Isolation was observed posted on the wall before entering Resident 2's room. CNA 1 stated they were about to put Resident 2 back to bed. CNA 1 stated Resident 2 was on contact precautions because of an urinary tract infection (UTI- an infection in the bladder/ urinary tract).During a review of Resident 2's admission Record, the admission Record indicated the Resident 2 was initially admitted on [DATE] and was readmitted on [DATE] to the facility. Resident 2 had diagnoses including UTI, extended spectrum beta lactamase (ESBL-group of bacteria that are resistant to common antibiotic and difficult to treat), depression (common, serious medical illness characterized by a persistent low mood, sadness, and loss of interest in daily activities) and chronic obstructive pulmonary disease(COPD-progressive lung disease that causes inflammation, damaging the airway and make it difficult to breathe).During a review of Resident 2's Minimum Data Set (MDS- resident assessment tool) dated 12/30/2025, the MDS indicated Resident 2 had moderately impaired cognitive skills ( a person had trouble remembering, learning, making decisions which make daily life challenging) and required substantial/ maximal assistance ( helper does more than half the effort) with transferring to and from a bed to a chair, bathing and toileting hygiene. The MDS indicated Resident was incontinent (unable to control bladder or bowels resulting in leaking urine accidentally) of urine.During a review of Resident 2's Care Plan titled, Resident on Isolation Precautions related to ESBL, dated 2/2/2026, the Care Plan interventions included maintaining contact isolation precautions as indicated and monitoring for signs and symptoms of infection.During a review of Resident 2 SBAR (Situation, Background, Assessment, Recommendation- provides a framework for communication between members of the healthcare team about a resident's condition) Communication Form dated 2/2/2026, the SBAR Communication Form indicated Resident 2 urine culture (a laboratory test that detects and identifies bacteria or yeast in a urine sample to diagnose UTI) was positive for ESBL and the physician was notified.During an interview on 2/4/2026 at 2:42 p.m. with CNA 1, CNA 1 stated he forgot Resident 2 was on contact isolation that's why he did not wear the isolation gown and gloves in the room. CNA1 stated the staff should wear an isolation gown, gloves and mask before entering Resident 2's room because he was on contact isolation.During an interview on 2/4/2026 at 2:59 p.m. with RN 1, RN 1 stated she forgot Resident 2 was on contact isolation and it was a mistake not wearing the proper PPE. RN 1 stated Resident 2 was on contact isolation because of the presence of ESBL in the urine.During a concurrent interview and record review on 2/4/2026 at 3:10 p.m. with the Infection Preventionist Nurse (IPN), Resident 2's urine culture and SBAR dated 2/2/2026 were reviewed. The IPN stated Resident 2's urine culture had ESBL in the urine and required contact isolation. The IPN stated CNA 1 and RN 1 should have worn PPE like gloves and isolation gown before entering the room. The IPN stated every time a staff member enters Resident 2's room, the staff should practice hand hygiene, wear isolation gown and gloves to prevent 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) and spread of infection among residents and staff. During an interview on 2/4/2026 at 5:00 p.m. with the Director of Nursing (DON), the DON stated not practicing contact precautions on Resident 2 could cause spread of infection to other residents and can result in an outbreak (sudden, unexpected increase in the number of disease cases in a specific localized area or group).During a review of facility's policy and procedure (P&P) titled, Infection Control- Transmission Based Precautions, revised 2/2018,the P&P indicated Contact Precautions are intended to prevent transmission of infections that are spread by direct ( person-to-person) or indirect contact with the resident or environment and require the use of gown and gloves upon entering the resident's room.

Based on interview and record review the facility failed to ensure grievances (a perceived wrong or other cause for complaint or protest, especially unfair treatment) made during resident Council (an independent organized group of residents of that facility who meet to discuss concerns, develop suggestions on improving services, and plan social activities) meetings regarding slow call-light response from the 11 p.m. to 7 a.m., shift was promptly addressed and did not negatively affect four of four sampled residents (Resident 1, Resident 2, Resident 3, and Resident 4).This deficient practice had the potential to cause delays in care and as a result of the deficient practice Resident 1, Resident 2, Resident 3, and Resident 4 continued to experience slow response times when pressing the call light during the 11 p.m. to 7 a.m. shift. Resident 1 felt pissed and Resident 2 felt scared due to the slow response times.Findings:1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including Hemiplegia (can't move one side of the body) affecting the left dominant side, contracture of muscle (the permanent shortening and stiffening of muscles, which limits the normal movement of a joint or body part), and osteoporosis (a condition in which there is a decrease in the amount and thickness of bone tissue).During a review of Resident 1's care plan dated 9/9/2024 titled Resident prefers the following, the care plan indicated a goal of Resident 1 adopting healthy coping practices and interventions that included ensuring Resident 1's call light was within reach and answered promptly.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 6/2/2025, the MDS indicated Resident 1 was cognitively (relating to or involving the processes of thinking and reasoning) intact. The MDS indicated Resident 1 required a wheelchair and was dependent (helper does all the effort) for toileting hygiene.2. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses of history of falling and absence of right leg below the knee (right leg missing below the knee).During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 was cognitively intact. The MDS indicated Resident 2 required a wheelchair and needed supervision or touching assistance (resident requires verbal queues or touching/ steadying while the resident performs the task) for toileting and chair to bed transfers.3. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses of injury in a motor-vehicle accident and depression (persistent feelings of sadness that can interfere with daily activities).During a review of Resident 3's care plan titled Activities of Daily Living (ADL, activities related to personal care) Function revised on 6/25/2025, the care plan indicated Resident 3 had general weakness and was dependent on staff for toilet use. The goals for Resident 3 included reducing the risk for fall and skin impairments. Interventions for Resident 3 included placing the call light within reach and answering the call light promptly.During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3's cognition was mildly impaired. The MDS indicated Resident 3 required a wheelchair and required substantial/ maximal assistance (helper does more that half the effort) for toileting hygiene.4. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses of multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves) and neuromuscular dysfunction of bladder (the nerves that carry messages back and forth between the bladder and the spinal cord and brain don't work the way they should, often leading to being unable to control urine).During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4 had mild cognitive impairment. The MDS indicated Resident 4 required substantial/ maximal assistance for toileting.During a review of Resident 4's care plan titled ADL Functional dated 8/5/2025, the care plan goals were reducing the risk for fall and skin impairments, the interventions included ensuring the call light was within reach and answering the call light promptly.During a review of the facility's grievances, a grievance was filed on 6/30/2025 by Resident 2. The grievance indicated Resident 2 raised concerns regarding delayed answering of call lights especially right during the 11 p.m. to 7 a.m. shift.During a review of the facility's Resident Council minutes dated 7/24/2025, the Resident Council minutes indicated the month prior (June 2025) during the Resident Council meeting the resident's brought concerns regarding slow call light response especially during the 11 p.m. to 7 a.m. shift. During the July 2025 meeting the resident were asked are call lights being answered in a timely manner? and the residents responded call lights were slow to be answered during the 11 p.m. to 7 a.m. Shift. The Resident Council minutes indicated Resident 2 complained she was not getting help to go to the toilet.During an interview on 8/20/2025 at 12:04 p.m., Resident 3 stated there were always issues with the call light being answered during the 11 p.m. to 7 a.m. shift. Resident 3 stated she had waited up to two hours for someone to answer her call light (unknown date) and when the staff (unknown) finally came in, Resident 3 asked what were you doing, sleeping? Resident 3 stated the long call light wait times were frustrating because she can't get out of the bed by herself and she wouldn't be pressing the call light if she did not need something. Resident 3 stated the long call light wait times had been discussed during multiple Resident Council meetings and it was still an ongoing issue.During an interview on 8/20/2025 at 12:41 p.m., Resident 1 stated there is a long call light response time for the 11 p.m. to 7 a.m. shift and sometimes she waited an hour or more to get help when she pressed the call light. Resident 1 stated the medication she takes gives her diarrhea, so she gets pissed that no one answers the call light, and she has to sit and wait in her shit. Resident 1 stated she starts phone calling up to the front desk during the 11 p.m. to 7 a.m. shift when the staff are not answering call lights. Resident 1 stated she was not going to the Resident Council meetings anymore because residents always had the same complaints (about 11 p.m. to 7 a.m. shift) and nothing was changing.During an interview on 8/21/2025 at 12 p.m., Resident 2 stated she was a high fall risk because she only had one leg, and the staff were supposed to supervise her while she tried to get up to the toilet. Resident 2 stated she presses the call light, but the staff take too long to come during the 11 p.m. to 7 a.m. shift, so she gets up to use the restroom by herself. Resident 2 stated she felt scared she might fall because she is getting up alone due to staff taking a long time to answer the call light. Resident 2 stated she made a grievance as well as the residents had made complaints about the 11 p.m. to 7 a.m. shift call lights during Resident Council meeting but it was still happening as recently as last night. Resident 2 stated she waited 45 minutes last night during the 11 p.m. to 7 a.m. shift to get help when she pressed her call light.During an interview on 8/21/2025 at 12:45 p.m., Resident 4 stated the call light waiting times during the 11 p.m. to 7 a.m. shift was long, and she wore diapers, so she had to wait in her dirty diaper until someone finally came to change her. Resident 4 stated the facility was aware of the complaints against the 11 p.m. to 7 a.m. shift but it was still an ongoing issue.During an interview on 8/21/2025 at 3 p.m., the director of staff development (DSD) stated she attended the Resident Council meetings and was aware of the issue with delayed response time to call lights during the 11 p.m. to 7 a.m. shift. The DSD stated she had been working at the facility for four months and when she started the complaints about call light response times were really bad and now, they are just bad not really bad. The DSD stated the expectation for answering call lights when residents needed something was right away or at least within 10 minutes. The DSD stated the potential outcome of not answering a resident's call light right away was falls, the resident could be sitting in urine or poop for extended periods of time, and the residents may feel terrible.During an interview on 8/21/2025 at 4:10 p.m., the director of nursing (DON) stated she was aware of complaints regarding the 11 p.m. to 7 a.m. call light wait times. The DON stated the potential outcome of extended wait times for call lights was the resident's needs were not being met, patient satisfaction goes down, and increased risk for falls so it was very important to answer call lights right away. The DON stated her staff were in-serviced regarding the long wait times during the 11 p.m. to 7 a.m. shift and the issue still continued. The DON stated her staff were not competent in answering the call lights in a timely manner or the importance of answering the call lights within a timely manner.During a review of the facility's policy and procedure (P&P) titled Call Lights and dated 1/2017, the P&P indicated it was the facility's policy to respond to the resident's requests and needs and call lights should be answered promptly.

Based on observation, interview, and record review, the facility failed to maintain accurate documentation on accountability record or controlled medication count sheet/controlled drug record ([CDR] - a document indicating perpetual inventory and administration of controlled substances affecting three residents (Residents 66, 76 and 90) in one of three inspected medication carts (Middle Medication Cart Skilled Nursing Facility [SNF] side).1.Resident 76's Pregabalin (a controlled medication [medications that the use and possession of are controlled by the federal government] used to treat fibromyalgia [pain in muscles and soft tissues] related pain, neuropathic (nerve related) pain and a subset of seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]).2.Resident 66's Clonazepam (a controlled medication used to treat panic disorder and seizure [a medical term used to describe sudden, uncontrolled burst of electrical activity in the brain]).3. Resident 90's Pregabalin.These deficient practices of failing to maintain accurate documentation of controlled medications had the potential to result in medication errors, controlled medication loss and/or drug diversion for Residents 66, 76 and 90. Findings:1a. During a review of Resident 76's admission Record, dated 7/17/2025, the admission Record indicated Resident 76 was admitted to the facility on [DATE] with diagnoses including muscle weakness and type 2 diabetes mellitus ([DM]-a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 76's History and Physical (H&P), dated 1/30/2025, the H&P indicated Resident 76 had the capacity to understand and make decisions.During a review of Resident 76's Minimum Data Set (MDS -resident assessment tool), dated 5/5/2025, the MDS indicated, Resident 76's cognition (ability to think, understand, learn, and remember) was intact. The MDS indicated Resident 76 was independent in performing activities of daily living (ADLs) such as eating, oral hygiene and personal hygiene, needed clean-up assistance from the facility staff for upper body dressing, supervision or touching assistance for toileting hygiene and showering and moderate assistance for lower body dressing and putting on or taking off footwear.During a concurrent observation, interview and record review on 7/17/2025 at 1:29 p.m. with Licensed Vocational Nurse (LVN) 5 of Middle Medication Cart SNF, Resident 76's medication card / bubble pack (a card that packages doses of medication within small, clear, plastic bubbles), facility's controlled medication count sheet (CDR) and the medication administration details in electronic Medication Administration Record (eMAR) for pregabalin 25 milligrams ([mg] a unit of measurement for mass) and pregabalin 100 mg were reviewed. Resident 76's medication card / bubble pack for pregabalin 25 mg contained a quantity of nine capsules remaining, with instructions as take one capsule (with 100 mg total dose of 125 mg) by mouth two times a day for neuropathic (nerve) pain, fill date 7/7/2025. The facility's CDR indicated a quantity of 10 capsules remaining with the last dose administered on 7/16/2025 at 3:00 p.m. Resident 76's medication card / bubble pack for pregabalin 100 mg contained a quantity of nine capsules remaining, with instructions as take one capsule with 25 mg (total dose of 125 mg) by mouth two times a day for neuropathic pain, fill date 7/7/2025. The facility's CDR indicated a quantity of 10 capsules remaining with the last dose administered on 7/16/2025 at 7/16/2025 at 3:00 p.m. The administration details in eMAR indicated the instructions as Lyrica (pregabalin) capsule 25 mg, give 5 capsules (125 mg) by mouth two times a day for neuropathic pain and the last dose of 5 capsules of pregabalin 25 mg was documented as administered on 7/16/2025 at 5:31 p.m. LVN 5 stated she forgot to document the pregabalin 25 mg and pregabalin 100 mg after they were administered to Resident 76 on 7/17/2025 at morning time in CDR and in eMAR. During a concurrent interview and record review on 7/17/2025 at 2:01 p.m. with Registered Nurse Supervisor (RNS) 2, the order details for Resident 76's pregabalin and physician orders for pregabalin 100 mg and pregabalin 25 mg were reviewed. The order details in Resident 76's medical record indicated only Lyrica oral capsule 25 mg (pregabalin) controlled drug, give 5 capsules by mouth two times a day for neuropathic pain, give 5 capsules of 25 mg ( total of 125 mg). The physician order for pregabalin 100 mg, give 1 capsule by mouth two times a day for neuropathic pain was discontinued on 6/16/2025 with the reason indicated as increased to 125 mg two times a day. The document contained a new order for pregabalin oral capsule 25 mg, give 5 capsules by mouth two times a day for neuropathic pain. Give 5 capsules of 25 mg (total of 125 mg). RNS 2 stated he could not speak much of the order because he did not administer the medications for Resident 76. During an interview on 7/17/2025 at 2:06 p.m. with LVN 5, LVN 5 stated she should have informed pharmacy about the changes in how Resident 76's pregabalin order was written by the physician to be five capsules of 25 mg instead of 1 capsule of 25 mg and 1 capsule of 100 mg for a total dose of 125 mg, to prevent medication errors and to maintain accurate documentation in the medical records. During a review of Resident 76's Order Summary Report, dated 7/17/2025, the Order Summary Report indicated the following physician orders: Lyrica oral capsule 25 mg (pregabalin), give five capsules by mouth two times a day for neuropathic pain, give 5 capsules of 25 mg (total of 125 mg), order date 6/16/2025, start date 6/17/2025 Lyrica oral capsule 100 mg (pregabalin), give 1 capsule by mouth two times a day for neuropathic pain, give 1 capsule of 100 mg with 1 capsule of 25 mg to total 125 mg, order date 7/17/2025, start date 7/17/2025 Lyrica oral capsule 25 mg (pregabalin), give 1 capsule by mouth two times a day for neuropathic pain, give 1 capsule of 25 mg with 1 capsule of 100 mg to total 125 mg, order date 7/17/2025, start date 7/17/2025During a review of Resident 76's Medication Administration Report (MAR) dated 7/1/2025 to 7/31/2025, the MAR indicated, Lyrica 25 mg (pregabalin), give 5 capsules by mouth two times a day for neuropathic pain, give five capsules of 25 mg ( total of 125 mg), start date 6/17/2025, discontinue date (d/c) 7/17/2025 was documented as administered 29 times.During a review of Resident 76's MAR, dated 6/1/2025 to 6/30/2025, the MAR indicated, a. Pregabalin was administered under physician order that indicated, Lyrica oral capsule 100 mg (pregabalin), give 1 capsule by mouth two times a day for neuropathic pain, start date 6/11/2025, discontinue (d/c) date 6/16/2025 from 6/11/2025 to 6/16/2025.b. Pregabalin was administered under physician order that indicated, Lyrica oral capsule 25 mg (pregabalin), give five capsules by mouth two times a day for neuropathic pain, give 5 capsules of 25 mg (total of 125 mg), start date 6/17/2025, d/c date 7/17/2025 from 6/17/2025 to 6/30/2025.2. During a review of Resident 66's admission Record, dated 7/17/2025, the admission Record indicated Resident 66 was admitted to the facility on [DATE] with diagnoses including osteomyelitis (bone infection) of the vertebrae ( back bone), DM, and dysphagia ( difficulty swallowing). During a review of Resident 66's MDS, dated [DATE], the MDS indicated Resident 66's cognition was moderately impaired. The MDS indicated Resident 66 needed supervision assistance from the facility staff for eating, moderate assistance for oral hygiene and upper body dressing, maximal assistance for showering, lower body dressing and putting on or taking off footwear, and dependent on facility staff for toileting hygiene. During a concurrent observation, interview and record review on 7/17/2025 at 1:29 p.m. with LVN 5 of Middle Medication Cart SNF, Resident 66's medication card / bubble pack, facility's CDR and the medication administration details in eMAR for clonazepam 0.5 mg were reviewed. Resident 66's medication card / bubble pack for clonazepam 0.5 mg contained a quantity of eight tablets remaining. The facility's CDR indicated a quantity of nine tablets remaining with the last dose administered on 7/16/2025 at 5:00 p.m. The administration details in eMAR indicated the last dose of one tablet of clonazepam 0.5 mg for Resident 66 was documented as administered on 7/17/2025 at 9:36 a.m. LVN 5 stated she forgot to document in CDR after administering clonazepam 0.5 mg to Resident 66. LVN 5 stated she documented in electronic medical records but did not document in the controlled drug record so the quantity on medication card and CDR did not match.During a review of Resident 66's Order Summary Report, dated 7/17/2025, the Order Summary Report indicated, but not limited to the following physician order: Clonazepam tablet 0.5 mg, give 1 tablet by mouth two times a day for anxiety manifested by (m/b) verbalization of being anxious, order date 5/26/2025, start date 5/27/2025.3. During a review of Resident 90's admission Record, dated 7/17/2025, the admission Record indicated Resident 90 was admitted to the facility on [DATE], with diagnoses that included but not limited to, type 2 diabetes mellitus with diabetic neuropathy (nerve damage caused by diabetes, often affecting the legs and feet ).During a review of Resident 90's History and Physical (H&P), dated 12/19/2024, the H&P indicated Resident 90 had the capacity to understand and make decisions.During a review of Resident 90's MDS, dated [DATE], the MDS indicated Resident 90's cognition was moderately impaired. The MDS indicated Resident 90 needed setup or clean-up assistance from the facility staff for eating and oral hygiene, moderate assistance for personal hygiene, maximal assistance for toileting hygiene, showering, upper body dressing, and dependent on facility staff for lower body dressing and putting on or taking off footwear.During a concurrent observation, interview and record review on 7/17/2025 at 1:29 p.m. with LVN 5 of Middle Medication Cart SNF, Resident 90's medication card / bubble pack, facility's CDR and the medication administration details in eMAR for pregabalin 75 mg were reviewed.Resident 90's medication card / bubble pack for pregabalin 75 mg contained a quantity of nine capsules remaining. The facility's CDR indicated a quantity of 10 capsules remaining with the last dose administered on 7/16/2025 at 5:00 p.m. The administration details in eMAR indicated the last dose of one tablet of pregabalin 75 mg for Resident 90 was documented as administered on 7/17/2025 at 11:48 a.m. LVN 5 stated she forgot to document in CDR after administering pregabalin 75 mg to Resident 90. LVN 5 stated she documented in electronic medical record but did not document in the controlled drug record so the quantity on medication card and CDR did not match. LVN 5 stated she should have documented all the controlled medications immediately after they were administered to residents to ensure accuracy and safety of residents, and to prevent medication errors, drug diversion and misuse.During an interview on 7/17/2025 at 5:14 p.m. with the Director of Nursing (DON), the DON stated the licensed nurses should sign the CDR and electronic medical record after the controlled substances were administered to maintain accuracy of the medications being given. The DON stated it was very important to account for the controlled medications, to prevent medication errors and drug diversion. The DON stated for Resident 76, the licensed nurse should have sent the physician order that indicated five capsules of 25 mg Lyrica instead of the current medication cards as one capsule of 25 mg and one capsule of 100 mg to maintain accuracy and to match the physical medication cards and quantities with corresponding physician orders.During a review of the facility's policy and procedure (P&P) titled, Controlled Medications, dated 4/20028, the P&P indicated, Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility, in accordance with federal and state laws and regulations. C. When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR): 1) Date and time of administration, 2) amount administered, 3) signature of the nurse administering the dose on the accountability record at the time the medication is removed from the supply, 4) Initials of the nurse administering the dose on the MAR after the medication is administered.

Based on observation, interview, and record review, the facility failed to ensure resident's pain was managed for one of two sampled residents (Resident 100); who had multiple pressure ulcers (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence), a healing right arm fracture, and right knee surgical site. Specifically, the facility failed to:1. Ensure that staff followed Resident 100's care plan titled, Alteration in Comfort - Pain which indicates to provide nursing measures that will provide comfort and lessen intensity of pain by repositioning, offering pain medication, and reassessing effectiveness of pain medication after 30 minutes.2. Ensure that Treatment Nurse (TN) 1 did not continue providing wound care treatment when Resident 100 had facial grimacing (a facial expression where the mouth and face are twisted, often to indicate disgust, disapproval, or pain) and complained of having severe pain (a pain rating of seven to ten in the numeric pain scale) during the care.3. Ensure Licensed Vocational Nurse (LVN) 6 followed the physician's orders to give two tablets of Norco (pain medication) 5/325 milligrams (mg- a unit of measurement) for severe pain when Resident 100 complained of having a seven-out-of-ten pain. 4. Ensure that staff medicated Resident 100 with Tylenol (pain medication) 500 mg 30 minutes prior to wound care treatment as ordered by the physician.These deficient practices had a potential for Resident 100 experiencing unrelieved and uncontrolled pain manifested by facial grimacing, stiffening, and verbalizing having severe pain when treatment nurses provided wound care treatment. Findings:During a review of Resident 100's admission Record (AR), the AR indicated Resident 100 was originally admitted to the facility on [DATE] with diagnoses including fracture of right humerus (long bone in the upper arm, extending from shoulder to elbow) and right radius (one of two long bones in the forearm, located on the thumb side), infection and inflammatory reaction due to internal right knee prosthesis (artificial internal body part), osteomyelitis (inflammation of bone or bone marrow) of right tibia (the shinbone, the larger of the two bones in the lower leg between the knee and ankle) and right fibula (the calf bone, located on the outer side of the lower leg between the knee and ankle), tracheostomy (surgically created opening in the neck that extends into the windpipe) with ventilator (a medical device to help support or replace breathing) dependence, infection of the skin and subcutaneous tissue (layer of fat and tissue under the skin), and myositis (inflammation of the muscles that causes weakness and pain) of the right thigh. During a review of Resident 100's History and Physical (H&P) dated 7/11/2025, the H&P indicated that Resident 100 was hospitalized on [DATE] for sepsis (life-threatening blood infection) from infected right elbow fracture and infected right knee replacement and was readmitted to the facility on [DATE]. The H&P indicated Resident 100 has a fluctuating capacity to understand and make decisions. During a review of Resident 100's Minimum Data Set ([MDS] resident assessment tool) dated 7/17/2025, the MDS indicated Resident 100 was dependent (helper does all the effort or two or more helpers is required for the resident to complete the activity) on staff for bed mobility, moving from sitting on side of bed to lying flat on bed, toileting hygiene, bathing, dressing, personal hygiene, and oral hygiene. The MDS indicated Resident 100 has a deep tissue injury (pressure ulcer where damage occurs to the underlying soft tissues often beneath intact skin) on the left heel and a stage 2 pressure ulcer (partial-thickness loss of skin, presenting as a shallow open wound) on the right heel. The MDS indicated that Resident 100's primary language is Spanish.During review of Resident 100's Care Plan (CP) titled Impaired Communication dated 7/13/2025, the CP states, Do not hurry when trying to communicate (with resident). 1. During a concurrent observation and interview on 7/15/2025 at 10:38 a.m. with Resident 100, Resident 100 was grimacing in bed. A communication board with Spanish words and phrases hanging on the wall was used to communicate with Resident 100. Resident 100 stated she was in pain and would like pain medication.During an observation on 7/15/2025 at 10:43 a.m. in Resident 100's room, LVN 4 instructed Resident 100 (in English) that Tylenol was administered at 8:45 a.m. and to wait for the medicine to kick in about 45 minutes to an hour. Resident 100 shook her head and mouthed, No se (I don't understand). LVN 4 replied, No pain? Okay and left the room. During an interview on 7/15/2025 at 10:50 a.m. with LVN 4, LVN 4 stated that he did not use the communication board to assess Resident 100's uncontrolled pain. During a subsequent observation on 7/15/2025 at 10:52 a.m. in Resident 100's room with LVN 4 and Resident 100, Resident 100 stated she was in ten-out-of-ten pain in her right leg. LVN 4 asked Resident 100, Are you sure you're in pain? I just gave you medicine at 8:45 (a.m.) Resident 100 was grimacing and nodded her head. During an interview on 7/15/2025 at 11:05 a.m. with LVN 4, LVN 4 stated he was not aware that two hours had passed since he gave Resident 100 Tylenol 500 mg. LVN 4 stated that he did not do a follow up pain assessment after giving Resident 100 Tylenol at 8:45 a.m. because we don't do follow up (assessments) for routine medications. LVN 4 stated that it's important to give pain medication and provide non-medication interventions when a resident asks for it to manage the resident's pain. During a review of the facility's Policy and Procedure (P&P) titled Pain Management Protocol dated 10/2017, the P&P indicated to assess effectiveness of pain medication with routine and PRN (as needed) pain medication approximately 30 minutes after administration.During review of Resident 100's CP titled Alteration in Comfort - Pain dated 7/10/2025, the CP indicated to:a. Assess non-verbal resident for possible signs and symptoms of pain ex. Grimacesb. Administer pain medication per physician's order c. Re-assess for pain after 30 minutes and notify physician for possible need for increased pain medicationd. Provide nursing measures that will provide comfort and lessen intensity of painDuring a review of Resident 100's Pain Level Summary (PLS) dated 7/18/2025, the PLS indicated that no pain assessments were done for Resident 100 between 7/14/2025 at 9:21 p.m. and 7/15/2025 at 11:15 a.m. The PLS indicated LVN 4 did not do a pain assessment for the Tylenol given at 8:45 a.m. and did not reassess the resident to measure its effectiveness. During an interview on 7/18/2025 at 9:44 a.m. with Resident 100, translation services by telephone were used to communicate with Resident 100. Resident 100 stated that she is not happy with her care in the facility and her pain is not managed well.During an interview on 7/18/2025 at 1:13 p.m. with the Director of Nursing (DON), the DON stated improper pain assessments lead to inadequate interventions for residents experiencing pain like Resident 100. The DON stated improper pain assessments are a competency issue for better and thorough assessments. 2. During a concurrent observation and interview on 7/16/2025 at 11:15 a.m. with TN 1, Certified Nursing Assistant (CNA) 2, and Resident 100 during Resident 100's wound care treatment, Resident 100 was noted grimacing and bucking the ventilator (when a patient is not synchronized with the ventilator's breaths due to pain, anxiety, or other factors that disrupt the normal breathing pattern) when CNA 2 lifted Resident 100's right leg to turn her. During a subsequent observation and interview with TN 1 on 7/16/2025 at 11:27 a.m., TN 1 stated, We are going to continue (the wound care treatment). [Resident 100] has a post-op appointment in an hour and needs to get cleaned. Resident 100 was grimacing, stiffening her body when being moved, and bucking the ventilator while TN 1 and CNA 2 continued wound care treatment. Resident 100 stated her pain was seven-out-of-ten during wound treatment.During an interview on 7/16/2025 at 4:45 p.m., LVN 4 reported that when TN 1 informed him of Resident 100's pain during wound care treatment, he instructed TN 1 to assess whether Resident 100 could tolerate completing the treatment. LVN 4 also mentioned that he gave Resident 100 pain medication only after the treatment was finished. During an interview on 7/16/2025 at 4:16 p.m. with TN 1, TN 1 stated that the wound care treatment should have been stopped when Resident 100 showed signs of discomfort and reported pain. TN 1 indicated that LVN 4 should have administered pain medication immediately rather than waiting until after the treatment. TN 1 noted that continuing the treatment resulted in additional pain for Resident 100.During a concurrent interview and record review on 7/17/2025 at 2:31 p.m. with Registered Nurse Supervisor (RNS) 3, Resident 100's H&P was reviewed. RNS 3 stated the reason Resident 100 was hospitalized on [DATE] was because of uncontrolled pain in her right leg and right arm. RNS 3 stated that pain management has been an ongoing issue for Resident 100.During a review of the facility's P&P titled Wound Care, dated 4/2017, the P&P indicated to assess any change in the resident's condition, how the resident tolerates the procedure, and to report other information in accordance with facility policy and professional standards of practice. 3. During an observation on 7/18/2025 at 9:58 a.m. in Resident 100's room, LVN 6 asked Resident 100 if she had pain but did not ask where the location of the pain was. During a concurrent observation and interview on 7/18/2025 at 10:06 a.m. with LVN 6, LVN 6 administered one tablet of medication via Resident 100's gastrostomy (a surgical opening into the stomach for feeding and medications) tube (g-tube). LVN 6 stated he gave one tablet of Norco 5-325 mg. He mentioned that he did not ask Resident 100 about the location of her pain because it was difficult to communicate with her at that time since she is Spanish speaking and the CNA who usually translates was busy. LVN 6 stated that Resident 100 has a communication board but did not use it when he should have. LVN 6 stated it's important to effectively communicate with the resident so the resident can properly express their needs and it's important to determine the location of the resident's pain because it can be a new onset of pain or an emergency like chest pain which could indicate a heart attack. LVN 6 stated, I did not do an accurate pain assessment.During an interview on 7/18/2025 at 10:36 a.m. with Resident 100, Resident 100 stated she was still experiencing seven-out-of-ten pain 30 minutes after receiving her pain medication. During a concurrent interview and record review on 7/18/2025 at 10:37 a.m. with LVN 6, Resident 100's Medication Administration Record (MAR) dated 7/18/2025 was reviewed. The MAR indicated the following: a. Norco 5-325 mg give one tablet via g-tube every six hours as needed for moderate pain (four to six)b. Norco 5-325 mg give two tablets via g-tube every six hours as needed for severe pain (seven to ten) LVN 6 stated, [Resident 100] complained of seven-out-of-ten pain and I should have given her two tablets (of Norco 5-325 mg) instead of one. Following the physician's order is important for resident safety. If not, the resident may continue to experience pain and discomfort. During a review of the facility's P&P titled Medication Administration, dated 4/2025, the P&P indicated Medications must be administered in accordance with the physician orders, including any required time frame.During review of Resident 100's CP titled Alteration in Comfort- Pain, dated 7/10/2025, the CP indicated to determine location of the resident's pain.4. During a review of Resident 100's Order Summary Report (OSR) dated 7/18/2025, the OSR indicated the following physician's order: a. Acetaminophen (Tylenol) oral tablet: Give 500 mg via g-tube every day shift for pain management, give one tablet 30 minutes prior to wound care every day, not to exceed three grams (g- a unit of measurement) in 24 hours. During a concurrent interview and record review on 7/16/2025 at 4:16 p.m. with TN 1, Resident 100's MAR and Treatment Administration Record (TAR) dated 7/18/2025 were reviewed. The MAR and TAR indicated that Tylenol was not administered 30 minutes prior to wound care treatment as follows:a. On 7/12/2025, MAR indicated Tylenol 500 mg administered at 12:55 p.m., and the TAR indicated wound care treatment was provided at 12:44 p.m.b. On 7/13/2025, the MAR indicated Tylenol 500 mg administered at 2:14 p.m., and the TAR indicated wound care treatment was provided at 4:36 p.m.c. On 7/14/2025, MAR indicated Tylenol 500 mg administered at 11:59 a.m., and TAR indicated wound care treatment was provided at 6:38 p.m.d. On 7/15/2025, MAR indicated Tylenol 500 mg administered at 8:54 a.m., and TAR indicated wound care treatment was provided at 5:31 p.m.TN 1 stated that LVN 4 did not coordinate when to give Tylenol 500 mg on 7/15/2025 and therefore the medication was given earlier than it should have been on that day. TN 1 stated, The pain medication and when the treatment is done does not coincide with the order.During an interview on 7/18/2025 at 10:24 a.m. with Resident 100's family member (FM 2), FM 2 stated the facility is not doing their best because the facility told him that Resident 100 would be taken care of when she left the hospital, but Resident 100 was reinfected at this facility. FM 2 stated the facility mistook Resident 100's grimacing for smiling which caused her pain to be untreated. FM 2 stated, [Resident 100] was showing her teeth like she was grimacing and to me, she just didn't look good. She was in a lot of pain. I don't feel like her pain is managed well there (in the facility). [The facility] did not have strong enough pain medication for her, and they couldn't understand that she was constantly in pain. There was a communication barrier because she's Spanish speaking and on top of that, she can't really talk because of the breathing tube (tracheostomy).During a review of the facility's P&P titled Wound Care, dated 4/2017, the P&P indicated to review the resident's plan of care for any special needs of the resident, including pain medication to be administered prior to wound care.

Based on observation, interview, and record review, the facility failed to ensure a resident with a gastrostomy tube (GT-a tube that is passed through the abdominal wall to the stomach used to provide nutrition) site was not leaking from January 2025 to present for one out of eight residents (Resident 8). This deficient practice resulted in continuous leakage of tube feeding formula around Resident 8's stoma (surgically created opening on the abdomen that allows waste to exit the body) site with Resident 8 being transferred to the General Acute Care Hospital (GACH) and had the potential to cause skin breakdown around the site, lead to malnutrition, infection and Resident 8 not receiving the volume of tube feeding formula ordered by the physician.Findings:During a concurrent observation and interview on 7/16/2025 at 2:46 p.m., with Treatment Nurse (TN 1), Resident's 8 g-tube dressing was observed leaking out through the g-tube dressing. TN1 stated it was observed today that the g-tube was leaking.During a review of Resident 8's admission Record/Face sheet ( a document that summaries key information about a person, thing or situation), the admission Record indicated Resident 8 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, gastrostomy status (the presence of a gastrostomy tube, which is a surgical procedure that creates an opening in the stomach through the abdominal wall.), dysphagia ( a medical term for difficulty swallowing. ), tracheostomy ( a surgical procedure that creates an opening in the trachea [windpipe]to help with breathing).During a review of the care plan (CP) titled, Alteration in skin integrity dated 2/01/25, the CP indicated the interventions included to notify MD for G-tube leakage if no progress was made towards healing or any signs or symptoms of decline. During a review of Resident's 8 Significant Change in Status Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 04/21/2025, the MDS indicated the resident had severely impaired cognitive (process of thinking) skills for daily decision making. The MDS also indicated the Resident's 8 was totally dependent (helper does all the effort) on bed mobility, transfer, locomotion, dressing, tube feeding, toilet use, and personal hygiene.During a record review on 7/17/24 of Resident 8's transfer record, the transfer record indicated to send Resident 8 to the GACH for a G-tube evaluation and management related to the stoma site leaking. During an interview on 7/17/25 at 10:39am with TN1. TN1 stated she called the doctor because the g-tube was leaking excessively. TN1 stated she thinks the stoma was too large, and that is why the g-tube was leaking. During a concurrent interview and record review on 7/17/225 at 2:23 pm with The Assistant Director of Nursing (ADON), the ADON stated Resident 8's was transferred to the GACH today because the G-tube was leaking with excess amounts of caramel colored fluid. The ADON stated the doctor was called and gave an order to transfer Resident 8 to the GACH for a g-tube replacement. The ADON stated Resident 8'medical records indicated the G-tube was leaking since 1/31/25. The ADON stated the evaluation of g-tube should have been done by the doctor and the licensed nurses should have follow up. The ADON stated the leaking of the g-tube can cause skin irritation, redness and could make Resident 8 uncomfortable. During a concurrent interview and record review on 7/17/25 at 3:13 pm with TN2 of Resident 8's weekly skin assessment was reviewed. TN2 stated she should have called and followed up with the doctor that g-tube was still leaking with no progress. TN 2 stated, this was a delay in treatment. During a review of Resident 8's weekly skin assessment, the following measurements of the G-tube were documented: -On 7/6/25 1x1centimeter ([cm] unit of measurement) in size with redness.-On 7/16/25 2x2 cm in size with redness and leaking. During a concurrent interview and record review on 7/17/25 at 3:46 pm with the Director of Nursing (DON), the DON stated Resident 8 should have been evaluated earlier for G-tube leaking because it can cause skin irritation and redness. The DON stated licensed nurses in the facility should report any abnormal changes to the doctor. During a review of the facility's policy and procedure (P&P) titled, Gastrostomy Tube Feeding via Continuous Pump dated 1/2017, the P&P indicated to Report complications promptly to the supervisor and the attending physician.

Based on observation, interview, and record review, the facility failed to:1. Store, label and/or discard Resident 41 or 42's Epogen ([generic name - epoetin alfa] a medication used to treat anemia [low red blood cell count]) and Resident 100's Retacrit ([generic name - epoetin alfa-epbx] a medication used to treat anemia) in accordance with manufacturer's specifications and facility's policy and procedure (P&P) titled, Vials and Ampules of Injectable Medications, dated 4/2008, affecting one of one inspected medication room (Medication Room).2. Ensure removal of expired docusate sodium (a medication used to relieve constipation), Resident 55's latanoprost (a medication used to treat high eye pressure) eye drops from the medication cart, and ensure Resident 76's Basaglar ([generic name - insulin glargine] a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication), Resident 63's insulin lispro pen and Resident 77's insulin lispro pen were labeled with an open date, in accordance with manufacturer's specifications and facility's policy and procedure (P&P) titled, Storage of Medications, dated 4/2008, affecting two of three inspected medication carts inspected (Middle Medication Cart Skilled Nursing Facility [SNF] side and Medication Cart 2 Subacute).3. Ensure the facility's licensed nursing staff did not leave Resident 40's medications unattended, that included artificial tears eye drops, calcium carbonate (a supplement used to relieve acid reflux), prednisone (a medication used to treat inflammation), Eliquis ([generic name - apixaban] a medication used to prevent blood clots, midodrine (a medication used to treat low blood pressure) and levetiracetam (a medication used to treat seizure [a medical term used to describe sudden, uncontrolled burst of electrical activity in the brain] oral solution, affecting one of seven residents observed during medication administration (Resident 40).4. Maintain a clean and safe environment for medication storage in two out of three inspected medication carts, by failing to remove and dispose of medications, discarded and used vials that were stored in unsealed red biohazard containers in an irretrievable manner (Medication Cart 2 Subacute and Medication Cart 3 Subacute). These deficient practices resulted in an unclean and unsecure environment for medication storage, had the potential to result in medication errors, and Residents 40, 41 or 42, 55, 63, 76 and 77 receiving medications that were discontinued, expired, ineffective, or toxic due to improper storage and labeling possibly leading to adverse health consequences such as anemia, eye complications, abnormal blood glucose levels and hospitalization. Findings:1. During a concurrent observation and interview on [DATE] at 4:43 p.m. with Registered Nurse Supervisor (RNS) 3, in Medication Room Refrigerator Subacute, the medication refrigerator contained the following medications that were found stored in a manner contrary to manufacturer requirements:a. One open multidose vial of Epogen 20,000 units per milliliters ([mL] a unit of measurement for volume) with no opened date label for Resident 41 or 42.b. Two unopened multidose vials of Epogen 20,000 units/mL for Resident 41 or 42.According to the manufacturer's product labeling, a multidose vial would be stable for up to 21 days when stored at 2-to-8 degrees Celsius ([ C] is a unit of temperature [36-to-46 degrees Fahrenheit ([ F] is a unit of temperature) after it was opened.c. One open single dose vial of Retacrit 10,000 units/mL for Resident 100.d. One unopened single-use or single dose vial of Retacrit 10,000 units/mL for Resident 100.According to the manufacturer's product labeling, unopened single-use vials should be stored between 2 and 8 C (36 and 46 F) and unused portions of single-use should be discarded and not reused.RNS 3 stated the licensed nurse staff should have discarded the partial dose from the single use vial because the single dose vials should not be reused because it would increase the risk for infection. RNS 3 stated the single dose vial would not be safe or effective for residents to treat anemia.2a. During a concurrent observation and interview on [DATE] at 12:39 p.m. with Licensed Vocational Nurse (LVN) 5 of Middle Medication Cart SNF, the medication cart contained the following medications either expired, or stored and labeled in a manner contrary to the facility's P&P titled, Storage of Medications and manufacturer requirements:a. One opened bottle of docusate sodium 100 milligrams ([mg] a unit of measurement for mass) with an expiration date of 7/2025.LVN 5 stated it would not be safe for facility residents to receive an expired medication, and docusate sodium should have been removed from the medication cart three months before its expiration date.b. One bottle of opened latanoprost eye drops with an opened date of [DATE] for Resident 55.According to the pharmacy label on latanoprost eye drops, the unused portion of the medication was supposed to be discarded after 28 days.LVN 5 stated Resident 55's latanoprost eye drops should have been removed from the medication cart after 28 days, on [DATE], for the resident's safety. LVN 5 stated there was a risk for eye irritation, and the medication would not be effective for treating glaucoma.c. One unopened Basaglar 100 units/mL KwikPen with no open date or date it was removed from the refrigerator for Resident 76.According to the manufacturer's product labeling, the unopened / not in-use prefilled pen should be stored at 36 F to 46 F (2 C to 8 C) and opened / in-use prefilled pen, if stored at room temperature (up to 30 C [86 F]) must be discarded after 28 days. LVN 5 stated Resident 76's Basaglar was not opened but should have been labeled with an opened date when it was removed from refrigerator to be able to determine its expiration date. LVN 5 stated the medication would not be safe or effective in controlling blood glucose levels for Resident 76.2b. During a concurrent observation and interview on [DATE] at 2:23 p.m. with LVN 3, of Medication Cart 2 Subacute, the medication cart contained the following medications stored and labeled in a manner contrary to the facility's P&P titled, Storage of Medications and manufacturer requirements:a. One opened insulin lispro kwikpen 100 units/mL with no open date for Resident 77.b. One insulin lispro kwikpen 100 units/mL with no open date for Resident 63.According to the manufacturer's product labeling, once opened / in-use or once stored at room temperature, insulin lispro must be used within 28 days or be discarded.LVN 3 stated i would say dangerous and in other words, it would not be safe or effective to give expired or insulin with no opened date to the residents. LVN 3 stated it would not help manage blood glucose levels for the residents.During an interview on [DATE] at 5:14 p.m. with the Director of Nursing (DON), DON stated she would need to double check with the pharmacy, but facility staff should have discarded the multidose vials after they were opened. DON stated the medications should have been removed from the medication cart before they expired at least one month before the expiration date. DON stated those medications requiring refrigeration such as insulin and some eye drops should have an open date to be able to determine their expiration date after they were removed from the refrigerator.3. During a concurrent observation and interview on [DATE] at 9:45 a.m. with LVN 4, LVN 4 prepared the following six medications to be administered to Resident 40:a. A vial of artificial tears (a medication used to treat dry eyes) eye drops to administer one drop for the right eyeb. One tablet of calcium carbonate (a medication used to treat symptoms of acid reflux) 500 milligrams ([mg] a unit of measurement for mass)c. One tablet of prednisone (a medication used to treat inflammation and pain) 5 mgd. One tablet of Eliquis ([generic name - apixaban] a medication used to treat blood clots) 2.5 mge. One tablet of midodrine 2.5 mgf. 7.5 milliliters ([mL] a unit of measurement for volume) of levetiracetam (a medication used to treat seizures [sudden, uncontrolled electrical disturbances in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]) 100 mg per mLLVN 4 entered Resident 40's room, placed the medications on the bedside cart and stepped away to go to the medication cart and observed looking for something. LVN 4 returned to the resident's bedside and resumed medication administration.During an interview on [DATE] at 2:05 p.m. with LVN 4, LVN 4 stated it was important to secure and keep the medications safe and should not have left them unattended. LVN 4 stated he should not have turned around to get the alcohol wipes to sanitize the tip of the artificial tears eye drops bottle.During an interview on [DATE] at 11:48 a.m. with DON, DON stated the licensed nursing staff should have been careful not leaving medications unattended for safety reasons and to prevent accidental ingestion. 4a. During a concurrent observation and interview on [DATE] at 2:42 p.m. with LVN 3, of Medication Cart 2 Subacute, the medication cart contained one red container with a transparent/clear open lid, filled with several retrievable empty looking Heparin (a medication administered as an injection to prevent blood clots) vials and other medication vials in the bottom drawer. LVN 3 stated there was a risk that someone could reach in and misuse the vials and it was a potential hazard. LVN 3 stated the vials should have been thrown in the Sharps container on the side of the cart which would be more secure and irretrievable.4b. During a concurrent observation and interview on [DATE] at 2:55 p.m. with LVN 8, of Medication Cart 3 Subacute, the medication cart contained one red container with transparent/clear open lid, filled with several retrievable unlabeled/unidentified tablets, capsules, empty looking shells of capsules in the bottom drawer. LVN 8 stated she should have disposed of the contents in biohazard container before it got full to ensure safety and to make sure it was irretrievable. During an interview on [DATE] at 5:14 p.m. with the DON, DON stated the staff should have followed the facility's medication disposal policy by disposing of the empty heparin vials in the red sharps container but also covered with water or powder to make them irretrievable and discarded when it was three-quarters (3/4) full. DON stated the container with tablets and empty capsule shells should have been emptied out by staff frequently so that it became irretrievable. During a review of the facility's P&P titled, Medication Administration, dated 4/2025, the P&P indicated, The expiration date on the medication label must be checked prior to administration. When a multi-dose container is opened, the date opened should be recorded on the container. Vials labeled as single dose, or single use should not be used on multiple residents. These vials will only be used for one resident in a single procedure.During a review of the facility's P&P titled, Storage of Medications, dated 4/2008, the P&P indicated, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized. The P&P indicated, M. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists. N. Medication storage areas are kept clean, well-lit, and free of clutter and extreme temperatures.During a review of the facility's P&P titled, Vials and Ampules of Injectable Medications, dated 4/2008, the P&P indicated, Vials and ampules of injectable medications are used in accordance with the manufacturer's recommendations or the provider pharmacy's directions for storage, use, and disposal. B. The date opened and the initials of the first person to use the vial are recorded on multi-dose vials (on the vial label or an accessory label affixed for that purpose). C. Ampules and single-use vials (containing no preservative) are discarded immediately after use.During a review of the facility's P&P titled, Medication Destruction, dated 4/2008, the P&P indicated, All medications are placed in the proper waste container per facility policy. Medication destruction occurs in the presence of two licensed nurses.

Based on observation, interview, and record review, the facility failed to follow infection control precautions for three of four sampled residents (Resident 100, Resident 8 and Resident 40) when:1a.Certified Nursing Assistant (CNA) 2 picked up a pillow and bed linen from the floor and placed it on Resident 100's lower extremities (lower legs, feet).1b.CNA 2 did not follow the standard of practice of wiping front to back when cleaning Resident 100's rectum. 1c.CNA 2 did not perform hand hygiene after providing perineal ( the area of the body between the anus and the external genitalia) care on Resident 100.1d.CNA 2 failed to doff (remove) personal protective equipment (PPE) before leaving Resident 100's room.2. Infection control precautions were not observed while administering Resident 8's medications via gastrostomy tube (g-tube - a surgically placed tube used to administer mediations or food directly into the stomach)3.Licensed Vocational Nurse (LVN) 4 failed to wash hands before administering Resident 40's eye drops, during medication administration. These deficient practices placed Resident 100, 8 and 40 at risk of infection, cross contamination (process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another) and contamination of medications. Findings: 1.During a review of Resident 100’s admission Record, the admission Record indicated Resident 100 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including fracture (broken bone) of right humerus (long bone in the upper arm, extending from shoulder to elbow) and right radius (one of two long bones in the forearm, located on the thumb side), infection and inflammatory reaction due to internal right knee prosthesis (artificial internal body part), osteomyelitis (inflammation of bone or bone marrow, usually due to infection) of right tibia (the shinbone, the larger of the two bones in the lower leg between the knee and ankle) and right fibula (the calf bone, located on the outer side of the lower leg between the knee and ankle), infection of the skin and subcutaneous tissue (layer of fat and tissue under the skin). During a review of Resident 100’s Minimum Data Set ([MDS] resident assessment tool) dated 7/17/2025, the MDS indicated Resident 100’s cognition was severely impaired. The MDS also indicated Resident 100 was dependent (helper does all the work) with activities of daily living (ADLs- activities such as toileting and personal hygiene a person performs daily).The MDS also indicated Resident 100 had a multi-drug -resistant organism (MDRO- microorganisms that are resistant to at least one class of antibiotics). During a review of Resident 100’s History and Physical (H&P) dated 7/11/2025, the H&P indicated that Resident 100 had fluctuating capacity to understand and make decisions for herself. During a review of Resident 100’s Order Summary Report dated 7/18/25, the Order Summary Report indicated Resident 100 was on enhanced barrier precautions (EBP- an infection control strategy primarily used in nursing homes, to reduce the spread of MDRO’s) for Candida Auris (C-Auris type of yeast that can cause severe illness and spreads easily among patients in healthcare facilities), Carbapenem-Resistant Acinetobacter baumanni (CRAB- a type of antibiotic resistant bacteria that causes serious infections in healthcare facilities). The Order Summary Report also indicated Resident100 was taking Cephalexin (antibiotic used to treat bacteria) 250 milligrams (mg- unit of measure) every 12 hours one capsule through a gastrostomy tube (g-tube- tube inserted through the abdominal wall directly into the stomach) for right elbow infection. During a review of Resident 100’s Care plan titled on Enhanced Barrier Precaution related to (r/t) C-auris and CRAB dated 7/10/25, the care plan interventions indicated staff were to use personal protective equipment (PPE-gloves, gown, mask) when providing care to Resident 100, to keep PPE cart outside resident’s room with proper disposable materials and staff need to do frequent hand washing. During an observation on 7/16/25 at 11:11am in Resident 100’s room , CNA2 was assisting Treatment Nurse 1 (TXN1) with wound care on Resident 100. CNA 2 was observed placing a wet towel on Resident 100’s bed on a dirty chux (absorbent pads used to protect bedding from bodily fluids like urine and blood). CNA 2 was also observed cleaning Resident 100’s rectum using the same towel that was on the dirty chux and wiping from back to front. CNA 2 was also observed picking up a pillow and bed linen off the floor and placing it back on Resident 100’s bed touching her lower extremities. CNA 2 was also observed taking dirty linen out of Resident 100’s room and failing to doff his PPE (gown, gloves). CNA 2 proceeded to grab a pillowcase and returned to Resident 100’s room wearing the same gown. CNA 2 was then observed putting on gloves and completed Resident100 care. CNA 2 did not do hand hygiene when providing Resident 100’s personal care. During an interview on 7/16/25 at 1:32 pm with CNA 2,CNA 2 stated that he was aware he should have used a basin with soap and water when providing care for Resident 100, but he did not see one in her bedside drawer. CNA 2 also stated that when he was cleaning Resident 100’s bottom he should have cleaned from front to back not back to front and changed his gloves and washed his hands after cleaning Resident 100’s bottom, because there was a potential for Resident 100 to have cross contamination from feces causing her to have an infection. CNA 2 stated when the pillow and bed linen touched the floor he should not have put it back on Resident 100’s bed because the pillow and bed linen were contaminated. CNA 2 also stated that Resident 100 was on EBP for her infections and that he should have taken off his PPE before exiting Resident 100’s room to prevent cross contamination. During an interview on 7/16/25 at 4:04 pm with TXN 1, TXN 1 stated Resident 100 was on EBP because of her infected wounds. TXN 1 stated she did see CNA 2 place the wet towel on Resident 100’s dirty chux and that he did clean Resident 100’s bottom from back to front and that she did not see CNA 2 wash his hands or change his gloves after cleaning Resident 100’s bottom. TXN 1 stated she saw CNA 2 pick up the pillow and bedlinen off the floor and place it back on Resident 100’s bed and that the linen was contaminated and should not have been put back on Resident 100’s bed. TXN 1 the reason she did not correct CNA 2 was because she was focusing on Resident 100’s wound treatment. During an interview with the Director of Staff Development (DSD) on 7/17/25 at 4:18 pm, the DSD stated when providing any kind of perineal care on the residents the CNA needs to get two basins, one for clean and one for dirty water and six towels, they need to wipe and dump meaning, that you should wipe from front to back then toss the towel and get a new one. The DSD stated CNA needs to change their gloves and wash their hands after cleaning residents bottoms, to prevent the spread of infection from cross contaminations. The DSD also stated that any time a pillow or bedlinen touches the floor the CNA was to get a clean set of bedlinens and place the linen that fell on the ground in the dirty linen barrel to prevent the spread of infection. The DSD stated that anytime the CNAs wear PPE they need to take it off before leaving the residents’ room and they need to wash their hands and put on new PPE before reentering residents’ room when providing the residents with care to protect the residents from infection. During an interview on 7/18/25 at 12:26 pm with the Director of Nursing (DON), the DON stated Resident 100 was on EBP and the staff need to wear PPE when providing direct care to Resident 100. The DON stated she was made aware of CNA 2 failure to follow infection control practices. The DON stated Resident 100 was at risk for worsening infection and rehospitalization. During a review of the facility’s policy and procedures (P&P) titled Hand Hygiene, dated 7/2019 the P&P indicated “It is the policy of the facility that all staff members perform hand hygiene before and after direct resident care and after contact with potentially contaminated substances to prevent, to the extent possible, the spread of infection. Hand hygiene will be performed by staff as follows, before taking care of susceptible residents such as those who are severely immunosuppressed. During care when moving from a contaminated activity to a clean activity (for example after assisting a resident with toileting, before assisting with clean clothing). Immediately after glove removal, After taking care of an infected resident or one who is likely to be colonized with micro-organisms of special clinical or epidemiologic significance (e.g., multiple resistant bacteria, MRSA); and before and after giving personal care to residents and/or self. If gloves are worn for a procedure, hand hygiene is to be performed before putting gloves on and after removal and disposal of gloves. During a review of the facility’s policy and procedures (P&P) titled Perineal Care dated 10/2018, the P&P indicated, “Wash perineal area with the washcloth or personal cleansing cloths, wiping from front to back. Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks. Do not reuse the same washcloth or water to clean the labia or use the same personal cleansing cloth.” 2.During a review of Resident 8’s admission Record, dated 7/16/2025, the admission Record indicated, Resident 8 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but not limited to, sepsis (a life-threatening blood infection), chronic kidney disease (a condition where the kidneys are damaged and cannot filter blood as well as they should), gastrostomy status, personal history of urinary tract infections (infection in any part of the urinary system), pneumonia (an infection/inflammation in the lungs) and history of other infectious and parasitic diseases. During a review of Resident 8’s History and Physical (H&P), dated 2/4/2025, the document indicated Resident 8 did not have the capacity to understand and make decisions. During a review of Resident 8’s Minimum Data Set (MDS-resident assessment tool), dated 4/21/2025, the MDS indicated Resident 8 was on g-tube feedings, fully dependent on facility staff for Activities of Daily Living (ADLs) such as oral hygiene, toileting hygiene, showering, upper and lower body dressing, putting on or taking off footwear and personal hygiene. During a concurrent observation and interview on 7/16/2025 at 9:00 a.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 prepared six medications and supplements by crushing them individually using a crushing device to be administered to Resident 8 via g-tube. LVN 4 stated he used five to 10 mL water to dissolve each medication separately. LVN 4 started to administer medications one by one using gravity method followed by water in between each medication. LVN 4 then stepped away from the bedside with the syringe in his hand that was used to administer water and g-tube medications, and walked to the medication cart, which exposed the syringe to other factors in the environment. LVN 4 returned to bedside with the same syringe and resumed medication administration. During an interview on 7/16/2025 at 2:47 p.m. with LVN 4, LVN 4 stated he should not have taken the syringe used for g-tube medication administration with him to the medication cart. LVN 4 stated he should have changed gloves and sanitized hands if he needed to move away from the resident. LVN 4 stated there was a risk of contamination when he removed the syringe away from the resident's area. LVN 4 could not say that it was important to take precautions to prevent infection but stated to prevent any bacteria and prevent contamination. During an interview on 7/17/2025 at 11:48 a.m. with the Director of Nursing (DON), the DON stated nurses should not have brought the syringe that was used to administer g-tube medications away from the resident care area to medication cart because that would increase the risk for contamination and infection when the syringe was reintroduced to administer g-tube medications. 3. During a review of Resident 40’s admission Record, dated 7/16/2025, the admission Record indicated Resident 40 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including tracheostomy (a surgical procedure to create an opening in the neck and into the trachea [windpipe] to allow for breathing when the upper airway is blocked or when prolonged breathing assistance is needed) status and unspecified glaucoma (an eye condition that increased eye pressure). During a review of Resident 40’s MDS, dated [DATE], the MDS indicated Resident 40’s cognition (ability to think, understand, learn, and remember) was intact. The MDS indicated Resident 40 needed setup or clean-up assistance from the facility staff for activities of daily living (ADLs) such as eating, supervision assistance for oral hygiene, moderate assistance for upper body dressing and personal hygiene, maximal assistance for lower body dressing, putting on or taking off footwear, and dependent for toileting hygiene. During a concurrent observation and interview on 7/16/2025 at 9:45 a.m. with LVN 4, LVN 4 prepared six medications to be administered to Resident 40 which included artificial tears eye drops. LVN 4 stated Resident 40 was supposed to receive one drop of artificial tears into the right eye four times a day for dryness. LVN 4 was not observed washing hands after preparing medications, before wearing gloves and before administering artificial tears eye drops to Resident 40. During a medication reconciliation review on 7/16/2025 at 1:12 p.m., Resident 40’s Order Summary Report, dated 6/1/2025 and 7/17/2025 indicated the following physician order: “Artificial Tears Ophthalmic (eye) Solution (carboxymethylcellulose sodium) instill 1 drop in right eye four times a day for dry eyes/itchiness, order date 4/4/2023, start date 4/4/2023.” During an interview on 7/16/2025 at 2:05 p.m. with LVN 4, LVN 4 stated he should have washed his hands before administering artificial tears eye drops to Resident 40 to prevent contamination and infection. During an interview on 7/17/2025 at 11:48 a.m. with the DON, the DON stated it was very important for nurses to wash their hands before putting on gloves and before administering eye drops to prevent infection. During a review of the facility’s policy and procedure (P&P) titled, “Hand Hygiene,” dated 7/2019, the P&P indicated, “It is the policy of the facility that all staff members perform hand hygiene before and after direct resident care and after contact with potentially contaminated substances to prevent, to the extent possible, the spread of infection. Hand hygiene will be performed by staff as follows: during care when moving from a contaminated activity to a clean activity (for example .clothing).” During a review of the facility’s P&P titled, “Medication Administration,” dated 4/2025, the P&P indicated, “Staff shall follow facility infection control procedures, i.e., handwashing, antiseptic techniques, gloves, isolation precautions, etc. as applicable.”

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 75) was free of unnecessary physical restraints (any object or device that an individual cannot remove easily which restricts freedom of movement) by failing to:1.Ensure physician order for the use of restraint was obtained before initiating a physical restraint in the form of a sock which covered the right arm and right hand with tape wrapping the fingers.2. Ensure an assessment and monitoring of the use of physical restraint for the right arm and hand were implemented and documented.This failure had the potential to place Resident 75 at risk for unnecessary prolonged use of restraints, and could lead to decline in physical functioning, impaired blood circulation, and skin injuries. Findings:During a concurrent observation and interview on 7/15/2025, at 10:35 a.m. in the room of Resident 75 with a family member (FM1), Resident 75's right arm and right hand were covered with a blue sock with white tape wrapped around the portion of the fingers. During a review of Resident 75's admission Record, the admission Record indicated the resident was initially admitted on [DATE] and was readmitted on [DATE] to the facility with diagnoses including anoxic brain damage(occurs when the brain was completely deprived of oxygen causing brain cells to die leading permanent problems like memory loss, or trouble speaking ) , diabetes mellitus(DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), gastrostomy(a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) dysphagia (difficulty of swallowing) and encephalopathy(disturbance of brain function).During a review of Resident 75's Minimum Data Set (a resident assessment tool) dated 6/7/2025, the MDS indicated Resident 75 had unclear speech and was rarely or never understood. The MDS indicated the resident was dependent (helper does all the effort to complete the activity) on the staff with bathing, dressing, dressing, toileting hygiene, bed mobility and oral hygiene.During a review of Resident 75's History and Physical (H&P) dated 3/5/2025, the H&P indicated the resident did not have the capacity to understand and make decisions.During a review of Resident 75's Order Summary Report on 7/15/2025 at 12:00 p.m., the Order Summary Report did not indicate any order for physical restraint for resident's right arm or right hand.During a review of Resident 75' medical chart on 7/15/2025 at 4:30 p.m., the medical chart did not indicate a consent for the use of a restraint for the right arm.During an interview on 7/15/2025 at 1:43 p.m. with Certified Nursing Assistant (CNA) 3 in Resident 75's , CNA 3 stated the blue sock that was applied on the right arm and hand of Resident 75 was a mitten to protect the gastrostomy tube (GT- tube inserted through the abdomen directly into the stomach for feeding and medication administration ) from being pulled out by the resident.During an interview on 7/16/2025 at 1:50 p.m. with CNA 1, CNA1 stated the blue sock on his hand was a form of restraint and could cause impairment of Resident 75's skin circulation and restrict the movement of his right arm and hand. During an interview on 7/16/2025 at 2:05 p.m. with Licensed Vocational Nurse (LVN) 1, LVN1 stated the blue sock on the right arm and hand should have been removed by the staff and obtained a physician order for a physical restraint because the blue sock could cause skin problems and poor circulation.During an interview on 7/17/2025, at 4:50 p.m. with RN Supervisor (RNS) 1, RNS 1 stated the family of Resident 75 requested the sock on the right arm of the resident. RNS1 agreed it was the responsibility of the facility to monitor and assess the use of the restraint on Resident 75. RNS 1 stated Resident 75 could develop impaired skin and poor circulation because of the skin being covered and not being checked by staff. RNS 1 stated prior to initiating a form of physical restraint on a resident, the facility should use the least restrictive measure by redirecting the behavior, checking the resident more often or utilizing the family member to watch the resident. RNS 1 stated monitoring and assessment of the use of restraints should be documented on the residents' chart.During an interview on 7/18/2025, at 10:43 a.m. with the Director of Nursing (DON), the DON stated there should be a physician order, consent for the placement of restraint, assessment and monitoring for the use of restraint and quarterly restraint assessment to ensure if the resident still requires the use of restraint. The DON stated the blue sock used a restraint was not acceptable form of restraint because the material is not breathable and could make Resident 75's skin prone to breakdown and cause restriction on the movement of his right arm and hand. The DON stated the staff should have removed the sock from Resident 75's right arm, assessed the need for the use of restraint and notified the physician that the resident required a hand mitten or restraint to obtain an order.During a review of facility's policy and procedure (P&P) titled, Physical Restraints. revised 9/2017, the P&P indicated restraints will only be used after other alternatives have been tried unsuccessfully and only after a thorough assessment, informed consent from the resident or their responsible party, a physician's order and a care plan to address the use of restraints. The P&P indicated the facility may not use restraints based on the legal surrogate or representative's request and family must be educated for the risks of restraint usage. The P&P indicated the only acceptable forms of physical restraints shall be soft ties (soft cloth which does not cause abrasions and does not restrict circulation), soft cloth mittens, seatbelts and trays with spring release devices, and to use restraints that can be easily removed under the supervision of the staff.

Based on observation, interview, and record review, Licensed Vocational Nurse (LVN) 4 failed to ensure Resident 8's Acidophilus ([generic name - lactobacillus] a probiotic supplement used to improve gut health) was completely dissolved before being administered via gastrostomy tube (g-tube - a surgically placed tube used to administer medications or food directly into the stomach). LVN 4 failed to safely administer medications via g-tube by failing to follow infection control practices throughout medications administration, for one of seven sampled residents observed during medication administration. This failure to administer g-tube medications for Resident 8 in accordance with professional standards of care and increased the risk for discomfort, clogging of g-tube, infection and contamination of medications. Findings:During a review of Resident 8's admission Record, dated 7/16/2025, the admission Record indicated, Resident 8 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but not limited to, sepsis (a life-threatening blood infection), chronic kidney disease (a condition where the kidneys are damaged and cannot filter blood as well as they should), gastrostomy status, personal history of urinary tract infections (infection in any part of the urinary system), pneumonia (an infection/inflammation in the lungs) and history of other infectious and parasitic diseases.During a review of Resident 8's History and Physical (H&P), dated 2/4/2025, the document indicated Resident 8 did not have the capacity to understand and make decisions.During a review of Resident 8's Minimum Data Set (MDS-resident assessment tool), dated 4/21/2025, the MDS indicated Resident 8 was on g-tube feedings, fully dependent on facility staff for Activities of Daily Living (ADLs) such as oral hygiene, toileting hygiene, showering, upper and lower body dressing, putting on or taking off footwear and personal hygiene.During a concurrent observation and interview on 7/16/2025 at 9:00 a.m. with LVN 4, LVN 4 prepared the following six medications and supplements by crushing them individually using a crushing device to be administered to Resident 8 via g-tube. LVN 4 stated he used five to 10 milliliter( ml-unit of measurement) water to dissolve each medication separately.1. One tablet of buspirone (a medication used to treat anxiety [a medical condition described by feeling of fear or uneasiness]) 5 milligrams ([mg] - a unit of measurement for mass)2. One tablet of metformin (a medication used to treat diabetes mellitus [DM]-a disorder characterized by difficulty in blood sugar control and poor wound healing) 500 mg3. One tablet of metoclopramide (a medication used to treat gastroesophageal reflux disease ([GERD - digestive disorder where stomach acid frequently flows back into the esophagus, causing irritation and discomfort], and nausea and vomiting) 5 mg4. One tablet of sucralfate (a medication used to treat and prevent ulcer) 1 gram ([g] a unit of measurement for mass)5. Ferrous sulfate (a medication used to treat low level of iron) 7.5 milliliters ([mL] a unit of measurement for volume) 200 mg/5 mL 6. One capsule of AcidophilusLVN 4 started to use syringe to pull out water from water cup to use it as flush for g-tube, before starting to administer medications. The surveyor prompted LVN 4 to explain his steps, which was when LVN 4 corrected his technique by using the gravity method instead, to flush g-tube by administering 30 mL water into the syringe. The water started flowing out of the g-tube onto Resident 8's bed. LVN 4 stated Oh sorry, I didn't adjust the clamp on the g-tube for medication administration. LVN 4 fixed the issue and continued to administer medications one by one using gravity method followed by water in between each medication. LVN 4 then stepped away from the bedside with the syringe in his hand that was used to administer water and g-tube medications, and walked to the medication cart, which exposed the syringe to other factors in the environment. LVN 4 returned to bedside with the same syringe and resumed medication administration. During the administration of Acidophilus through the syringe into g-tube, the syringe looked cloudy with its powder stuck on the walls of the syringe. LVN 4 stated he will add more water to dissolve the powder. LVN 4 was not able to administer the remaining powdered solution through g-tube. LVN 4 then pushed with the syringe plunger which helped the remaining Acidophilus to be administered via g-tube to Resident 8. During a review of Resident 8's Order Summary Report, dated 7/17/2025, the Order Summary Report indicated but not limited to the following physician orders: Acidophilus oral tablet, give 1 tablet via g-tube one time a day for supplement, order date 1/31/2025, start date 2/1/2025. Buspirone hydrochloride (HCl) tablet 5 mg, give 1 tablet via g-tube every 12 hours for anxiety manifested by (m/b) inability to relax, order date 1/31/2025, start date 2/1/2025. Carafate ([generic name - sucralfate] oral tablet 1 g, give 1 tablet via g-tube four times a day for gastroesophageal reflux disease (GERD - digestive disorder where stomach acid frequently flows back into the esophagus, causing irritation and discomfort)/gastritis, order date 6/22/2025, start date 6/22/2025. Ferrous sulfate oral solution 220 (44 iron [Fe] mg per 5 ml, give 7.5 ml via g-tube one time a day for supplement, give 7.5 ml = 330 mg, order date 5/5/2025, start date 5/6/2025. Metformin HCl oral tablet 500 mg, give 1 tablet via g-tube two times a day for order date 1/31/2025, start date 2/1/2025. Metoclopramide HCl oral tablet 5 mg, give 1 tablet via g-tube every 12 hours for GERD, order date 1/31/2025, start date 2/1/2025.During an interview on 7/16/2025 at 2:47 p.m. with LVN 4, LVN 4 stated it was his mistake that he did not make sure to close the g-tube bulb so that water did not leak out of the g-tube. LVN 4 stated the Acidophilus was not properly dissolved, so it was not moving through the g-tube smoothly and was possibly getting stuck, clogging the g-tube. LVN 4 stated it was important to dissolve the medications and supplements well before administering them via g-tube. LVN 4 stated he should not have taken the syringe with him to the medication cart, away from the resident's care area. LVN 4 stated he should have changed his gloves and sanitized hands if he needed to move away from resident's care area to prevent contamination.During an interview on 7/17/2025 at 11:48 a.m. with the Director of Nursing (DON), the DON stated the facility nursing staff should make sure that the medications and supplements were dissolved well before administering via g-tube, otherwise they could clog the g-tube, prevent medications and supplements from moving through the g-tube smoothly, and gravity method might not work. The DON stated the correct technique to administer g-tube medications was by using gravity and water should not be pulled inside syringe. The DON stated LVN should have closed the clamp as they were pouring water or medications so that it did not leak out of the opening. The DON stated if the nurses used the wrong g-tube technique then the residents would not be treated for their conditions properly and would not receive medications effectively. The DON stated it would increase the risk of clogging the g-tube if the medication was not dissolved well. The DON stated the facility nurse should not be bringing the syringe away from the resident's care area to prevent contamination and infection.During a review of the facility's policy and procedure (P&P) titled, Medication Administration via Enteral Tube, dated 4/2017, the P&P indicated, Crushed tablets should be dissolved with at least 10 cc (mL) of water or other appropriate liquid. Administer medications: 1. Allow each medication to flow down the tube by gravity.During a review of the facility's P&P titled, Hand Hygiene, dated 7/2019, the P&P indicated, It is the policy of the facility that all staff members perform hand hygiene before and after direct resident care and after contact with potentially contaminated substances to prevent, to the extent possible, the spread of infection. Hand hygiene will be performed by staff as follows: during care when moving from a contaminated activity to a clean activity (for example.clothing).

Based on observation, interview, and record review, the facility failed to ensure that staff used a communication board (tool used for communicating with residents that speak another language) for one of four sampled residents (Resident 100) as written in her care plan. This deficient practice had a potential for staff to ineffectively communicate with Resident 100's care and had a potential to delay medicating Resident 100 when she complained of being in pain. Findings: During a review of Resident 100's admission Record , the admission Record indicated Resident 100 was originally admitted to the facility on [DATE] with diagnoses including cerebrovascular accident (CVA- stroke, loss of blood flow to part of the brain) and tracheostomy (surgically created opening in the neck that extends into the windpipe) with ventilator (a medical device to help support or replace breathing) dependence. During a review of Resident 100's History and Physical (H&P) dated 7/11/2025, the H&P indicated that Resident 100 was hospitalized on [DATE] for sepsis (life-threatening blood infection) from infected right elbow fracture and infected right knee replacement and was readmitted to the facility on [DATE]. The H&P indicated Resident 100 has a fluctuating capacity to understand and make decisions. During a review of Resident 100's Minimum Data Set (MDS- resident assessment tool) dated 7/17/2025, the MDS indicated Resident 100 was dependent (helper does all the effort or two or more helpers is required for the resident to complete the activity) on staff for bed mobility, moving from sitting on side of bed to lying flat on bed, toileting hygiene, bathing, dressing, personal hygiene, and oral hygiene. The MDS indicated that Resident 100's primary language is Spanish. During review of Resident 100's Care Plan titled Impaired Communication dated 7/13/2025, the Care plan interventions indicated Do not hurry when trying to communicate (with resident). During a concurrent observation and interview on 7/15/2025 at 10:38 a.m. with Resident 100, observed Resident 100 grimacing and uncomfortable in bed. A communication board with Spanish words and phrases hanging on the wall was used to communicate with Resident 100. Resident 100 stated she was in pain and would like pain medication. During an observation on 7/15/2025 at 10:43 a.m. in Resident 100's room, Licensed Vocational Nurse (LVN) 4 instructed Resident 100 that Tylenol was administered at 8:45 a.m. and to wait for the medication to kick in about 45 minutes to an hour in English. Resident 100 shook her head and mouthed, No se (I don't understand). LVN 4 replied, No pain? Okay and left the room. During an interview on 7/15/2025 at 10:50 a.m. with LVN 4, LVN 4 stated that he did not use the communication board to assess Resident 100's uncontrolled pain. During a subsequent observation on 7/15/2025 at 10:52 a.m. with LVN 4 and Resident 100 in Resident 100's room, Resident 100 stated she was in ten-out-of-ten pain in her right leg. LVN 4 asked Resident 100, Are you sure you're in pain? I just gave you medicine at 8:45 (a.m.) Resident 100 was grimacing and nodded her head. During an interview on 7/17/2025 at 2:31 p.m. with Register Nurse Supervisor (RNS) 3, RNS 3 stated that staff should be using the communication board when communicating with Resident 100 because it was important for her to make her needs known. RNS stated that staff was trained in how to use the communication board and what it was part of new hire orientation. RNS 3 stated that LVN 4 did not try to understand Resident 100 and this had the potential for Resident 100 to continue being in pain. During an interview on 7/18/2025 at 12:26 p.m. with the Director of Nursing (DON), the DON stated that staff can neglect residents' needs when they don't use the communication board and that is why all staff should be using it. During a review of Resident 100's Policy and Procedures (P&P) titled, Activities of Daily Living, Quality of Care, Routine Resident Monitoring, and Scope of Services dated 6/2022, the P&P stated, The facility will provide. communication (speech, language and other means such as a communication board) to residents assessed to require these services.

Based on interview and record review, the facility failed to ensure the resident, who had a history of acute stroke ([CVA]- loss of blood flow to a part of the brain) and complained of having a slurred speech, a headache, and severe pain in left arm was timely transferred to a general acute care hospital (GACH) to prevent ischemic (a condition that occurs when blood flow to an organ, muscle group, or tissue is reduced resulting in a lack of oxygen) stroke for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure Licensed Vocational Nurse (LVN unknown) assessed Resident 1 when Certified Nursing Assistant (CNA) 1, reported on 1/9/2025 at 1 p.m. Resident 1 complained of having severe pain in left arm rated 9 out of 10 on a pain scale (pain screening tool using numerical value to assess the level of pain ranging from 0 to 3-mild pain, from 4 to 6- moderate pain, and from 7 to 9-severe pain, and 10- the worse pain possible) and verbalized of not feeling right. 2. Ensure the licensed nurses transferred Resident 1 to the GACH when Resident 1's Family Member 1 (FM) 1 reported the resident was having symptoms of Transient Ischemic Attack ([TIA] - a brief period when blood flow to the brain is cut off) such as slurred speech and difficulty speaking. 3. Ensure the Nurse Practitioner (NP) 1 ordered Resident 1's transfer to GACH to prevent a delay in transferring the resident beyond acceptable three hours window to treat the resident with thrombolytic (a medical treatment used to dissolve blood clots) to prevent ischemic stroke. 4. Ensure staff follow the facility's policy and procedure (P&P) titled Emergency Care, revised 9/2017, which indicated to provide emergent care to a resident in need of urgent service; if a resident's condition is observed to have changed, assess the resident, notify the resident's attending physician, and report any changes in condition and provide emergency care as necessary. 5. Ensure staff followed the facility's P&P titled Change in Condition, revised 3/2021, which indicated the changes in the resident's condition be thoroughly assessed and evaluated with physician notification for early clinical management; thorough assessment will include all important information related to the resident such as onset of current symptoms, including vital signs. These failures resulted in five hours delay in transferring Resident 1 to a GACH from the time Resident 1 reported having symptoms of TIA including, slurred speech, and difficulty speaking. These failures led to Resident 1 not being able to receive thrombolytic therapy to prevent from having ischemic stroke. Resident 1 was subsequently diagnosed with left frontal lobe ischemic stroke and to have permanent brain damage. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparesis (weakness on one side of the body) following a cerebral infarction (also known as a stroke, where blood flow to the brain is interrupted causing brain tissue to die) affecting the left side of the body, and trigeminal neuralgia (a chronic pain disorder affecting trigeminal nerve [provides sensation and controls muscles in the face and head]). During a review of Resident 1's Minimum Data Set ([MDS] - resident assessment tool) dated 11/28/2024, the MDS indicated Resident 1's had intact cognition (ability to think and reason). The MDS indicated Resident 1 was dependent (helper does all the effort) on staff with lying to sitting on the side of the bed, from sitting to standing, and with transferring from the bed to chair. During a review of Resident 1's SBAR (situation, background, assessment, recommendation - a communication tool used by healthcare workers when there is a change of condition among the residents) form dated 1/9/2025 timed at 3:00 p.m., the SBAR form indicated Licensed Vocational Nurse (LVN) 1 notified Physician (MD) 1 about Resident 1's inability to speak and a high blood pressure (BP) of 152/96 millimeters of mercury ([mm/Hg]- a unit of pressure used to measure blood pressure. Reference range for normal BP is less than 120/80 mm/Hg). The SBAR indicated MD 1 recommendations included to monitor Resident 1. During a review of Resident 1's Nurses Progress Note dated 1/9/2025 for 7 a.m. to 3 p.m. shift, Nurses Progress Notes indicated Resident 1 was being monitored by LVN 1 when Certified Nursing Assistant (CNA) 1 reported Resident 1 was not able to speak. During a review of Resident 1's Nurses Progress Note dated 1/9/2025 timed at 2:30 p.m., the Nurses Progress Note indicated CNA 1 reported to LVN 2 that Resident 1 wanted to speak to a supervisor or desk nurse. The Nursing Progress Note indicated LVN 2 assessed Resident 1 and Resident 1 did not have any new onset of symptoms. During a review of phone text messages dated 1/9/2025 timed at 2:31 p.m., between LVN 2 and the Nurse Practitioner (NP) 1, the text messages indicated LVN 2 wrote Resident 1 complaint of hard time speaking after lunch and felt she was having another TIA. LVN 2 wrote Resident 1 was speaking right now and feels fine. NP 1 wrote back to keep an eye on Resident 1 and do neuro checks (series of tests that assess the nervous system [brain, spinal cord] that can help identify disorders of the brain) every four hours. During a review of Resident 1's Nurses Progress Note dated 1/9/2025 and timed at 3:15 p.m., the Nurses Progress Note indicated, LVN 2 asked RN 1 to assess Resident 1 as family member (FM) 1 voiced concerns of Resident 1 having slurred speech (a condition where a person's speech is difficult to understand). The Nursing Progress Note indicated Resident 1's blood pressure was 152/88 mm/Hg. The Nurses Progress Note indicated Resident 1 was awake, alert, oriented to person, place, and time, was coherent, had clear speech, and did not have expressive aphasia (a language disorder that makes it difficult to understand or express language). During a review of phone text message dated 1/9/2025 timed at 3:43 p.m., between LVN 2 to NP 1, the phone text message indicated LVN 2 informed NP 1 of Resident 1's having slurred speech and difficulty remembering. LVN 2 wrote RN 1 assessed Resident 1 which revealed no slurred speech, strong hand grip on the right hand and weak hand grip on the left hand due to previous stroke. Resident 1 was able to move right side extremities with no problem and no impaired vision. NP 1 responded Resident 1 was fine when she saw the resident the morning of 1/9/2025. NP 1 wrote if LVN 2 felt there was a change Resident 1 should have a Computerized Tomography (CT scan- medical imaging). LVN 2 responded that she did not see any issue with Resident 1 now. During a review of phone text message dated 1/9/2025 timed at 3:50 p.m. between LVN 2 to NP 1, the phone text message indicated LVN 2 wrote FM 1 was adamant that something was wrong with Resident 1. LVN 2 wrote FM 1 was requesting Resident 1 be transfer to GACH, NP 1 responded fine. During a review of Resident 1's Nurses Progress Note dated 1/9/2025, the Nurses Progress Note indicated 911 was called at 4:43 p.m. and Resident 1 was transferred to the GACH for slurred speech at 5:08 p.m. During a review of Resident 1's Emergency Transport Record (Paramedic Run Sheet) dated 1/9/2025, the Emergency Transport Record records indicated Paramedics were dispatched to the facility at 4:42 p.m. The Emergency Transport Record indicated at 4:55 p.m. Resident 1 had a blood pressure of 210/110 mmHg. The Emergency Transport Record indicated Resident 1 reported to the Paramedics of having trouble speaking around noon on 1/9/2025, and headache that has been unresolved throughout the day. During a review of Resident 1's Emergency Department (ED) Encounter Notes dated 1/9/2025, the ED Encounter Notes indicated Resident 1 presented to the GACH at 5:16 p.m. with a complaint of expressive aphasia (a disorder that makes it difficult to speak, usually seen in patients who are experiencing a TIA or stroke) and inability to speak full sentences. The ED note indicated Resident 1 had a last known well time (medical term used to describe the last time a patient was known to be free of stroke symptoms) of 12 p.m. and was not a candidate for intravenous ([IV] - medication and/or fluids given directly into the vein) thrombolytic due to the last known well time of greater than three hours. During a review of Resident 1's GACH Magnetic Resonance Imaging ([MRI] - a non-invasive test that uses radio waves and magnets to create a detailed image of the brain) dated 1/10/2025 and timed at 1:01 a.m., the MRI indicated Resident 1 had a new six millimeter (mm-unit of measurement) focus of restricted diffusion in the left frontal (at the front) cortical (outer layer of the cerebrum)/subcortical (region of the brain below the cortex ) region suggesting small acute or subacute infarct (lack of adequate blood supply to the brain ) During a review of Resident 1's GACH Discharge Summary Note dated 1/14/2025 and timed at 3:36 p.m., the GACH Discharge Summary indicated Resident 1's principal diagnosis was acute left frontal lobe (the largest section of the brain which is located in the front of the head) ischemic stroke (when a blood vessel that supplies blood to the brain is blocked, cutting off oxygen and nutrients to brain cells). During an interview on 1/22/2025 at 10:16 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated after lunch, around 1 p.m. to 1:30 p.m. Resident 1 verbalized not wanting to go back to bed which was unusual for Resident 1. CNA 1 stated Resident 1 complained of having severe pain 9 out of10 on a pain rating scale on her left arm. CNA 1 stated Resident 1 verbalized not feeling right. CNA 1 stated she reported it to a charge nurse (LVN) but could not remember which LVN she spoke to. During an interview on 1/22/2025 at 10:53 p.m. with FM 1, the FM 1 stated on 1/9/2025 around 1:30 p.m. he received a phone call from Resident 1 stating she believed she was having a stroke. FM 1 arrived at the facility around 2:30 p.m. and noticed Resident 1 was having slurred speech, difficulty in finishing her sentences, and difficulty remembering events throughout the day. FM 1 stated he asked the nurses to talk to the doctor, as he was concerned about Resident 1's worsening condition and requested Resident 1 to be transfer to the GACH as soon as possible FM 1 stated the nurse (unknown) told him the NP 1 said to continue to monitor Resident 1. FM 1 stated he insisted a second time to the licensed nurses to transfer Resident 1 to the GACH and Resident 1 was eventually transferred to the GACH at 5:03 p.m. via 911 (four hours after Resident 1 started to verbalize having difficulty to talk and not feeling well). During an interview on 1/22/2025 at 1:35 p.m., the NP 1 stated she saw Resident 1 on 1/9/2025 in the a.m. (time unknown) when Resident 1 reported to have a headache. The NP 1 stated Resident 1 had a history of trigeminal neuralgia, so she ordered her pain medication. NP 1 stated she had received a phone text messages around 2:30 p.m. on 1/9/2025 from unknown nursing staff who stated Resident 1 complained of difficulty to talk. The NP 1 stated vital signs were not provided in the phone text messages, but nurse (LVN 2) stated Resident 1 seems fine, so she recommended to monitor Resident 1 every four hours. The NP 1 stated she believed Resident 1 was having a transient ischemic attack ([TIA] known as a mini stroke with a temporary interruption of blood flow to the brain which causes stroke like symptoms but usually resolves within 24 hours). The NP 1 stated it was not a medical emergency because she did not present neurological symptoms based on nurse's report and therefore it must have resolved. The NP 1 stated the reason why she did not recommend sending Resident 1 to the GACH emergency department was because they would just treat it with blood thinners, and the resident was already on Aspirin (a blood thinner). The NP 1 stated around 3:30 p.m. she received a phone text message again from nursing staff (LVN 2) who stated FM 1 was insisting on Resident 1's transfer to the hospital, so she agreed since FM 1 insisted. During an interview on 1/22/2025 at 2:59 p.m., MD 1 stated he does not recall getting notified about Resident 1's change of condition on 1/9/2025. The MD 1 stated if he would have been notified that Resident 1 was having a slurred speech, he would order to send the resident to the hospital right away because monitoring would be a loss of time when Resident 1 was having a cerebral infarction. During an interview on 1/22/2025 at 3:50 p.m. RN 1 stated when she arrived to work at 3 p.m. LVN 2 reported to her Resident 1 was complaining about slurred speech. RN 1 stated she went to check on Resident 1 around that time, but her assessment was negative for any neurological changes. RN 1 stated she informed LVN 3 to check Resident 1's vital signs but did not actually witness vital signs being taken and does not know what time they were taken. RN 1 stated she was not the one to contact the physician or communicate to the physician about Resident 1's change of condition. During an interview on 1/22/2025 at 4:22 p.m., LVN 2 stated CNA 1 reported to her around 2:30 p.m. that the Resident 1 was having trouble speaking and she was the one who was in contact with NP 1 throughout the day. LVN 2 stated she told LVN 1 to take Resident 1's vital signs and fill out the SBAR form, but she did not relay the vital signs to NP 1. During an interview on 1/23/2025 at 9:28 a.m. RN 2 stated if Resident 1 reported having slurred speech, which could be a sign of a stroke, but she did not observe a resident have it upon assessment, she would still send a resident to the hospital right away for evaluation. RN 2 stated there is a four-hour window to treat certain stroke, such as tissue plasminogen activator ([tPA] a medication approved to treat ischemic strokes within the first 4.5 hours of a stroke.) that would help Resident 1. RN 2 stated she would monitor the resident vital signs which should be taken once there was reported change of condition. During an interview on 1/23/2025 at 12:13 p.m. with the Director of Nursing (DON), the DON stated that vital signs should be taken when there is a change of condition and document on the SBAR form and report to the physician because vital signs could indicate what was going on with the resident and will determine the course of treatment/action. The DON stated if a resident was reporting difficulty speaking, and a family member was reporting the resident experienced slurred speech, that was enough to send Resident 1 to GACH for evalution and treatment. The DON stated when the resident exhibiting symptoms of a slurred speech the licensed nurses do not need permission from the MD to call 911 and must have immediate interventions to transfer the resident to GACH During an interview on 1/24/2025 at 1:16 p.m. LVN 1 stated she filled out the SBAR form but did not actually speak with MD 1 or any other physician regarding Resident 1's change of condition when Resident first reported difficulty to talk. LVN 1 stated she did not check Resident 1's blood pressure upon the change of condition and documented Resident 1's vital signs taken on 1/9/2025 at 9:27 a.m. on SBAR form timed at 3 p.m. on 1/9/2025. LVN 1 stated when there was a change of condition vital signs should be done at the time of a condition change because they reflect the status of the resident for the doctor to decide what the plan of care. LVN 1 stated the reason why she did not take Resident 1's blood pressure was because she assumed another nurse did it. LVN 1 stated she did not receive any report from the CNA 1 that Resident 1 had severe headache but does recall that Resident 1 did not want to get back into bed. LVN 1 stated it was not until around 2 p.m. to 2:30 p.m. on 1/9/2025 when Resident 1 notified staff she had trouble speaking. LVN 1 stated she did not notify RN 3 when Resident 1 had a change of condition for RN 3 to assess Resident 1's slurred speech. During a review of facility's policy and procedure (P&P) titled Emergency Care, revised 9/2017, the P&P indicated it is the policy of the facility to provide emergent care to a resident in need of urgent service. The P&P indicated if a resident's condition is observed to have changed, assess the resident, notify the resident's attending physician, and report any changes in condition and provide emergency care as necessary. Always take, report, and document the resident's vital signs when a resident is assessed to have a change in condition. During a review of an online article titled, American Heart Association Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke, revised 2019, the article indicated tPA is recommended for selected patients who may be treated within 3 hours of ischemic stroke symptom onset or patient last know well or at baseline state and is also recommended for selected patients who can be treated within 3 and 4.5 hours of ischemic symptoms onset or patient last known well. The article indicated treatment should be initiated as quickly as possible within the listed time frames of 3 to 4.5 hours because time to treatment is strongly associated with outcomes. https://www.ahajournals.org/doi/10.1161/STR.0000000000000211#sec-2 During a review of facility's P&P titled Change in Condition, revised 3/2021, the P&P indicated the purpose of the policy for changes in the resident's condition be thoroughly assessed and evaluated with physician notification for early clinical management to avoid unnecessary readmissions to acute hospitals. The P&P indicated thorough assessment will include all important information related to the resident such as onset of current symptoms, including vital signs. The P&P indicated thy physician is responsible for making the decision for the resident to be treated at the facility or be transferred to the acute hospital for treatment.

Based on interview and record review, the facility failed to ensure a resident, who was admitted with intact skin did not develop a pressure injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) while in the facility, and a resident who was admitted with a pressure injury had measures in place to prevent the existing pressure injury from getting worse for two of two residents (Resident 2 and 12). The facility failed to: 1. Implement Resident 2's care plan, titled Alteration in Skin integrity intervention to turn and reposition the resident at least every two hours and as needed from 1/2024 to 3/2024 to prevent Resident 2 from developing the pressure injuries to the right and left lateral (to the side of, or away from, the middle of the body) malleolus (the bone on the outside of the ankle joint). 2. Ensure Resident 2 was assessed by the Registered Dietician (RD -food and nutrition expert) on 2/11/2024 when the deep tissue injury (DTI - persistent non-blanchable [something does not fade when pressure is applied, such as a rash or skin discoloration] deep red, maroon, or purple discoloration, related to damage from pressure and/or shear) to the left lateral malleolus was first identified, as indicated in the care plan titled, Alteration in Skin integrity and as the Wound Consultant recommended on 2/13/2024. 3. Ensure Resident 2's Wound Consultants' recommendation to cleanse the wound to the left lateral malleolus with Normal Saline (mixture of salt and water solution) prior to applying Betadine (a solution that kills germs promptly) was implemented starting on 2/11/2024. 4. Implement Resident 12's care plan, titled Alteration in Skin integrity, intervention to turn and reposition the resident at least every two hours and as needed from 1/1/2024 to 3/31/2024 which had the potential to slow the healing of Resident 12's pressure injury to the sacrum (lower back area). 5. Implement the facility's policy and procedure (P&P) titled, Pressure Injury also known as, Pressure Sore Management, revised 10/2017, that indicated to prevent the development of skin breakdown/pressure injuries the staff need to implement the care plan to reposition the resident at least every two hours and follow the RD's and physician's recommendations. These failures resulted in Resident 2, who was assessed as a moderate risk for developing a skin injury and had intact skin upon admission on 1/9/2024 developing the following pressure injuries: 1a. A facility-acquired preventable Stage IV pressure injury (full-thickness skin and tissue loss with exposed muscle or bone) to the left lateral malleolus, measuring 2.2 centimeters (cm) long by 1.6 cm wide by 0.3 cm deep on 3/26/2024, 77 calendar days from admission. The wound bed was 30 percent (%) slough (yellowish material), 60% granulation (new tissues, bright red or pink, soft, moist, bumpy, and be raised), and 10% epithelial tissue (appears pink or pearly white, occurs in the final stage of healing). 1b. A Stage III pressure injury (full-thickness loss of skin, dead and black tissue may be visible), to the right lateral malleolus, measuring 1.2 cm long by 1.2cm wide with undetermined depth (UTD) with100% slough. 2. These deficient practices placed Resident 12 at risk for pressure injury to the sacrum (lower back area) delayed healing or to progress to worse. Findings: 1. During a review of Resident 2's Admission Record, the Admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure (when the lungs and blood are unable to exchange gases properly), generalized muscle weakness, hyperglycemia (a condition where there is too much glucose in the blood ), acute kidney failure (kidneys suddenly can't filter waste products from the blood), with gastrostomy ([GT] - a soft tube surgically placed into the stomach to provide nutrition, hydration and medication) in place. During a review of Resident 2's Minimum Data Set ([MDS], a resident assessment tool) dated 1/16/2024, the MDS indicated Resident 2's cognitive (ability to think and reason) skills for daily decision-making were severely impaired. The MDS indicated Resident 2 was totally dependent on staff for all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). The MDS indicated Resident 2's skin was intact and did not have any ulcers, wounds, and skin problems. During a review of Resident 2's Braden Scale (a scoring tool used to predict residents' risk of developing a pressure injury, total scores range from 6 - 23. A lower score indicating a higher risk of developing a pressure injury) assessment dated [DATE], the Braden Scale Assessment indicated Resident 2's score was 14 indicating Resident 2 was at moderate risk for developing a pressure injury. The Braden Scale Assessment indicated Resident 2's skin was occasionally moist, the resident was chairfast (capable of maintaining a sitting position but lacking the capacity of bearing own weight), had very limited mobility (ability to change and control body position), was unable to make frequent or significant positional changes independently and required moderate to maximum assistance (helper does more than half the effort) when moving. During a phone interview on 11/26/2024 at 9:04 a.m., family member (FM 1) stated Resident 2 had a pressure sores (in reference to a pressure injuries) because the facility did not turn Resident 2 frequently. FM 1 stated she remembered one incident when the resident's indwelling urinary catheter (a soft flexible tube inserted into the urinary bladder to drain urine into a collection bag outside the body) had been accidentally removed and no one discovered it until later. FM 1 sated if they were turning the resident every two hours, they would have seen it and identified the problem with skin sooner. During a concurrent interview and record review on 11/26/2024 at 12:36 p.m. with the Assistant Director of Nursing (ADON) Resident 2's MDS, dated [DATE], Resident 2 's Initial Nursing History and Assessment, dated 1/9/2024, and Resident 2's Braden Scale Risk Assessment, dated 1/9/2024, were reviewed. The ADON stated Resident 2 's Initial Nursing History and Assessment, and Resident 2's Braden Scale Risk Assessment indicated Resident 2's skin was intact upon admission and Resident 2 was at moderate risk for developing pressure injuries. The ADON stated Resident 2 was dependent on staff for all ADL's including turning and repositioning in bed. The ADON stated Resident 2 was totally dependent on staff to implement interventions for preventing the development of pressure injuries, since Resident 2 could not independently reposition himself. During a concurrent interview and record review on 11/26/2024 at 12:40 p.m., with the ADON, Resident 2's Situation Background Appearance Review (SBAR) Communication Form, dated 2/11/2024, was reviewed. The ADON confirmed the SBAR indicated that 32 days after the resident's admission Resident 2 developed a purplish discoloration on the left lateral malleolus measuring 2.5 cm by 2.5 cm., which was a sign of a pressure injury development. During a concurrent interview and record review on 11/26/2024 at 12:44 p.m., with the ADON, Resident 2's Wound Consultant Progress Notes, dated 2/13/2024, were reviewed and the ADON confirmed the Wound Consultant classified the purplish discoloration on the left lateral malleolus as a DTI. The ADON stated the Wound Consultant recommended to turn and reposition the resident every two hours, keep the skin clean and dry, and to avoid massaging bony prominences (areas where bones are close to the surface). The ADON stated the Wound Consultant also recommended the RD to assess Resident 2 to ensure adequate intake of protein and calories, to maintain the current level of activity, mobility, and range of motion, to use positioning devices to prevent prolonged pressure on bony prominences. The ADON stated the treatment plan was to cleanse the left lateral malleolus DTI with sterile (free of infection causing organisms) Normal Saline, pat dry, apply Betadine directly to the wound bed of the left lateral malleolus DTI and cover with dry sterile dressing. The ADON stated the treatment plan was also to change dressing daily and as needed for loss of integrity and soiling. During a concurrent interview and record review on 11/26/2024 at 12:47 p.m., with the ADON, Resident 2's care plan titled, Alteration in skin Integrity, started on 2/11/2024, was reviewed and the ADON confirmed the care plan goal indicated Resident 2's left lateral malleolus DTI would heal without complications. The ADON stated two of the care plan interventions included the RD's evaluation of Resident 2's nutritional needs for pressure injury healing to left lateral malleolus DTI, and to turn and reposition Resident 2 at least every two hours. During a concurrent interview and record review on 11/26/2024 at 12:49 p.m., with the ADON, Resident 2's Wound Consultant Progress Notes, dated 2/27/2024, were reviewed. The ADON stated the Wound Consultant Progress Notes indicated Resident 2's DTI to the left lateral malleolus opened up and it was reclassified as an unstageable pressure injury (when the stage is not clear because the base of the wound is covered by a layer of dead tissue) measuring 2.9 cm long by 2.5 cm wide with UTD depth and 100% necrotic (dead tissue in the wound itself). The Wound Consultant Progress Notes indicated a recommendation to turn the resident every two hours and to follow the registered dietitian's recommendations. The ADON stated the facility should have recommended the use of a low air loss mattress (a mattrass designed to prevent and treat pressure injuries) before Resident 2's left lateral DTI worsened to an unstageable pressure injury. During a concurrent interview and record review on 11/26/2024 at 12:50 p.m., with the ADON, Resident 2's Nutrition Care Progress Notes from 1/10/2024 to 3/29/2024 were reviewed and the Nutrition Care Progress Notes indicated the RD did not make any recommendations for Resident 2's pressure injury healing until 3/5/2024, which was 23 days after the Wound Consultant's and care plan recommendations for the RD to assess Resident 2. The ADON confirmed the RD did not assess Resident 2 and make recommendations for Resident 2's wound healing interventions until 3/5/2024. The ADON stated Resident 2 should have been seen by the RD sooner so the RD's recommendations could be implemented quicker to promote Resident 2's pressure injury to start healing. A review of Resident 2's Nutrition Care Progress Notes, dated 3/5/2024, indicated the RD made recommendations as followed: a. Discontinue current GT feeding of Fibersource High Nitrogen (formula for nutrition) 1.2 at 65 milliliters/hour over 20 hours and change formula with Jevity 1.5 Cal (high protein formula) 237 milliliters ([ml] a liquid weight measurement) 5 times a day via bolus (a single dose administered all at once) at 6 a.m., 10 a.m., 2 p.m., 6 p.m., 10 p.m., to provide a1185 ml equivalent to 1778 kilocalories (unit of energy), 76 grams of protein, and 901 ml of water. b. Fluid restriction to 1500 ml was discontinued. c. Discontinue folic acid (supplement). d. Discontinue free water flush (water used to clear the g-tube before and after administering medications). e. Start free water flush of 25 ml before and after each bolus feeding. f. Zinc (supplement) 50 milligrams ([mg] weight measurement) daily for 5 days. g. Discontinue Pro- Stat (liquid protein supplement). During a concurrent interview and record review on 11/26/2024 at 12:58 p.m., with the ADON, Resident 2's Documentation Survey Reports for January, February, and March 2024 were reviewed. The Documentation Survey Reports indicated the column titled, Turn and Reposition Every Two Hours and As Needed indicated Resident 2 was not turned and repositioned every two hours and as needed on each shift in January, February, and March 2024. The ADON stated The Documentation Survey Reports indicated there were six eight-hour shifts in January, five shifts in February, and eight shifts in March 2024 that were left blank which meant there was no documented evidence Resident 2 was turned and repositioned every two hours on every shift in January, February, and March 2024. The ADON stated if it was not documented it was not done. During a review of Resident 2's Wound Consultant Progress notes, the Wound Consultant Progress notes indicated following: a. On 3/12/2024, the pressure injury on the left lateral malleolus had gotten worse and was reclassified as Stage III pressure injury (Full-thickness loss of skin, dead and black tissue may be visible) measuring 2.8 cm long by 1.5 cm wide, with undetermined depth. b. On 3/19/2024, the pressure injury on the left lateral malleolus had gotten worse and was reclassified as Stage IV pressure injury measuring 1.5 cm long by 1.8 cm wide by 0.4 cm deep. The notes indicated a new DTI was noted on right lateral malleolus DTI measuring 2.0 cm long by 2.0 cm wide with undetermined depth. c. On 3/26/2024, the notes indicated the Stage IV pressure injury to the left lateral malleolus measured 2.2 cm long by 1.6 cm wide and 0.3 cm. deep. The wound bed was 30% slough (yellowish material), 60% granulation (new tissues, bright red or pink, soft, moist, bumpy, and raised), and 10% epithelial tissue (appears pink or pearly white occurs in the final stage of healing). The right lateral malleolus DTI had gotten worse and was reclassified as a Stage III pressure injury measuring 1.2 cm long by 1.2 cm wide with undetermined depth and 100% slough. excisional debridement (surgical removal or cutting away of such tissue, necrosis, or slough) was performed on both right and left lateral malleolus pressure injuries. During an interview and record review on 12/2/2024 at 10:12 a.m., with the Director of Nursing (DON), Resident 2's Wound Consultant Notes dated 2/ 13/2024 and Physician's Orders dated 2/2024 were reviewed. The Wound Consultant Notes indicated the treatment plan for the left lateral malleolus was to cleanse the wound with sterile Normal Saline, pat dry, apply Betadine directly to wound bed and cover with dry sterile dressing. Change dressing daily and as needed for loss of integrity/soiling. Resident 2's Physician Orders dated 2/11/2024, 2/16/2024, and 2/27/2024 indicated the order for the left lateral malleolus was to paint with Betadine, allow to dry and then cover with Silicone Foam (a type of wound dressing that seals the wound and absorbs any fluids) dressing every day shift. The DON stated the recommendations of the Wound Consultant to clean the DTI with sterile Normal Saline first before applying Betadine was not implemented and instead the DTI was just being painted with betadine without being cleaned with sterile Normal Saline first. The DON stated the physician's recommendations should have been followed to ensure proper wound healing. The pressure injury was just being painted with Betadine without being cleaned with normal saline first from 2/11/2024 to 3/11/2024. During an interview on 12/2/2024 at 11:00 a.m., the DON stated residents should be turned at least every two hours to prevent the resident from getting a pressure injury or the pressure injury getting worse. The DON stated residents should not develop a pressure injuries in the facility . The DON stated the care plan meeting to plan and implement proper interventions for Resident 2 when the DTI was first identified should have included the RD. The DON stated back in January to March of 2024, the facility was going through changes in administration, and she was not sure why the RD was not involved in Resident 2's care sooner. 2. During a review of Resident 12's Admission Record, the Admission Record indicated Resident 12 was admitted to the facility on [DATE] with diagnoses including pressure injury of sacral (lower back) region, type 2 diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), obesity (chronic disease when someone has excessive amount of body fat that can lead to health problems) and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 12's MDS, dated [DATE], the MDS indicated Resident 12's cognitive skills for daily decision-making were intact. The MDS indicated Resident 12 needed maximal assistance (helper does more than half the effort) with toileting hygiene, showering, and rolling left and right on the bed. The MDS indicated Resident 12 was at high risk for developing pressure injuries and the resident had one or more unhealed pressure injuries. During a review of Resident 12's Initial Nursing History and Assessment, dated 12/5/2022, the Initial Nursing History and Assessment indicated Resident 12 had an unstageable pressure injury to the sacrococcyx (lower back tailbone area) area measuring 4.5 cm long by 4 cm wide, with 3.0 cm. depth. During a review of Resident 12's care plan titled, Alteration in skin Integrity, started on 12/6/2022, the care plan goal indicated Resident 12 would show progress towards wound healing over the next three months. One of the care plan interventions included to provide turning and repositioning at least every two hours. During a review of the Resident Council (facility residents who meet regularly to improve their quality of life and quality of care) meeting Minutes dated 3/28/2024, the document indicated Resident 12 complained that staff was not turning and repositioning the resident every two hours. During an interview on 11/27/2024 at 1:45 p.m., in Resident 12's room, Resident 12 stated in the beginning of the year (January to March 2024), the staff were not turning and repositioning her. Resident 12 stated she complained about staff not turning her in March 2024 at the Resident Council meeting and signed a statement. During an interview on 11/27/2024 at 1:58 p.m., Certified Nurse Assistant (CNA 1) stated turning and repositioning the resident at least every two hours was important and documentation on turning and repositioning was completed after the resident was turned and repositioned. CNA 1 stated if it was not documented it was not done. During an interview and record review on 11/27/2024 at 3:00 p.m., with the ADON Resident 12's Documentation Survey Report for January, February, and March 2024, were reviewed and the task indicating Resident 12 was turned and repositioned at least every 2 hours and as needed, did not indicate Resident 12 was consistently turned and repositioned every two hours and as needed on every shift for three months in January, February, and March 2024 The ADON stated there were four shifts in January, five shifts in February, and nine shifts in March 2024, that were blank which meant there was no documented evidence Resident 12 was turned and repositioned every two hours on each shift for the months of January, February, and March 2024. The ADON stated if it was not documented it was not done. During an interview on 11/27/2024 at 3:10 p.m., the ADON stated Resident 12 consistently complained in March 2024 about not being turned every two hours. The ADON stated dependent residents should be turned at least every two hours to prevent a pressure injury development and facilitate the healing of existing pressure injuries. During a review of Pressure Injury Prevention Points Portable Document Format (PDF) published by the National Pressure Injury Prevention Advisory Panel, copyright 2020, the PDF indicated the following pressure injury prevention recommendations: a. Consider bedfast and chairfast individuals to be at risk for development of pressure injury. b. Develop a plan of care based on the areas of risk, rather than on the total risk assessment score. For example, if the risk stems from immobility, address turning, repositioning, and the support surface. c. Turn and reposition all individuals at risk for pressure injury, unless contraindicated due to medical condition or medical treatments. d. Continue to reposition an individual when placed on any support surface. e. Reposition weak or immobile individuals in chairs hourly (www.npiap.com) During a review of the facility's P&P titled, Pressure Injury aka Pressure Sore Management, revised 10/2017, the P&P indicated: a. It was the policy of the facility to provide guidelines for the treatment of pressure injuries to facilitate healing. b. The diet of the resident with a pressure injury should contain nutrients adequate to support healing as recommended by the RD. c. A plan of care will be initiated upon admission and identification of residents at high risk for development of pressure injuries and implemented. d. Residents will be turned and repositioned every two hours or as needed. Frequent toileting and efforts to keep residents dry. e. Ongoing programs including emphasis on turning schedule by supervisory staff.

Based on observation, interview and record review, the facility failed to ensure residents with diagnoses of seizure (a sudden, uncontrolled burst of electrical activity in the brain), convulsions ( rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement ) or epilepsy (a brain condition that causes recurring seizures), and on anti-seizure medications (medications used to prevent or treat seizures or convulsions by controlling abnormal electrical activity in the brain), had seizure precautions (safety measures to prevent/lessen possible injuries during a seizure activity such as padded siderails and bed in low position), in place for three of 25 sampled residents. The facility failed to: 1.Ensure Resident 1, who had diagnosis of epilepsy, was identified upon admission to the facility on [DATE], as being at risk for seizures and placed on seizure precautions. 2. Have a policy and procedure (P&P) in place regarding the management and care of residents with the diagnoses of seizures, convulsions, and epilepsy, including how to identify those residents at risk and implement seizure precautions. 3. Identify, assess, and implement seizure precautions for 24 residents, in the facility with diagnoses of seizures, convulsions, epilepsy, and on anti-seizure medications These deficient practices resulted in Resident 1 falling from the bed during a seizure activity, sustaining a laceration (a cut) on top of her head that required admission to a general acute care hospital (GACH) for evaluation and treatment. Resident 1 became unresponsive and was intubated (a tube placed into the windpipe to aid in breathing) and the resident ' s cut on top of her head was sutured (process of closing a cut on your skin) of the cut on top of her head. These deficient practices placed the other 24 residents with diagnoses of seizure, convulsions, or epilepsy at risk for falls and injuries during seizure activities. On 3/15/2024 at 3:09 p.m., 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 to a resident) was called in the presence of the facility ' s Administrator (ADM) and the Director of Nursing (DON) for the facility ' s failure to implement seizure precautions for Resident 1 and 24 other residents at risk for injuries related to seizures. On 3/17/2024, the facility submitted an acceptable IJ Removal Plan ([IJRP] interventions to immediately correct the deficient practices). After onsite verification of the facility ' s IJRP ' s implementation through observation, interview, and record review, the IJ was removed on 3/17/2024 at 4:03 p.m., in the presence of the DON and ADM. The IJRP included the following immediate actions: 1. Resident 1 was readmitted to the facility on [DATE], and seizure precautions such as bed in low position, half bilateral (two sides) padded side rails, bilateral floor mats, and a neurology (a branch of medicine concerned with disorders of the brain and nervous system) consult was ordered. Resident 1 ' s physician ordered Keppra (seizure medication) and to monitor for signs and symptoms of seizure every shift. On 3/15/2024, a blue seizure identification sticker was placed on Resident 1 ' s name plate outside of her room. Seizure interventions were documented in Resident 1 ' s care plan and implemented. The Registered Nurse Supervisor (RNS) and the licensed nurses will monitor every shift that all ordered seizure precautions were in place and documented on the seizure monitoring log. 2. Registered Nurses (RN) and licensed nurses were given in-services on 3/15/2024 by the DON on the new seizure management policy to include but not limited to identify residents with epilepsy and/or seizure diagnosis on admission, monitoring seizure, prevention and management of resident having seizure episodes. The RNS will monitor seizure prevention and management of residents with seizure episodes. 3. On 3/15/2024 an in-service was initiated for Certified Nursing Assistant (CNAs) on signs and symptoms of seizure, management of seizure activity and prevention. 4. On 3/15/2024 the facility initiated a policy and procedure for seizure management including assessment, prevention, and management of seizures. 5. On 3/15/2024, the DON and licensed nurse designee conducted a review of all current residents ' medical record to identify residents with seizure, epilepsy, and other convulsion diagnosis. There were 24 residents identified and reassessed for appropriate interventions. On 3/15/2024 the residents ' attending physicians ' were notified and preventive measures (padded half side rails, bed in low position, and monitoring for signs and symptoms of seizure) were implemented immediately for all residents at risk. 6. On 3/15/2024 the facility adopted a practice of using blue seizure identification blue sticker on resident ' s name plate on the resident ' s door to identify those with diagnoses of seizures, epilepsy, and convulsions. 7. New admissions, readmitted , and current residents with diagnosis of seizure and/or epilepsy will be assessed to ensure appropriate interventions were ordered such as padded half siderails, low bed position, and seizure monitoring with the use of the monitoring tool, and blue seizure identification stickers placed on their name plates. 8. A monitoring tool was created to check the adherence of the specific precautionary measures as ordered by resident physician. Designated staff will complete a monitoring tool every shift to check the adherence of the specific precautionary measures for residents with seizures, epilepsy, or convulsions. 9.The residents ' physicians may order padded full siderails and/or bolsters as needed. 10. RNs, Licensed Vocational Nurse (LVNs), and CNAs will be given annual in-services on seizure management and will be part of the new hire training. 11. DON and/or designee will review new admissions and/or readmission the following day, the RN supervisor will review on the weekend to ensure residents with seizure and/or epilepsy diagnosis have seizure precautions and monitoring of seizure activity by use of the monitoring tool in the next 3-months. Findings will be reported to the monthly QAPI Meeting. 12. The DON and/or designee will make rounds daily using the monitoring tool in the next 3 months to ensure residents with seizure and/or epilepsy diagnosis have seizure precautions in placed. Findings will be reported to the monthly Quality Assurance and Performance Improvement (QAPI - data driven and proactive approach to quality improvement) Meeting. 13. The Administrator and/or designee will make rounds three times weekly for the next 3-months and review 10 random residents charts with diagnosis of seizure and/or epilepsy and ensure seizure precautions are in place. Findings: a.During a review of Resident 1 ' s Admission Record, the Admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including epilepsy and systemic lupus erythematosus (SLE- when the body ' s immune system attacks the tissue and organs). During a review of Resident 1 ' s History and Physical (H&P) dated 2/13/2024, the H&P indicated Resident 1 had a fluctuating capacity to understand and make decisions. During a review of Resident 1 ' s Care Plan titled High risk of injury due to seizure activity dated 2/12/2024, indicated a goal for Resident 1 was to have no injury daily for the next three months. The care plan interventions included to implement fall and or seizure precautions, and provide a safe environment free of clutter, adequate lighting and non-slippery. During a review of Resident 1 ' s care plan titled High risk for trauma/injuries and ineffective breathing pattern related to diagnosis of complex partial epilepsy (seizures that result in a sudden absence of awareness regarding surroundings) dated 2/12/2024, the care plan goal indicated Resident 1 will not have a significant injury if seizure activity occurred through next review. The care plan ' s interventions included keep environment free of safety hazards. During a review of Resident 1 ' s Situation, Background, Assessment, Recommendation ([SBAR] a verbal or written communication tool that helps provide essential, concise information, usually during a crucial situation) dated 3/4/2024, the SBAR indicated Resident 1 was found lying on the floor on the left side of the bed, non-responsive to verbal stimuli (open eyes in response to a spoken word or phrase directed towards the resident). The SBAR indicated Resident 1 had tonic clonic generalized seizures (loss of consciousness and violent muscle contractions), and bleeding on the left side of the head. The SBAR indicated Resident 1 ' s physician was notified, and the physician recommended staff to apply pressure to Resident 1 ' s left side of the head and transfer the resident to the GACH. During a review of Resident 1 ' s ambulance report dated 3/4/2024, the report indicated the facility ' s staff found Resident 1 on the ground (floor) beside her bed with blood on the ground (floor). The report indicated Resident 1 had a two inches (unit of measurement) laceration to the back of her head and exhibited decerebrate posturing (posture characterized by a stiff body, straight legs, and clenched fists usually from severe brain damage). The ambulance report indicated upon emergency services (EMS) assessment Resident 1 began to have full body tonic clonic shaking. The ambulance report indicated midazolam (medication commonly used as emergency treatment for seizures) was administered to Resident 1 via intravenous (IV- through the veins) access. The ambulance report indicated upon arrival to the GACH, Resident 1 had another seizure. During a review of Resident 1 ' s Face Sheet from the GACH, the Face Sheet indicated Resident 1 was admitted on [DATE] with diagnosis of status epilepticus (a seizure that lasts longer than 5 minutes or has more than one seizure within a five-minute period without returning to a normal level of consciousness between seizures). During a review of Residents 1 ' s Trauma H&P from the GACH dated 3/4/2024, the Trauma H&P indicated Resident 1 had an unwitnessed fall. The Trauma H&P indicated upon arrival to the GACH, Resident 1 was actively seizing and was intubated for airway management (procedures used to maintain or restore a patient ' s airway). The Trauma H&P indicated Resident 1 had a small left tempo parietal (side of the head) hematoma (collection of blood that forms in tissue, organ, or body space because of broken blood vessels due to injury). During an interview on 3/13/2024 at 11:05 a.m., with Paramedic ([PAR] a person trained to give emergency medical care) 1, PAR 1 stated when he entered the room, Resident 1 was in bed, actively seizing. PAR 1 stated Resident 1 ' s bed did not have side rails and there were no floor mats. PAR 1 stated he observed a 12-inch blood stain on the floor, next to the resident ' s bed. PAR 1 stated Resident 1 was transported to the GACH via ambulance and had a seizure activity upon arrival to the GACH. b. During a review of Resident 2 ' s Admission Record, the Admission Record indicated Resident 2 was admitted to the facility on [DATE] with the diagnosis of unspecified convulsions. During a review of Residents 2 ' s MDS dated [DATE], the MDS indicated Resident 2 was in a persistent vegetative state (awake with no signs of awareness). The MDS indicated Resident 2 was completely dependent on staff for activities of daily living (ADLs- eating, drinking, transferring, dressing and toileting). The MDS indicated Resident 2 had a diagnosis of a seizure disorder or epilepsy. During a review of Resident 2 ' s physician orders dated 11/30/2023, the order indicated give 10 milliliters ([ml] unit of measurement) Levetiracetam (medication used to treat seizures) through a gastrostomy tube (tube inserted through the wall of the abdomen into the stomach for food and medication administration) every eight hours for seizure disorder. During a review of Resident 2 ' s care plan titled High risk for trauma/injuries related to diagnosis of seizure disorder, dated 4/26/2023, the care plan goal indicated Resident 2 will not have a traumatic injury, if possible, within next 3 months. The care plan interventions included keeping environment free of safety hazards. a. During a review of Resident 3 ' s Admission Record, the Admission Record indicated Resident 3 was admitted to the facility on [DATE] with the diagnosis of other seizures. During a review of Residents 3 ' s MDS dated [DATE], the MDS indicated Resident 3 ' s cognition (ability to learn, remember, understand, and make decision) was severely impaired. The MDS indicated Resident 3 was completely dependent on staff for ADLs. The MDS indicated Resident 3 had a diagnosis of a seizure disorder or epilepsy. During a review of Resident 3 ' s physician order dated 8/14/2023, the order indicated Levetiracetam 10 milliliters every 12 hours through gastrostomy tube for seizure disorder. During a review of Resident 3 ' s care plan titled High risk for trauma/injuries and ineffective breathing pattern related to seizure disorder, dated 8/15/2023, the care plan goal indicated Resident 3 will not have any significant injury if seizure activity occurred through 5/2024. The care plan interventions included to keep the environment free of safety hazards, bilateral siderails while in bed for safety, proper positioning to prevent injury or fall, and monitor seizure activity every shift. During an observation on 3/13/2024 at 12:19 p.m., in Resident 2 and 3 ' s room, Resident 2 was in bed, with no side rails or floor mats on either side of the bed. Resident 3 was observed in bed with unpadded bilateral side rails. There were no floor mats on the right side of Resident 3 ' s the bed. During an interview on 3/13/2024 at 12:20 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Residents 2 and 3 were on seizure medications and should have seizure precautions such as bed in the lowest position and unpadded side rails if ordered by the physician. LVN 1 stated Resident 3 had siderails because the family requested the siderails for Resident 3 ' s comfort while positioning. During an interview on 3/13/2024 at 12:45 p.m. with Resident 1, Resident 1 stated there were no padded side rails or floor mats prior to her fall and seizure on 3/4/2024. Resident 1 stated she did not remember the details surrounding her seizure and only remembered when she was receiving stitches for the laceration on her head. Resident 1 stated she had her first seizure on 11/2023. During an interview on 3/13/2024 at 12:58 p.m. with the Director of Staff Development (DSD), the DSD stated on 3/4/2024 he found Resident 1 on the floor laying on her left side shaking. The DSD stated Resident 1 ' s bed had no side rails. The DSD stated he supported Resident 1 ' s head up so the resident would not hit her head on the floor repeatedly. The DSD stated residents with a history of seizures should be placed on seizure precautions including bed in lowest position, floor mats, pillows tuck under the resident on the side of their bed to prevent them falling. During an interview on 3/14/2024 at 1:27 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated when she provided care for Resident 1 on 3/4/2024 around 11 a.m., Resident 1 did not have padded side rails on the bed and floor mats. CNA 1 stated she was not aware Resident 1 had a history of seizures. During an interview on 3/14/2024 at 1:44 p.m., with the Assistant Director of Nursing (ADON), the ADON stated she responded to the DSD ' s call for help on 3/4/2024, at 11:35a.m., and found Resident 1 on the floor, seizing. The ADON stated when she put a pillow under Resident 1 ' s head, she noticed a large amount of blood on the resident ' s head. The ADON stated she was familiar with the resident ' s history of SLE and End Stage Renal Disease ([ESRD] medical condition in which a person's kidneys stop functioning on a permanent basis) but not of seizures. The ADON stated she reviewed Resident 1 ' s medication list but could not find any anti-seizure medications. The ADON stated she was unsure about Resident 1 ' s seizure history. The ADON stated Resident 1 should have had padded siderails which would have prevented her from falling out of the bed and being injured. During an interview on 3/14/2024 at 2:56 p.m., with LVN 2, LVN 2 stated residents with a history of seizures identified during admission should have seizure precautions implemented. LVN 2 stated the facility did not have a policy on how to identify residents with diagnosis of seizures, convulsions, or epilepsy, on anti-seizure medications and safety measures to implement. During an interview on 3/14/2024 at 3:14 p.m., with the Minimum Data Set (a comprehensive assessment and care screening tool) Nurse (MDSN), the MDSN stated the diagnosis list for each resident was generated from the resident ' s hospital records. The MDSN stated care plans were created from the diagnosis list. The MDSN stated seizure precautions should have been implemented for all residents with diagnosis of seizure, convulsions, and epilepsy. The MDSN stated if seizure precautions were not in place, a resident could fall from their bed and be injured. During an interview on 3/16/2024 at 9:36 a.m., with LVN 3, LVN 3 stated residents at risk for seizures were identified on admission by their diagnosis and medications ordered for seizures. LVN 3 stated seizure precautions should be implemented when residents were admitted with diagnoses of seizure, convulsion and epilepsy and were on anti-seizure medications to prevent falls and injuries seizures. During an interview on 3/16/2024 at 10:04 a.m., with RNS 2, RNS 2 stated seizure precautions should be implemented upon admission, if a resident was identified at risk for seizure. RNS 2 stated during meetings and huddles (short daily meetings) staff were notified of residents at risk for seizures. RNS 2 stated she was unsure if the facility had a method to identify residents at risk for seizures such as a wrist band. RNS 2 stated any resident on seizure medications should be on seizure precautions because the medications could limit seizures, but not prevent them. During an interview on 3/16/2024 at 11:45 a.m. with the DON, the DON stated upon admission a resident was identified as at risk for seizure based on the resident ' s seizure medications. The DON stated since Resident 1 was not prescribed any seizure medication, Resident 1 ' s seizure history was unknown. The DON stated if the seizure diagnosis was not identified and seizure precautions were not implemented, residents could suffer an injury during a seizure. The DON stated the MDSN and RNS should have followed up to ensure care plan interventions were implemented for seizure precautions for Resident 1. The DON stated the facility did not have a policy on seizure management and precaution. During a review of a facility ' s document titled Facility assessment dated [DATE], the Facility Assessment indicated residents accepted to the facility with diagnosis including seizure disorders that require complex medical care and management. During a review of the facility ' s Policy and Procedure (P&P) titled Comprehensive Care Planning, (undated) the P&P indicated the care plans were developed to address minimum health care information required to properly care for each resident, including goals and objectives. The P&P indicated the care plan must address effective and person-centered care that met professional standards for quality of care.

Based on observation, interview and record review, the facility failed to prevent the development of an avoidable Stage IV (skin damage that extends to the muscle, tendon, or bone) pressure sore (skin injury from prolonged pressure on the skin and tissue underneath) on the sacro-coccyx (tail bone area) area for one of two sampled residents (Resident 2) by failing to: a. Ensure Resident 2 was repositioned at least every two hours, as indicated in the care plan to relieve the pressure from the sacro-coccyx area. b. Ensure Licensed Vocational Nurse (LVN) 2 assessed Resident 2's sacro-coccyx pressure sore on 5/15/2023, 5/22/2023, 5/29/2023, 6/5/2023, 6/12/2023, and 6/19/2023, to reflect the size of the pressure sore and to reflect the correct classification of the pressure sore as a Stage III (damage extend to fat tissue) pressure sore. c. Ensure the licensed nurses, in charge of resident assessments, completed Resident 2's weekly skin assessments during 4/2023, to determine the condition of Resident 2's skin. These deficient practices resulted in Resident 2's moisture-associated skin damage ([MASD] term for inflammation or skin erosion [breakdown] caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or mucus) on the buttocks, which was identified on 5/15/2023, progressing to a Stage III (skin damage extending to the fat tissue) pressure sore to the sacro coccyx area on 6/23/2023, then progressing to an infected Stage IV pressure sore on the sacro-coccyx area on 7/4/2023. Resident 2's sacro-coccyx pressure sore measured 1.3 cubic centimeters ([cm] a unit of measurement) in length, 0.6 cm in width, 0.4 cm in depth, with undermining (region underneath the overlying loose skin around the pressure sore) of 2.0 cm at 6 to 2 o'clock (undermining is measured by the use of the clock hand positions), with moderate purulent (consisting of, containing, or discharging pus) exudate (fluid leaking out). The infected Stage IV pressure sore required consultation from a wound specialist, excisional (cutting away) debridement (the removal of damaged tissue or foreign objects from a wound), an x-ray of the sacrum (tail bone) to rule out osteomyelitis (serious infection of the bone), and intravenous (within the vein) Clindamycin (a medication used to treat infections) for fourteen days. Findings: During a review of Resident 2's Admission Record (Face Sheet), dated 10/6/2023, the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnosed including an ulcer (an open sore) of the intestines, gastrointestinal hemorrhage (bleeding in the stomach, bowels or anus), gastrostomy (a feeding tube inserted through the belly to deliver food and/or medication directly to the stomach), hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (a slight paralysis or weakness on one side of the body) following a nontraumatic intracranial (brain) hemorrhage (bleed) affecting Resident 2's left dominant side. During a review of Resident 2's Minimum Data Set ([MDS]), a standardized assessment and care screening tool) dated 2/14/2023, the MDS indicated Resident 2's cognitive skills (ability to think and reason) for daily decision-making was intact. The MDS indicated Resident 2 required extensive assistance from one person with bed mobility, personal hygiene, and toilet use; and required the assistance of two or more persons with transfers (how resident moves between surfaces like from bed to chair). The MDS indicated Resident 2 was at risk of developing pressure ulcers/injuries. The MDS indicated Resident 2 did not have any unhealed pressure sore/injuries. The MDS indicated Resident 2 did not have any ulcers, wounds, and skin problems. During a review of Resident 2's Braden Scale (scoring tool used to predict pressure sore risk), dated 2/14/2023, the Braden Scale indicated Resident 2's score was 13 indicating Resident 2 was at moderate risk for developing pressure sores. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 was at risk of developing pressure ulcers/injuries. The MDS indicated Resident 2 did not have any unhealed pressure sore/injuries. The MDS indicated Resident 2 had a moisture associated skin damage ([MASD] term for inflammation [body's natural reaction to injury] or skin erosion [breakdown] caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or mucus), no location was indicated. During a review of Resident 2's Care Plan, dated 8/19/2021, the care plan goals indicated the resident will not develop a pressure ulcer. The Care Plan indicated to reposition Resident 2 every two hours. During a review of Resident 2's Care Plan, dated 5/15/2023, the Care Plan indicated Resident 2 was at high risk for further skin breakdown related to Resident 2's moderate risk for developing pressure sores, incontinence (involuntary control of urination and defecation), poor skin turgor (elasticity), decreased mobility, hypertension (high blood pressure [force it takes for blood to pump]), history of coronavirus disease (contagious illness), and history of pressure sores. The care plan goals indicated the resident will not develop a pressure ulcer. Interventions indicated to monitor Resident 2's MASD for signs and symptoms (s/s) of redness, edema (an excess of watery fluid collecting in the tissues of the body), pain, drainage, pressure area/opening in the skin, to treat as ordered, use an LAL mattress and to notify the physician if s/s were noted and/or if no progress towards healing was noted. Interventions also indicated to check, turn, and reposition Resident 2 at least every 2 hours. The Care Plan indicated a revision date of 6/20/2023 to strictly reposition Resident 2 from side to side. During a record review of Resident 2's Situation Background Assessment and Review ([SBAR] a form of communication between members of a health care team), dated 5/15/2023, the SBAR indicated Resident 2's buttocks had a MASD that was moist and red. The SBAR indicated the physician recommended to treat Resident 2 based on facility recommendations to reposition the resident from side to side. During a record review of Resident 2's SBAR, dated 6/23/2023, the SBAR indicated Resident 2's wound in the sacro-coccyx deteriorated to a Stage III Pressure injury. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 was at risk of developing pressure ulcers/injuries. The MDS indicated Resident 2 had one unhealed pressure sore/injuries. The MDS indicated Resident 2 had one Stage 4 pressure ulcer that was not present upon admission. During a review of Resident 2's Weekly Summary SNF (weekly assessment of the residents' physical, behavioral, nutritional, functional, and mental condition) for 4/2023, the weekly summary indicated: 1. Resident 2's weekly skin assessment for 4/1/2023 to 4/9/2023 was not available for review in Resident 2's clinical record. 2. Resident 2's weekly skin assessment, dated 4/10/2023, was left blank without documentation of Resident 2's skin condition. 3. Resident 2's weekly skin assessment, dated 4/17/2023, did not indicate the condition of the resident's skin on the weekly summary form. 4. Resident 2's weekly skin assessment from 4/18/2023 to 4/30/2023 was not available for review in Resident 2's clinical record. During a review of Resident 2's Non-Pressure Skin Condition Report, dated 5/2023 and 6/2023, the report indicated Resident 2 had MASD on the sacro-coccyx area and the following: 1. On 5/15/2023 and 5/22/2023, Resident 2's MASD's size was not measured (left blank), there was scant serosanguineous exudate, and the note indicated the wound bed had granulation tissue (the development of new tissue and blood vessels in a wound during the healing process, the wound may appear bright red or pink, soft, moist, bumpy, and be raised above the surrounding skin). 2. On 5/29/2023, Resident 2's MASD's size was not measured (left blank), a small amount of serosanguinous exudate was noted, and the note indicated granulation tissue was present 3. On 6/5/2023, Resident 2's MASD's size was not measured (left blank), the surrounding skin color was pink and not normal, and the note indicated granulation tissue was present. 4. On 6/12/2023, Resident 2's MASD's size was not measured (left blank), a small amount of serosanguineous exudate was noted, and the note indicated the wound bed had granulation tissue present. 5. On 6/19/2023, Resident 2's MASD's size was not measured (left blank), a small amount of serosanguineous exudate was noted, the surrounding skin color was pink and not normal, the wound bed had granulation tissue present, and Resident 2's wound was stalling (not getting better). During a review of Resident 2's Task: Point of Care: turn and reposition at least every two hours and as needed record, from 6/5/2023 to 10/6/2023, the record indicated no documented evidence that Resident 2 was turned and repositioned at east every two hours and in what position. During a record review of Resident 2's Weekly Pressure Injury Record, the record dated 6/23/2023 indicated Resident 2's sacro-coccyx pressure injury, measured 1.0 cm in length by 1.0 cm in width by .03 cm in depth, with moderate serosanguinous drainage, the surrounding skin was pink, the wound bed was 10% slough and 90% granulation tissue. The record indicated treatment for Resident 2's Stage III pressure injury was initiated, a foley was applied to prevent wound contamination and side to side repositioning was done. During a review of Resident 2's order details, dated 6/23/2023 at 2:44 p.m., the order indicated to apply Medihoney wound/burn dressing external gel (type of gel that cleans and debrides [remove damaged tissue] the wound) to sacro-coccyx topically every dayshift, for the Stage III pressure injury for fourteen days. The order indicated to cleanse the pressure ulcer with Hibiclense (type of antiseptic [substance that prevent the growth of disease-causing germs] skin cleanser), rinse well and pat dry; then to apply Medihoney followed by Hydrofera blue (type of dressing) then cover with foam dressing and apply to sacro-coccyx topically as needed for soilage and dislodgement for fourteen days. During a review of Resident 2's Wound Care Physician Progress Note, dated 6/27/2023, the note indicated Resident 2 presented with a sacro-coccyx ulcer and current treatment will be continued. The note indicated Clindamycin 450 mg, every 6 hours was ordered for suspected infection and the pressure ulcer had a foul odor. During a review of Resident 2's Wound Care Physician Progress Note, dated 7/4/2023, the note indicated Resident 2's pressure ulcer progressed to a Stage IV pressure ulcer, measuring 1.3 cm in length by 0.6 cm in width and 0.4 cm in depth, with undermining at 2.0 cm at 6 to 2 o'clock with moderate purulent exudate which required excisional debridement. The note indicated an x-ray of Resident 2's sacrum was ordered to rule out osteomyelitis and intravenous Clindamycin 600 mg every six hours was started for an infected sacro-coccyx wound. During observations on 10/6/2023 at 10:00 a.m. and at 12:05 p.m., Resident 2 was observed laying on her back and not on her side. During a concurrent interview and record review on 10/6/2023 at 12:05 p.m., with the LVN 2, Resident 2's Task: Point of Care: turn and reposition at least every two hours and as needed record, dated from 6/5/2023 to 10/6/2023, was reviewed. Resident 2's record indicated there was no documented evidence to indicate if Resident 2 was turned every two hours or in what position he was turned. LVN 2 stated there was no documentation of Resident 2 being turned every 2 hours and what position the resident was in to relieve pressure to prevent injury. LVN 2 stated residents' skin was fragile and if the residents were not turned as care planned the residents could get a pressure injury. LVN 2 stated, Resident 2 had a facility acquired pressure ulcer that became infected. During an interview on 10/6/2023 at 10:30 a.m. with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated each time staff repositioned or turned residents it should have been documented in the ADL task record. CNA 1 stated all care provided to the resident needs to be documented so everyone in the facility will be aware of the type of care the resident has received. During an interview on 10/6/2023 at 12:20 p.m., and a subsequent interview on 10/9/2023 at 12 p.m., the Director of Nursing (DON), stated she was unaware that Resident 2 was not being turned and repositioned as care planned. The DON stated staff were expected to document at least 12 times in a 24-hour period to indicate if a resident was turned and repositioned. The DON stated with all the problems identified, Resident 2 developed a facility acquired Stage IV pressure ulcer that was avoidable. During a concurrent interview and record review on 10/9/2023 at 11:00 a.m., with LVN 2, Resident 2's Non-Pressure Skin Condition Reports from 5/15/2023 to 6/23/2023, were reviewed. Resident 2's report for 5/15/2023, 5/22/2023, 5/29/2023, 6/5/2023, 6/12/2023, and 6/19/2023 indicated the area to document the length, depth, and width of Resident 2's MASD was left blank. LVN 2 stated she did not know she had to measure Resident 2's MASD and the section was left blank because she did not measure Resident 2's wound. The report for 5/15/2023, 5/22/2023, 5/29/2023, 6/5/2023, 6/12/2023, and 6/19/2023 indicated granulation tissue was checked to indicate granulation tissue had formed in Resident 2's MASD (MASD is partial thickness [confined to the skin layers; damage does not penetrate below the top two layers of skin} with no granulation or slough). LVN 2 stated if granulation tissue was checked, it meant granulation issue was noted in Resident 2's MASD on the days it was documented. LVN 2 stated, she charted what she saw. LVN 2 stated Resident 2's MASD was moist, red, raw, with exudate. The report for 6/5/2023 indicated Resident 2's MASD had slough. LVN 2 stated, she did not remember seeing slough, she must have mistaken. During a concurrent interview and record review on 10/9/2023 at 11:30 a.m. with the Assistant Director of Nursing (ADON), Resident 2's Weekly Summary SNF for 4/2023 was reviewed. Resident 2's weekly skin assessment for 4/1/2023 to 4/9/2023 and 4/18/2023 to 4/30/2023 was unavailable for review in Resident 2's clinical record and Resident 2's weekly skin assessment for 4/10/2023 and 4/17/2023 was left blank with no documentation of the status of Resident 2's skin. The ADON stated, if there was no weekly skin assessment in Resident 2's clinical record Resident 2's skin assessment was not completed. The ADON stated on 4/10/2023 and 4/17/20233, the skin assessment portion of the weekly skin assessment should have indicated the condition and description of Resident 2's skin. If there was no documentation of Resident 2's skin assessment, then it was not completed. The ADON stated the skin assessments should be completed weekly to track the resident's skin condition. During a concurrent interview and record review on 10/9/2023 at 11:50 a.m., with the ADON, the description of the stages of pressure injuries on Resident 2's Weekly Pressure Injury Record and Resident 2's Non-Pressure Skin Condition Report, dated 5/15/2023 to 6/23/2023, were reviewed. The description indicated granulation tissue, slough, and eschar (dry dark scab) were not present in Stage II pressure sores/MASD; and granulation tissue, slough and eschar were often present and/or visible in Stage III pressure sores. The ADON stated according LVN 2's documented description, Resident 2's wound was a Stage III pressure injury. The ADON stated if Resident 2's sacro-coccyx MASD had granulation tissue present it progressed to a Stage III pressure ulcer and should have been reclassified as a Stage III pressure ulcer. The ADON stated there were six missed opportunities (5/15/2023, 5/22/2023, 5/29/2023, 6/5/2023, 6/12/2023, and 6/19/2023) where more aggressive interventions, such as a wound consult, a low air loss mattress (a mattress designed to distribute a patient's body weight over a broad surface area and help prevent skin breakdown), notification of Resident 2's physician, and an order for treatment of a Stage III wound not a MASD could have been ordered and/or implemented. The ADON stated the progression of Resident 2's MASD, which was acquired in the facility and progressed to a Stage IV pressure ulcer was avoidable. During a review of the facility's P&P titled, Pressure Ulcer/Injury Management, revised 7/2019, the P&P indicated there will be an emphasis on resident's turning schedule by all supervisory staff and residents will be turn and repositioned every two hours and as needed and the P&P indicated the licensed nurses shall: a. Assess the pressure injury(s) and pressure sore(s) for location, size (measure length, width, and depth), sinus tracts (narrow opening or passageway of a wound underneath the skin), undermining, (region underneath the overlying loose skin around the pressure sore), tunneling (passageways) exudates (fluid leaks out of blood vessels into nearby tissues), necrotic (dead) tissue, and the presence of absence of granulation tissue and epithelialization (process of becoming covered with or converted to epithelium[covers all internal and external surfaces of the body]); and b. Determine the ulcer/injuries current stage of development. c. Assess skin weekly as part of their weekly summaries.

Based on observation, interview and record review, the facility failed to ensure nutritional interventions were evaluated to prevent unplanned weight loss for 1 of 1 resident (Resident 42) by failing to: 1. Ensure facility developed a comprehensive care plan for Resident 42 to include past medical history/surgery and identify the resident's food preference. 2. Revise and develop an effective care plan after Resident 42 had significant weight loss and prevent further weight loss. 3. Provide a therapeutic diet, that considers the resident's clinical condition, and preferences, when there is a nutritional indication. These deficient practices resulted in Resident 42 (R42) to experience severe unplanned weight loss of 5.39% in 3 months and 12% in 90 days (previous admit weight was 186 pounds). Findings: During a concurrent observation and interview on 12/14/21 at 09:48 a.m. with R42, R42 stated, the food is the one down button. R42 stated, the facility should look at their menu because I have lost a lot of weight because, I don't really eat the food. R42 stated, his current weight is 158 pounds and he normally weigh in the 200's. Resident 42 further stated he did not want to lose any more weight and has spoken to staff on several occasions. During a review of Resident 42's Monthly Weight Form, the Monthly Weight Form indicated the following: September 2021: 186 pounds. October 2021: 167 pounds. November 2021: 168 pounds. December 3, 2021: 164 pounds. During a review of Resident 42 Face sheet, undated, the face sheet indicated Resident 42 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 42 Minimum Data Set (MDS - a comprehensive assessment and care-planning tool), Section C dated 10/16/21, indicated that R42 is alert and oriented. During a review of the Physician orders dated October 9, 2021, the orders indicated that the diet order was for a regular, low fat diet. During a review of weekly weight record dated 10/9/21-12/8/21, the weight record indicated that the re-admit weight for R42 was 167 pounds on 10/9/21. On 12/8/21, R42 weight was 158 pounds. R42 original admit weight in August 2021 was 186 pounds. R42 Ideal body weight (IBW) is between 176-216 pounds based on his height of 74 inches. During a review of the facility care plan titled Nutritional Risk, dated 10/13/21, it indicated that R42 was at nutritional risk for weight loss, malnutrition and dehydration (loss of electrolytes in the blood). The care plan also indicated that R42 loss 13-28 pounds (7%-14% weight loss) in 4 months. During a review of the lab pre-[MEDICATION(S)] (lab test to see if you are getting enough nutrients) test result dated 10/27/21, the result was 10.5 (low), normal levels are 17-34. During a review of the lab report for R42, dated 11/2/21, it indicated that R42, hemoglobin was 7.4 (normal value 13.5-16.9) and hematocrit was 22.4 (normal value 39.5-50.0). During a review of the facility Weight Variance progress notes, dated 11/4/21, the progress notes indicated R42 had an 18-pound weight loss in 90 days. During a review of the meal percentage record, starting date 12/1/21-12/6/21, the record indicated the following with multiple missed entries: 12/1/21 Breakfast- 26-50% 12/1/21 Lunch- 26-50% 12/2/21 Dinner- 26-50% 12/3/21 Breakfast- 51-75% 12/4/21 Breakfast- 26-50% 12/5/21 Dinner- 51-75% 12/6/21 Lunch- 0% 12/6/21 Dinner-26-50% During a review of the weekly Weight Variance Review dated 12/16/21, by the Registered Dietician (RD), it indicated that R42 was on a regular, fortified diet with ice cream with lunch and dinner. The record indicated, R42 generally eats between 26-75% of meals. It also indicated that R42 diet preferences were updated by the Dietary Supervisor (DS). During an interview on 12/15/21 at 4:08 p.m. with R42, R42 stated he didn't eat much of his lunch because it's the same old thing. R42 stated, he was not offered anything else or substitutes. During a concurrent interview on 12/15/21 at 4:14 p.m. with the Dietary Supervisor (DS) and R42, the DS stated, she was aware of R42 losing weight and R42 has been discussed on the weight variance meeting. The DS stated, nursing staff and the RD was aware too. The DS stated, she seen R42 on admission and got his food preferences. The DS offered R42 a [MEDICATION(S)] sandwich as a substitute choice. R42 stated he didn't eat bread because he can't digest it and it gets lodged in his stomach and causes pain. R42 informed the DS that he (R42) had gastric bypass surgery 7 or 8 years ago and can't eat bread. The DS stated, you didn't tell me before, I didn't know you didn't eat waffles, pancakes or toast. R42 stated, we never talked like this before. During an interview on 12/16/21 at 8:32 a.m. with CNA 4, CNA 4 stated, R42 eats ok, usually 70 or 80 % of his meals. CNA 4 stated that sometimes R42, doesn't like what he gets but he gets house nourishments (milk supplements supplied by the facility that provides extra calories) daily. CNA 4 stated that it was important to get nourishments when you don't eat much so you won't lose weight. CNA 4 stated, the facility staff always offer R42 a sandwich, sometimes he takes it and at times R42 states he doesn't like the food. CNA 4 stated, I report it to the Charge Nurse when he doesn't like to eat. During an interview on 12/16/21 at 8:44 a.m. with R 42, R42 stated he has not spoken with the DS since October 2021 and that no one asked if he had gastric bypass. R42 stated, he doesn't tolerate bread, it gets lodge in his stomach and makes him sick. When the facility serves sandwiches, he eats what's inside of it, but doesn't eat the bread. During an interview on 12/16/21 at 8:47 a.m. with LVN 4, LVN 4 stated, R42 was picky with his food. LVN 4 stated she was aware R42 had lost weight and it is important to prevent weight loss. LVN 4 stated R42 might get confused, lose electrolytes (minerals in your body that have an electric charge), and become dehydrated (harmful reduction of water in the body). LVN 4 stated that R42 ate 30% for dinner and 20% for breakfast and lunch on 12/15/21. During an interview on 12/16/21 at 9:03 a.m. with DS, the DS stated, she didn't know R42 had gastric bypass and was surprised yesterday. DS said, it wasn't on the chart that R42 had gastric bypass surgery 7 or 8 years ago. The DS says she sees residents and check their food preferences on every admission. DS stated, I have 3 days to do an assessment, but I haven't seen him since October 2021. DS stated that R42 is on the weight variance meeting weekly. During an interview on 12/16/21 at 9:12 a.m. with the Assistant Director of Nurses (ADON), the ADON stated she was aware that R42 was losing weight and that is why he was on the weight variance weekly meeting. The ADON stated, R42 told her he had gastric bypass, just recently on December 7, 2021. The ADON stated, the Weight Variance Committee will have another weight variance meeting today and she will let the team (RD, DS and licensed nurse) know today that R42 had gastric bypass. The ADON stated, I am the only person that knows, that he shared it with, but he didn't tell me he can't eat bread. The ADON stated that R42 was choosy with his food. During an interview on 12/16/21 at 9:58 a.m. with the Registered Dietician (RD), the RD stated in the weekly weight loss variance meetings, residents with significant weight changes like 5% or 5 pounds in one month, 7.5% in 90 days and 10% in 180 days or anyone that was a concern with poor oral intake. RD stated that R42 had a significant weight loss when he was readmitted on [DATE] from the hospital of 19 pounds, from 186 to 164 for the month of November 2021. The RD stated, R42 had a 12% weight loss percentage from September 2021, weighing 186 to December 2021, weighing 164. The RD stated that she did not know that R42 had gastric bypass surgery because it wasn't in the chart. RD stated that the DS told me yesterday (12/15). The RD stated that R42 preferences should be individualized because he could decline. RD stated the last line of defense for weight loss, is taking an oral (by mouth) appetite stimulant. During a review of the facility policy Dietary-Food and Nutrition Preparation and Service dated 1/2017, the policy indicated that: 1. The resident centered care plan will identify preferences of the resident. 2. Each resident will be provided a nourishing, palatable, well balanced diet that meets their daily nutritional and dietary needs while considering the preferences of the resident. During a review of the facility policy Weight Variance Committee, dated 10/2018, the policy indicated that the facility would review and monitor residents with weight variances at an interdisciplinary team meeting (IDT) on a regular scheduled basis and observe residents to determine reason for weight loss: 1. Inadequate meal portions 2. Dislikes of food; food preferences have changed 3. Improper meal texture due to chewing or difficulty swallowing

Based on interview and record review, the facility failed to provide the following care and services needed for one of two sampled residents (Resident 1), who had right and left vascular (pertains to the blood vessels (arteries, carry blood that is rich in oxygen away from the heart and veins, carry blood that is reduced in oxygen toward the heart)) great toe (big toe) gangrene (death of tissue, a dangerous condition that could end someone's life that happens when the blood flow to a large area of tissue cells is cut off): 1. The facility failed to develop a care plan that was consistent with Resident 1's specific risks for infection relating to vascular great toe gangrene. 2. The facility failed to assess Resident 1's left and right great toe gangrene from 10/30/16 (admitted ) to 1/4/17 (transfer date), for a total of more than two months in accordance with the facility policy and procedures. 3. The facility failed to refer Resident 1 to a podiatrist (a physician devoted to the study and medical treatment of [REDACTED]. The deficient practices resulted in delayed identification of infection (a change in condition) to Resident 1's right and left gangrenous great toes and provision of medical interventions that led to Resident 1 experiencing intractable (unmanageable) pain level of seven out of ten (7/10) in a pain rating scale of zero to ten (zero indicating no pain and ten indicating worst pain). Resident 1 was transferred to the general acute care hospital (GACH) emergency room (ER) on 1/4/17 at 4:50 p.m. Resident 1 was given local (uses injectable medicine to block sensations of pain from a specific area of the body) anesthetics (a substance that induces insensitivity to pain) and narcotics (controlled drugs affecting mood or behavior used medically to relieve strong pain) to relieve the pain then was admitted to the Intensive Care Unit (ICU, a specialized department in the hospital where seriously ill residents are cared for by specially trained staff) under serious condition on 1/5/17. The vascular surgeon (a specialist who diagnose and manage disorders that affect the arteries, veins and lymphatic systems (a network of tissues and organs that help rid the body of toxins, waste and other unwanted materials)) and podiatrist recommended for Resident 1 to undergo bilateral (both) [MEDICAL CONDITION] (an operation to remove all or part of a limb or extremity). Findings: A review of Resident 1's record titled, Resident Face Sheet (admission record), undated, indicated Resident 1 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 1's record titled, Comprehensive Resident Assessment, dated 10/30/16, indicated Resident 1 came to the facility with left and right great toe gangrene. There was no documented assessment of the left and right great toe gangrene upon admission on 10/30/16. A review of Resident 1's record titled, Physician Order Report, dated 10/30/16, indicated to treat and cleanse the left and right great toe gangrene with normal saline (salt in water), pat dry, apply [MEDICATION NAME] solution (used on the skin to treat minor wounds and decrease risk of infection), cover with dry dressing every day for 30 days and reassess. A review of Resident 1's record titled, Resident Care Plan, Risk for Skin Breaks/Pressure Ulcer (or pressure sore, areas of damaged skin caused by staying in one position for too long), developed 10/31/16, indicated, Resident (Resident 1) admitted with right and left great toe gangrene. Included in the approach plan for the staff to do skin checks every day, notify charge nurse of any skin changes in skin condition, and notify the physician of any significant changes in skin condition. There was no indication of how the staff would assess and monitor Resident 1's right and left great toe gangrene for signs (evidence of disease (infection) that can be detected by someone other than the resident affected by the disease) and symptoms (evidence of disease that is experienced by the resident affected by the disease) of infection. A review of the facility policy and procedures titled, Comprehensive Care Planning, dated 1/2017 indicated that the facility will develop a care plan for each resident. The care plan will address effective and resident-centered care (specific to Resident 1's care needs) that meets professional standards for quality of care (ethical (pertaining to right and wrong in conduct) or legal duty (the responsibility to others to act according to the law) of a professional to exercise the level of care, diligence (careful and persistent work or effort), and skill prescribed in the code of practice of his or her profession, or as other professionals in the same discipline would in the same or similar circumstances). A review of Resident 1's record titled, Minimum Data Set (MDS, a resident assessment and care screening tool), dated 11/6/16, indicated Resident 1 was assessed to be cognitively (refers to mental abilities) intact. The MDS indicated Resident 1 required extensive assistance (resident performed part of the activity; staff provided support with bearing weight; at times full staff performance of activity) with most activities of daily living (routine activities that people tend do everyday involving personal care and functional mobility (the manner in which people are able to move around in the environment or move from place to place)). A review of Resident 1's record titled, History and Physical (H&P), dated 11/18/16, indicated Resident 1 had the capacity to understand and make decisions. The H&P indicated Resident 1's [DIAGNOSES REDACTED].), diabetes (a disorder that affects the body's ability to use blood sugar resulting to high levels of sugar in the blood) and bilateral (both) great toe gangrene. According to the American Heart Association, last reviewed 04/21/2014, http://www.heart.org/HEARTORG/Conditions/Cholesterol/WhyCholesterolMatters/[MEDICAL CONDITION].jsp#.WO6P92egu1s indicated, Plaque may partially or totally block the blood's flow through an artery in the heart, brain, pelvis, legs, arms or kidneys. The arterial wall becomes markedly thickened by these accumulating cells and surrounding material. The artery narrows and blood flow is reduced, thus decreasing the oxygen supply. .if the oxygen supply to the extremities is reduced, gangrene can result. According to the National Institute of Diabetes and Digestive and Kidney Diseases, no date, https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-problems/foot-problems indicated, Diabetes also can lower the amount of blood flow in your feet. Not having enough blood flowing to your legs and feet can make it hard for a sore or an infection to heal. Sometimes, a bad infection never heals. The infection might lead to gangrene. Gangrene and foot ulcers that do not get better with treatment can lead to an amputation of your toe, foot, or part of your leg. A surgeon may perform an amputation to prevent a bad infection from spreading to the rest of your body, and to save your life. A review of Resident 1's record titled, Non-Pressure Sore Skin Problem Report, dated from 10/31/16 - 1/2/17, under Description (include size/extent), there was no documented description of Resident 1's left and right great toe gangrene. A review of the facility policy and procedures titled, Pressure Sore Management, dated 7/2015 indicated, Arterial Ulcer/ Wound is ulceration (wound) that occurs as the result of arterial (pertaining to artery) occlusive disease (blockage or narrowing of an artery) when non-pressure related disruption or blockage of the arterial blood flow to an area causes tissue necrosis (death). Inadequate blood supply to the extremity may initially present as intermittent claudication (crampy leg pain due to insufficient blood flow to the area caused by blocked arteries supplying that area). Key Procedural Points: Assess the pressure ulcer(s) for location, size (measure length, width, and depth), sinus tracts (a narrow opening or passageway underneath the skin that can extend in any direction through soft tissue and results in dead space with potential for abscess (is a collection of pus, a thick fluid that usually contains germs/bacteria) formation), undermining (deep tissue damage underneath intact skin at the wound margin/edge), tunneling (a track of tissue loss that extend in any direction away from the wound through soft tissue and muscle), exudates (a fluid substance can be pus-like or clear fluid that leaks out from a wound), necrotic tissue (dead tissue), and the presence or absence of granulation tissue (new tissue that form on the surface of a wound during the healing process) and [MEDICATION NAME] (the process of covering an open skin surface with epithelium (outside layer of cells)). Determine the ulcer's current stage (the level) of development. Assess the resident for pain related to the pressure ulcer. A weekly assessment of the pressure ulcer is to be done by the treatment nurse. Interventions: The documentation will include the date observed, location, and staging (level), size (Perpendicular measurement of the greatest extent of length and width of the ulceration), depth; and the presence, location and extent of any undermining or tunneling/sinus tract; exudate, if present; type (such as purulent (pus-like)/serous (clear fluid)), color, odor and approximate amount; pain, if present, wound bed: color and type of tissue/character including evidence of healing (e.g. (that is) granulation tissue), or necrosis (slough (yellowish, thick) or eschar (dry, thick, leathery, brown or black)): and description of wound edges and surrounding tissue (e.g. rolled edges, redness, induration (hardness), maceration (softened by extended exposure to wetness or moisture)) as appropriate. A review of Resident 1's record titled, Physician and Telephone Orders, dated 11/18/16 and 12/28/16, indicated Resident 1's Primary Physician's (PP1) order for podiatry follow up with in-house podiatrist. There was no podiatry consult found in Resident 1's clinical record. A review of Resident 1's record titled, Pain Assessment Flowsheet, dated 11/6/16 - 1/4/17 indicated Resident 1 received 30 doses of [MEDICATION NAME] ([MEDICATION NAME] (a narcotic) and [MEDICATION NAME] (an over the counter medication used to relieve pain) combination, used for the management of severe pain) 7.5-325 milligrams (mg), one tablet orally for severe pain, 8-9/10 pain, to great toe and to both (bilateral) lower extremities. A review of Resident 1's record titled, Licensed Personnel Weekly Progress Notes, dated 1/4/17, at 3:43 p.m., indicated PP1's covering physician (PP2) came to see Resident 1 on 1/4/17 and Resident 1 complained of bilateral foot pain of 7/10 that was not relieved with pain medications. The notes indicated PP2 ordered to transfer Resident 1 to the hospital. The notes indicated Resident 1 left the facility by regular ambulance at 4:50 p.m. on 1/4/17. A review of Resident 1's record titled, Transfer Record, dated 1/4/17, indicated Resident 1 was transferred to GACH for intractable pain 7/10. A review of Resident 1's hospital record titled, Emergency Department (ED) Encounter, dated 1/4/17, at 11:57 p.m., indicated Resident 1 presented to the ED with bilateral lower extremity (BLE) pain from toes to her thighs with pain 7/10. Resident 1's physical exam indicated, Multiple black necrotic toes with significant malodor (a very unpleasant smell) with tenderness (pain) diffusely (spread out or scattered widely) to the legs. The ED notes dated 1/5/17 at 1:23 a.m., indicated Resident 1 was given [MEDICATION NAME] injection (narcotic pain reliever used to treat moderate to severe pain) 4 mg intravenously (IV, given directly into a vein). The ED notes indicated Resident 1 was admitted to ICU under serious condition on 1/5/17 at 2:57 a.m. A review of Resident 1's hospital record titled, GACH Medications, indicated Resident 1 received the following additional pain medications: [REDACTED] 1. On 1/5/17, at 3:15 p.m., [MEDICATION NAME] (a local anesthetic (numbing medication), used to block nerve signals in the body) injection 0.1 milliliter (ml). 2. On 1/6/17, at 6:45 p.m., [MEDICATION NAME] ([MEDICATION NAME], a centrally acting (medication that act in the brain or spinal cord to block or slow the transmission of pain information) pain medication of the opioid class (narcotic)) injection 0.5 mg. 3. On 1/7/17, at 6:30 a.m., 10:43 a.m., 12:51 p.m., and 1 p.m., [MEDICATION NAME] injection 1 mg A review of Resident 1's hospital record titled, Physician Notes, dated 1/7/17, at 1:46 p.m., the podiatrist indicated, Per vascular (surgeon), revascularization (restoration of blood flow to the body part that has suffered inadequate blood supply) is high risk. Given patient's (Resident 1) comorbidities (other diseases or disorders) and significant vessel disease, we do not think feet are salvageable (could not be saved or fixed) at this time. Agree with vascular surgery recommendations for bilateral [MEDICAL CONDITION]. During an interview on 1/20/17 at 3:08 pm., Registered Nurse (RN1) stated that PP1 ordered to follow-up with in-house podiatrist for Resident 1. RN1 stated that she verbally told Social Worker (SW1) regarding the podiatry appointment. RN1 stated that she was not sure if the podiatrist came and examined Resident 1. RN1 reviewed Resident 1's clinical record and stated she could not find documentation that the podiatrist had seen Resident 1. During an interview on 1/20/16 at 3:55 p.m., SW1 stated Resident 1 was not seen by the podiatrist because the in-house podiatrist was on vacation and that no one was covering for the in-house podiatrist. SW1 stated he did not call any podiatrist to follow-up Resident 1. During an interview on 1/20/17 at 4:10 p.m., the Director of Nursing (DON) stated that if the in-house podiatrist was not available, the social worker or licensed nurse should have notified PP1 to make a referral to other podiatrist. During a telephone interview on 2/21/17 at 10:10 a.m., PP1 stated that he ordered podiatry consult to make sure that Resident 1's bilateral great toe gangrene were not infected. PP1 stated that he was not aware that Resident 1 was not seen by a podiatrist. PP1 stated that if he was informed that Resident 1 was not seen or could not have a follow-up by a podiatrist, PP1 stated he would have come and check to make sure Resident 1's bilateral great toe gangrene were not infected. During a telephone interview on 2/21/17 at 11 a.m., SW1 stated that he was responsible for making appointments in regard to in-house or outside physician referrals. SW1 stated he did not coordinate with PP1 in regard to podiatry consult for Resident 1. SW1 stated that Resident 1 had no podiatry consult from 11/18/16 to 1/4/17. During a telephone interview on 3/3/17 at 12:32 p.m., pertaining to Resident 1's assessments of the left and right great toe gangrene from 10/30/16 to 1/4/17, Licensed Vocational Nurse (LVN1) stated that her assessments were not accurate based on the facility policy and procedures. LVN1 stated that she should have measured the length, width, and depth of Resident 1's left and right great toe gangrene to make sure it was not spreading to other tissue. LVN1 stated that every time she provided the treatment to Resident 1's left and right great toe gangrene, she asked Resident 1 regarding the pain level. LVN 1 stated that she did not document the pain level in the treatment record. During a telephone interview on 3/23/17 at 1:48 p.m., the DON stated that the facility follows the policy and procedures on Pressure Sore Management for arterial ulcer/wound assessment. The DON stated that she expected LVN 1 to do a thorough and exact assessment of Resident 1's wound based on the facility policy and procedures. The DON stated that documentation of the wound assessment should have included the location, size, drainage, odor, pain level, and signs of infection including redness to surrounding tissues. During a telephone interview in regard to Resident 1's care plan, Risk for Skin Breaks/Pressure Ulcer on 3/23/17 at 3:30 p.m., for specific interventions on how the staff would assess and monitor Resident 1's right and left great toe gangrene for signs and symptoms of infection, the DON stated Resident 1's care plan will be improved to be more specific to Resident 1's bilateral great toe gangrene problem. A review of the facility's policy and procedures titled, Social Services Program, dated 7/28/15, indicated the facility will provide medically related social services to assure that each resident can achieve and maintain his/her highest practicable physical, mental, or psychosocial well-being.

Based on observation, interview and record review, the facility failed to ensure that one of one sampled resident (Resident 1) who was receiving oxygen therapy (the inhaling of oxygen under pressure, often inside a pressurized chamber, as a treatment for [REDACTED]. The facility also failed to ensure that two of two randomly selected residents (Residents 2, and 4) who were assessed as independent smokers did not keep their lighters in their own possession due to the fact that their roommates had doctor's order to receive oxygen therapy. As a result, Resident 1 sustained a second degree burn (a burn involving the epidermis (outer layer of the skin) and dermis (inner layer of the skin) and usually forming blisters (a collection of fluid underneath the top layer of skin) that may be swollen and painful) on his right eyebrow, right side corner of his nose, right outer nostril (outer openings of the nose), right inner cheek, right upper lip, right index finger, left index finger, left fourth finger, and left little finger, when Resident 1 accidentally dropped his lighter while receiving oxygen in his room. Also, had a potential to cause accidental fire injuries for Residents 2 and 4's roommate, as well as the other residents in the surrounding area. Findings: 1. On 2/13 /17, at 2:32 p.m., during an interview, Resident 1 stated that while he was receiving his oxygen therapy in his room and emptying the contents of his small pouch, the coins and his lighter fell on the over bed table and the lighter suddenly sparked. Resident 1 stated that he heard a hissing sound and saw a flame. Resident 1 stated he pulled his oxygen nasal cannula (a device consists of a lightweight tube which on one end splits into two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows. The other end of the tube is connected to an oxygen supply) from his nose and turned off his oxygen concentrator (a device which concentrates the oxygen from a gas supply (typically ambient air) to supply an oxygen enriched gas stream). Resident 1 stated that he had some blister on his hand because he was trying to put the fire out with his hands and blanket. Resident 1 stated that he had always had a lighter with him because he smoked outside the facility. A review of Resident 1's Admission Record indicated that Resident 1 was admitted to the facility on [DATE] and was re-admitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 11/22/16, indicated that Resident 1's cognitive skills for daily decision-making was intact. The MDS indicated that the resident required limited assistance from the staff with bed mobility, transfer and extensive assistance for dressing, toilet use, personal hygiene and bathing. The resident was assessed with [REDACTED]. A review of Resident 1's Physician Order, dated 10/21/15 indicated that the resident may have oxygen therapy at two (2) liter per minute as needed (PRN). A review of Resident 1's Smoking Risk assessment dated [DATE] indicated that the resident received a score of seven (7). A score of (7) indicated that the resident was an independent smoker. The form indicated that if a score is 10 or greater, then; the resident should be considered as being at high risk for potential injury. A review of Resident 1's Situation-Background-Appearance-and Review Communication Form (SBAR, a technique that can be used to facilitate prompt and appropriate communication), dated 2/12/17 indicated that Resident 1 had a burn on his right face and hands. A review of Resident 1's Treatment Flowsheet (Treatment Record), dated 2/12/17 - 2/28/17 indicated, that Resident 1's right eyebrow, right side corner of his nose, right nostril, right upper inner cheek, right upper lip, right index finger, left index finger, left fourth finger, and left little finger were treated with Silvadene cream (antibiotic used on the skin for second or third degree burns it helps to prevent or treat serious infection) twice a day for seven (7) days. On 2/13/17, at 2:56 p.m., during an interview, the certified nursing assistant (CNA 1) stated that on 2/12/17 around 6:50 a.m., Resident 1 called for assistance. CNA 1 stated that when she got in the room, she saw Resident 1 had a black mark around his right eye and the room smelled like something just burned. CNA 1 stated that she called the charge nurse and cleaned Resident 1's face and hands with small warm towel. During an interview on 2/15/17 at 11:59 a.m., CNA 2 stated that resident on oxygen therapy should not possess matches and lighters as a safety precaution. CNA 2 stated that licensed nurses knew that Resident 1 had his lighter with him. During an interview on 2/15/17 at 12:34 p. m, the registered nurse (RN) 1 stated that when she found out that Resident 1 had a lighter on 2/12/17, after the incident, she asked Resident 1 to give the lighter to her for safety. RN 1 stated that she was not aware that independent smokers were allowed to keep their smoking paraphernalia (smoking materials, such as lighter, cigarettes etc.) During an interview on 2/15/17 at 1:19 p.m., the DON stated that Resident 1 was assessed as an independent smoker. DON stated that Resident 1 did not have a care plan regarding on how, when, where and who was responsible to ensure that the resident's smoking paraphernalia would not be a potential fire hazard. The DON stated that resident safety was more important than resident rights. DON stated that the facility will be changing its policy and procedure regarding smoking. During an interview on 2/15/17 at 2:50 a.m., the Medical Director (MD) stated that he was aware of what happen to Resident 1, and stated that it was just common sense that if residents are on oxygen therapy the facility should not allowed any residents to have access to any lighter. The MD stated that he was not sure if he did approve the facility's policy and procedures regarding smoking. During an interview on 2/16/17 at 2; 20p.m., the director of staff development (DSD) stated that if the oxygen is in use, staff should be aware that per standard of practice there should be no matches, lighter or anything that can cause fire. A review of the undated facility's policy and procedure titled Oxygen Administration, stipulated that all potentially flammable items (e.g., lotions, oils, alcohol, smoking articles, etc.) should be removed from the immediate area where oxygen is to be administered. 2. During an interview on 2/13/17 at 3:13 p.m., Resident 2 stated that he kept his lighter and cigarette in his possession. Resident 2 stated that the staff does need to remind him of safety because he knows better. During an interview while conducting a tour of the facility on 2/15/17 at 11:18 a.m., the assistant director of nursing (ADON) noted that Resident 2 had a No Smoking Sign posted outside the resident's room. During an observation of Resident 2's room, the evaluator noted that Resident 2's roommate was observed with an oxygen concentrator at his bedside. ADON stated that Resident 2's roommate received oxygen therapy on as as needed. According to the admission record, Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 11/24/16 indicated that, Resident 2's cognitive skills for daily decision-making was intact. The MDS indicated that the resident required extensive assistance from the staff with bed mobility, dressing, toilet use, personal hygiene, bathing and transfer. A review of Resident 2's Smoking Risk assessment dated [DATE] indicated a score of six, which indicated that the resident was an independent smoker. A review of Resident 9's (Resident 2's roommate) Admission Record, indicated that Resident 9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 9's MDS dated [DATE] indicated that Resident 9's cognitive skills for daily decision-making were intact. The MDS indicated that the resident required extensive assistance from the staff for bed mobility, dressing, toilet use, personal hygiene and bathing and limited assistance for transfer. A review of Resident 9's Physician Order, dated 9/1/16 indicated that Resident 9 may have oxygen therapy at two (2) liter per minute PRN. 3. During an interview on 2/15/17 at 10:51 a.m., Resident 4 stated that he only smoked once. When the resident was asked if he had a lighter, Resident 4 stated that he gave his lighter to the social service last week. During the observation of Resident 4's room in the presence of the assistant director of nursing (ADON) on 2/15/17 at 11:22 a.m., the evaluator noted that Resident 4's roommate (Resident 10) was observed receiving oxygen therapy via nasal cannula. A review of Resident 4's Admission Record indicated that the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 4's Smoking Risk assessment dated [DATE] indicated a score of four and was assessed as independent smoker. A review of Resident 10 (Resident 4's roommate) Admission Record indicated that Resident 10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 10's MDS dated [DATE] indicated that Resident 10's cognitive skills for daily decision-making were severely impaired and was totally dependent on the staff for bed mobility, dressing, eating, toilet use, personal hygiene and bathing. A review of Resident 10's Physician order, dated 2/10/16 indicated that the resident may receive oxygen therapy at two (2) liter per minute via nasal cannula for shortness of breath. During a telephone interview on 3/8/17 at 12:39 p.m., the DON stated that she was aware that Resident 2 and Resident 4's roommate were on oxygen therapy. The DON stated that for safety precaution, the facility will install a Non- smoking sign. DON stated that the policy and procedures regarding steps to follow if a resident and/or if resident's roommate was using oxygen was not followed. The DON stated that it was important to follow the policy and procedures to prevent fire incident. According to the facility, there were a total 23 residents that were receiving As needed and continuous oxygen therapy in the North and South nursing station. The facility had 32 residents in Sub-acute unit (level of care that requires more intensive skilled nursing care than the majority of residents in a skilled nursing facility) on continuous use of oxygen. A review of the undated facility's policy and procedure titled Oxygen Administration, stipulated the following: i. Remove all potentially flammable items (e.g., lotions, oils, alcohol, smoking articles, etc.) from the immediate area where oxygen is to be administered. ii. Remove any woolen blankets, nylon, and/or rayon clothing, etc., from the immediate area where oxygen is to be administered. iii. Instruct the residents, his/her family, visitors and roommate (if any) of the oxygen safety precaution. A review of 11/2015, facility's policy and procedures titled Smoking Policy indicated that smoking policy had been implemented to promote residents safety.

Based on observation, interview, and record review, the facility failed to follow their policy and procedure in reporting to the Public Health Department and Licensing and Certification when a scabies outbreak occurred for 9 of 9 randomly selected residents (Residents 1, 4, 6, 9,10, 13, 16, 19 and 22) who had a rash and received [MEDICATION NAME] (an anti-parasitic medication used to treat scabies) treatment and their roommates (Residents 2, 3, 5, 7, 8, 11, 12, 14, 15, 17, 18, 23), staff and visitors did not received [MEDICATION NAME] treatment for [REDACTED]. and procedures. The facility also inappropriately used [MEDICATION NAME], a scabicide that could be toxic to the body, for all newly admitted residents as a scabies [MEDICATION NAME]. Also, during the investigation on February 25, 2011, the facility's hot water heater temperature in the laundry was subnormal at 96.4 degrees Fahrenheit (F) (normal temperature for washing clothes is 160 F). According to Titled 24, hot-water-heating equipment and distribution system shall be supplied in the laundry at 160 F. The facility also failed to follow their policy related to Clostridium Difficile (C Diff.) infection for Resident 4, by not following the physician's orders [REDACTED]. Resident 1, who was non-ambulatory and could not make her needs known, and was dependent on the staff for all care, had an ongoing generalized body rash with itching. The resident received [MEDICATION NAME] treatment without resolving of the rash. The resident received another application of [MEDICATION NAME] and remained to have an ongoing rash, as of February 25, 2011. The resident was seen by the dermatologist on February 25, 2011 and he ordered [MEDICATION NAME] to be applied again that day and repeated in seven days in combination with Ivermectin 9 milligrams (mg) (an oral antiparasitic used for the treatment of [REDACTED]. A review of the Medication Administration Record (MAR) for the month of February 2011 indicated the resident received [MEDICATION NAME] 25 mg (an [MEDICATION NAME] used for itching) per GT 16 times for itching. The resident's rash was observed with Treatment Nurse 1 on February 28, 2011 to be scattered red lesions with some tracking all over the body, mostly on the back. The resident was not placed in isolation during the [MEDICATION NAME] treatment and the roommates (Residents 2 and 3) were not treated simultaneously. The residents' room was not decontaminated as per the facility's policy. Resident 4, who was alert and ambulatory, developed a rash on her arms and legs with itching and scratching and was treated with [MEDICATION NAME]. The resident stated the itch was "horrible, especially at night." The resident's rash was observed on February 28, 2011 with Treatment Nurse 1 to be red and prickly all over the resident's arms and legs with scratch marks. The resident stated she was not placed in isolation and her clothes were not washed. The resident was seen by the dermatologist after the surveyor questioned the facility staff about many resident's with rashes. The resident's roommate (Resident 5) was not treated with [MEDICATION NAME] at the time Resident 4 was treated and the residents' room and clothes were not decontaminated. Resident 6 received [MEDICATION NAME] treatment after the resident developed a rash on the right leg and left arm. The physician ordered [MEDICATION NAME] for that day and to repeat in a week. Resident 6 was not isolated and the resident's room and clothes were not decontaminated. The resident's roommate, Resident 7, did not receive [MEDICATION NAME] treatment [MEDICATION NAME]. Resident 8 and 9 both had rashes and received [MEDICATION NAME] cream on readmission for [MEDICATION NAME]. They were not placed in isolation and their room and clothes were not decontaminated. Resident 10, who had been admitted to an acute care hospital several times, was treated with [MEDICATION NAME] for an ongoing body rash twice in 2010. The resident's roommates, Resident 11 and 12 did not receive [MEDICATION NAME] treatment at the time Resident 10 was treated, but both residents were treated at readmission to the facility. There was also no evidence the residents were placed in isolation and the residents' room and clothes decontaminated. Resident 13 had a skin rash and was treated with [MEDICATION NAME] upon readmission to the facility on [DATE]. The resident's rash continued after treatment and was seen by the dermatologist after the surveyor questioned the staff about resident's rashes. The resident's roommates, Resident 14 and 15 were not treated with [MEDICATION NAME] and Resident 13's room and clothes were not decontaminated. Resident 16 had a rash with multiple scratches over the body was treated with [MEDICATION NAME]. The resident's roommate, Resident 17, also had an ongoing generalized body rash since December 2010, but did receive [MEDICATION NAME]. Resident 16's other roommate, Resident 18, also had a rash, but was not treated with [MEDICATION NAME]. There was no evidence the residents were placed in isolation and/or their rooms and clothes decontaminated. Resident 19 had a scattered body rash in February 2010 and was treated with [MEDICATION NAME] and [MEDICATION NAME] 25 mg. for itching. According to a Non-Pressure Sore Skin Problem Report, dated January 4, 2011, the resident remained to have the body rash with ongoing skin treatment. Resident 22 was diagnosed with [REDACTED]. On January 27, 2011 the resident continued to have a body rash and was treated with [MEDICATION NAME] and repeated the following week. The resident was not placed in isolation the room was not decontaminated. Resident 23, roommate to Resident 22, had a generalized body rash with a history of being treated with [MEDICATION NAME] in March 2010. Resident 23 was not treated at the same time as Resident 22, per the facility"s policy. Findings: On February 11, 2011, the Department received an anonymous complaint alleging the facility's Director of Nursing (DON) was not qualified and that thirty-five percent of the residents had rashes due to dirty beds. On February 25, 2010, at 7:45 a.m., an unannounced visit was made to the facility. On February 25, 2010 at 8:35 a.m., during an observation, the hot water heater in the laundry temperature was 96.4 Fahrenheit (F). The maintenance supervisor stated it was too low because the temperature should be 160 F for washing clothes. On February 28, 2011 the following records were reviewed and indicated the following: a. Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS), a standardized assessment and care screening tool, dated February 17, 2010, indicated the resident was non-ambulatory and had unclear speech evidenced by slurred or mumbled words. The resident rarely or never was able to make herself understood and rarely or never had the ability to understand others. The resident's cognitive skills were severely impaired. According to the MDS, the resident was totally dependent on staff for all activities of daily living (ADL) which included bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. Her range of motion was impaired on both sides of her upper extremities (shoulder, elbow, wrist, hand). A review of the Non-Pressure Sore Skin Problem Report dated December 5, 2010, indicated the resident had a scattered rash on the back and breasts. According to the skin report on December 26, 2010, the resident's rash was ongoing. A review of the nurse's notes dated January 1, 2011, indicated the resident had multiple scratch marks on her left forearm. The nurse's note on January 4, 2011, indicated the resident still had the rash with multiple scratch marks to the left forearm. The nurse's note on January 15, 2011 indicated the resident had a whole body rash. A review a physician's telephone order dated January 27, 2011, indicated to apply [MEDICATION NAME] cream from the head to toe and leave on for 12 hours, shower in the morning and then repeat in seven days. There was no order for isolation. A review of the Medication Administration Record (MAR) dated January 27, 2010, indicated the resident was treated with [MEDICATION NAME] cream for the body rash. However, there was no documented evidence the resident was placed in isolation, the room and clothes decontaminated, and the resident's roommates (Resident 2 and 3) received treatment. A review of the Non-Pressure Sore Skin Problem Report dated January 30, 2011, indicated the resident's rash remained scattered over the body. The report dated February 6, 2011 and February 21, 2011 indicated the scattered rash was ongoing all over the body and abdomen area. A review of a dermatologist (a doctor who specializes in treating conditions that affect the skin, hair, and nails) progress note dated February 25, 2011 indicated he saw the resident and order new treatment for [REDACTED]. A review of the MAR for the month of February 2011, indicated the resident was given 16 doses of [MEDICATION NAME] (an ant-[MEDICATION NAME] used for itching). On February 28, 2011 at 4:35 p.m., during an observation, Resident 1's rash was scattered bright red and prickly spots all over the body, mostly on her back and right breast area and there was also some tracking observed. b. Resident 2, one of Resident 1's roommate, face sheet indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of a care plan dated November 11, 2010, indicated the resident had a rash between the toes (inter-digits) on both feet. A review of a nurse's note dated November 26, 2010, indicated Resident 2 had a rash on both feet. The nurse's note on December 14, 2010 indicated the resident developed a rash on the right hand and left arm. A review of the MDS dated [DATE], indicated the resident had unclear speech, and a limited ability at making concrete requests. According to the MDS, the resident was totally dependent on the staff for all ADLs, including bed mobility, transfers, walking, dressing, toileting, and personal hygiene. A nurse's note dated January 6, 2011, indicated the resident had scratches on the left arm and on the back of the left shoulder. Another nurse's note dated January 9, 2011, indicated the resident had a rash on the abdomen and a nurse's note dated January 12, 2011, indicated the resident's rash was ongoing with multiple scratch marks on the left knee. According to the resident's record the resident was not treated with [MEDICATION NAME] for the rash or [MEDICATION NAME] when Resident 1 was treated as indicated in the facility's policy and procedure for scabies. c. Resident 3, a roommate to both Resident 1 and 2, face sheet indicated the resident was admitted to the facility on [DATE], and readmitted on [DATE], the resident with [DIAGNOSES REDACTED]. A review of the MDS dated [DATE], indicated the resident had limited ability in making concrete requests. The MDS indicated the resident was totally dependent on staff for bed mobility, transfers, dressing, toileting and personal hygiene. According to the record review, Resident 3 had no rash and was not treated [MEDICATION NAME] when Resident 1 was treated for [REDACTED]. d. A review of Resident 4's record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE]. The resident's [DIAGNOSES REDACTED]. A review of a "Short Term Problem" dated February 4, 2011, indicated the resident had a generalized body rash. A review of an acute hospital physician's progress note dated February 8, 2011, indicated the resident had a skin rash while in the acute hospital. A review of the MAR for the month of February 2011, indicated the resident was treated with [MEDICATION NAME] cream on February 9, 2011 upon readmission to the facility. A review of the nurse's notes dated February 11, 2011, indicated the resident had several bowel movements resulting in loose stools. A review of the MDS dated [DATE], indicated the resident spoke clearly and was able to understand others. According to the MDS, the resident required limited assistance with activity of daily living (ADLs). A review of the physician's orders [REDACTED]. However, on February 28, 2011 the facility failed to follow the physician's orders [REDACTED]. infection. On February 28, 2011 at 8:35 a.m., during an interview, the resident stated she had been very itchy as a result of the rash all over her body, especially at night. She stated the dermatologist had been to see her several times. The resident's rash was prickly red with many scratch marks on her arms and legs. Resident 4 also stated she was never placed in isolation nor were her clothes ever taken to be washed and/or room decontaminated. In addition, the resident stated she had diarrhea for three weeks and was just starting to feel better. The resident stated she had collected the stool samples and given them to the nurse. During an interview on February 28, 2011, at 8:50 a.m., the assistant director of nurse (ADON) stated she was unable to locate Resident 4's stool specimen. She stated she called the laboratory and it was not done. On February 28, 2011, at 9 a.m., during an interview, the DON stated if a resident was suspected to have[DIAGNOSES REDACTED]. they should be placed in isolation and have stool specimens obtained. When she was asked if Resident 4's stool specimens were collected she replied after reviewing the resident's record, "It was not collected." e. Resident 5, Resident 4's roommate, record indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a physician's orders [REDACTED]. There was no documented evidence the facility isolated Resident 5 while [MEDICATION NAME] was applied and/or the resident's room and clothes decontaminated as their policy stipulates. f. According to the face sheet, Resident 6 was admitted to the facility on [DATE], with the most recent readmission on September 28, 2010. The resident [DIAGNOSES REDACTED]. A MDS dated [DATE] indicated the resident was totally dependent in dressing, eating, toilet use, personal hygiene, and bathing. According to the MDS, the resident was incontinent (no voluntary control) of bowel and bladder. The MDS indicated Resident 6 had rashes. A September 24, 2010 entry on the Short Term Problems indicated "RUE (right upper extremity) swollen with redness and rash. " A November 15, 2010 entry indicated " right lower extremities rash. " A review of a Short Term Care Plan dated October 15, 2010, indicated the resident had a skin rash on the right foot. A review of a Non-Pressure Sore Skin Problem Report, dated November 15, 2010, indicated the treatment was initiated to the right lower extremity rash. Another entry dated February 11, 2011, indicated the resident had a scattered body rash. According to the Treatment Record, the resident received the second treatment of [REDACTED]. On January 27, 2011 the physician's orders [REDACTED]. Repeat in one week as [MEDICATION NAME]. " A February 25, 2011 dermatology consult, indicated the resident was seen for suspicion of scabies. The dermatologist documented to continue to monitor. There was no documented evidence the resident was placed in isolation and the room and clothing decontaminated as per the facility's policy. g. Resident 7, roommate to Resident 6, was admitted to this facility on June 30, 2004, with the most recent readmission on May 15, 2007. The resident's [DIAGNOSES REDACTED]. A MDS dated [DATE], indicated Resident 7 required extensive assistance in dressing, toilet use, personal hygiene, and bathing. The resident was incontinent (no voluntary control) of bowel and bladder. There was no documented evidence Resident 7 was treated with [MEDICATION NAME] when the roommate, Resident 6 was treated as indicated by the facility's policy and procedure. h. According to the Admission face sheet Resident 8 was admitted on [DATE] and readmitted on [DATE]. The resident's [DIAGNOSES REDACTED]. According to the readmission orders [REDACTED]. A MDS dated [DATE], indicated the resident was non-ambulatory and was totally dependent upon the staff for care. According to a Treatment Record dated February 23, 2011 the resident was identified to have a rash on the right upper arm. There was no documented evidence the resident was placed in isolation during the [MEDICATION NAME] treatment and/or the resident's room and clothes were decontaminated as the facility's policy stipulated. i. Resident 9, a roommate to Resident 8, admission face sheet indicated the resident was admitted to the facility on [DATE]. There was no documented evidence the resident was placed in isolation and the room and clothing decontaminated as per the facility's policy. The Comprehensive Resident Assessment, incorrectly dated February 11, 2011, indicated the resident had a generalized body rash. The admission orders [REDACTED]. There was no documented evidence the resident was placed in isolation during the [MEDICATION NAME] treatment and/or the resident's room and clothes were decontaminated as the facility's policy stipulated. j. Resident 10 was admitted to the facility on [DATE], with the most recent readmission on October 10, 2010. The resident's [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A Non-Pressure Sore Skin Problem Report dated November 11, 2010, indicated the resident was readmitted with a red raised rash with a treatment obtained. On November 15, 2010, the facility received a new telephone order from the physician for the ongoing red raised body rash to discontinue [MEDICATION NAME] and change to [MEDICATION NAME] cream (TMC) 0.1% ointment and triple antibiotic twice daily for 30 days and continue to monitor. There was no documented evidence the resident was placed in isolation during the [MEDICATION NAME] treatment and/or the resident's room and clothes were decontaminated as the facility's policy stipulated. k. Resident 11, a roommate to Resident 10, was admitted to facility on November 9, 2010 and readmitted on [DATE]. The resident's [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. " There was no documented evidence the resident was placed in isolation during the [MEDICATION NAME] treatment and/or the resident's room and clothes were decontaminated as the facility's policy stipulated. l. Resident 12, a roommate to both Residents 10 and 11, was admitted to this facility on May 5, 2010, with the most recent readmission on October 27, 2010. the resident's [DIAGNOSES REDACTED]. A MDS dated [DATE] and January 10, 2011, indicated the resident was totally dependent on staff for dressing, eating, toilet use, personal hygiene, and bathing. Resident 12 was " incontinent of bowel. " Resident 12 had an indwelling catheter and used pads/briefs. A physician's orders [REDACTED]." There was no documented evidence the resident was placed in isolation during the [MEDICATION NAME] treatment and/or the resident' s room and clothes were decontaminated as the facility's policy stipulated. m. Resident 13 was admitted to this facility on September 8, 2009, with the most recent readmission on February 14, 2011. The resident's [DIAGNOSES REDACTED].) and anemia (a condition in which blood lacks adequate healthy red blood cells). A MDS dated [DATE], indicated the resident required extensive assistance in dressing, supervision in eating, personal hygiene, and physical help in bathing. According to the MDS, the resident had rashes and was receiving application of ointments/medications. A September 16, 2010 physician's orders [REDACTED]. Another physician's orders [REDACTED]. There was no documented evidence the resident was placed in isolation during the [MEDICATION NAME] treatment and/or the resident's room and clothes were decontaminated as the facility's policy stipulated. n. Resident 14, roommate to Resident 13, admission face sheet indicated the resident was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. A MDS dated [DATE] indicated Resident 14 required extensive assistance in dressing, totally dependent in eating, personal hygiene, and was totally dependent in bathing and toilet use. The resident was incontinent of bowel and bladder. According to the documentation, Resident 14 did not have a rash and was not treated with [MEDICATION NAME] for [MEDICATION NAME] on admission or when the roommate, Resident 13 was treated with [MEDICATION NAME] as indicated by the facility's policy. o. Resident 15, roommate to both Resident 13 and 14, record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE]. The resident's [DIAGNOSES REDACTED]. A physician's orders [REDACTED]." A review of a MDS dated [DATE] indicated Resident 15 was totally dependent on staff for dressing, eating, toilet use, personal hygiene, and bathing. A Non-Pressure Sore Skin Problem Report entry dated January 4, 2011 indicated "rash on the right and the left arms." There was no documented evidence the resident was placed in isolation during the [MEDICATION NAME] treatment and/or the resident's room and clothes were decontaminated as the facility's policy stipulated. p. Resident 16 was admitted to this facility on May 17, 2010, with the most recent readmission on October 11, 2010. The resident's [DIAGNOSES REDACTED]. A December 6, 2010 entry on the Non-Pressure Sore Skin Report indicated the resident had generalized rash. A review of a MDS dated [DATE] indicated the resident was totally dependent on the staff for dressing, eating, toilet use, personal hygiene, and bathing. Resident 16 was incontinent of bowel and bladder. A February 3, 2011 entry on the Treatment Record indicated "[MEDICATION NAME] cream from neck to toes leave for 12 hours then shower in the morning for [MEDICATION NAME]. " There was no documented evidence the resident was placed in isolation during the [MEDICATION NAME] treatment and/or the resident's room and clothes were decontaminated as the facility's policy stipulated (specify something). q. Resident 17, a roommate to Resident 16, was admitted to this facility on January 5, 2010, with the most recent readmission on April 29, 2010. The resident's [DIAGNOSES REDACTED]. A review of a MDS dated [DATE] indicated the resident was totally dependent in dressing, eating, toilet use, personal hygiene, and bathing. According to the MDS, Resident 17 was incontinent of bowel and bladder. A review of a " Non-Pressure sore Skin Problem Report " dated February 14 and 21, 2011, indicated the resident had a generalized body rash that was identified on December 6, 2010. The plan was to continue with the ointment TMC 0.1% everyday. There was no documented evidence the resident received [MEDICATION NAME] treatment when the resident's roommate (Resident 16) received it as stipulated in the facility's policy. r. Resident 18, roommate to both Residents 16 and 17, was admitted to the facility on [DATE] and readmitted on [DATE]. The resident's [DIAGNOSES REDACTED]. A review of a MDS dated [DATE] indicated the resident was totally dependent on staff for dressing, eating, toilet use, personal; hygiene, and bathing. Resident 18 was incontinent of bowel and bladder. A physician's orders [REDACTED]. " A February 7, 2011 entry on the Non-Pressure Sore Skin Problem Report indicated " rash, body generalized. " A February 23, 2011 entry indicated the resident remained to have a red raised generalized body rash. There was no documented evidence the resident was treated again with [MEDICATION NAME] when the roommate (Resident 16) received treatment as stipulated in the facility's policy. s. Resident 19 was admitted on [DATE] and readmitted on [DATE]. The resident's [DIAGNOSES REDACTED]. A review of a physician's telephone order dated February 23, 2010, indicated the resident received [MEDICATION NAME] cream and [MEDICATION NAME] 25 mg. by mouth every six hours as needed for itching. A MDS dated [DATE], indicated the resident was alert and able to make needs known, but required extensive assistance to being totally dependent with the ADLs. According to a Non-Pressure Sore Skin Problem Report, dated January 4, 2011, the resident remained to have a scattered body rash. A review of a dermatology consult note dated February 25, 2011, indicated no signs of scabies, but to continue to monitor. t. Resident 22 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. As a result, you may experience uncontrolled movements, emotional disturbances and mental deterioration). A physician's orders [REDACTED]. A review of a Non-Pressure Sore Skin Problem Report dated October 4, 2010, indicated the resident had a scattered rash to the right leg, body, abdomen, and back. A review of the MDS dated [DATE] and December 9, 2010, indicated the resident was totally dependant on the staff for ADLs. A review of the MAR for the month of February 2011 indicated an order for [REDACTED]. On February 25, 2011, a dermatologist saw the resident and documented no signs of scabies infection, but to continue to monitor. There was no documented evidence the resident was placed in isolation during the [MEDICATION NAME] treatment and/or the resident's room and clothes were decontaminated as the facility's policy stipulated. u. Resident 23, a roommate to Resident 22, was admitted to the facility on [DATE] and readmitted on [DATE]. The resident's [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. A review of the MDS dated [DATE], indicated the resident was able to speak clearly, make himself understood and able to understand others. There was no documented evidence the resident was placed in isolation during the [MEDICATION NAME] treatment and/or the resident's room and clothes were decontaminated as the facility's policy stipulated. On February 28, 2011, at 9:20 a.m., during an interview, the assistant director of nursing (ADON) stated the facility had a lot of residents with rashes, but the dermatologist recently saw them. The ADON stated she was unaware if the Health Department was notified of the rashes. When she was asked if they tracked the resident's rashes she stated, "No." On February 28, 2011, at 9:30 a.m., the director of nurses (DON), stated the facility did not have any cases of suspicion of scabies and that was why they did not call and report it to the Health Department. The DON stated the facility would continue to treat and retreat the rashes when the rashes came back. She stated that was the reason the facility treated all new admissions and readmission residents with [MEDICATION NAME] for [MEDICATION NAME] treatment. The DON stated