Every finding on record at Pavilion on Pico Healthcare & Wellness Centre, LP

Based on interview, and record review, the facility failed to ensure the policy and procedures for post dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) treatment evaluation was competed, for one of two sampled residents (Resident 2). This failure resulted in an incomplete medical record for Resident 2 and had the potential to affect the delivery care and services.During a review of Resident 2's admission Record, dated 3/27/26, indicated Resident 2 was admitted to the facility on [DATE], with a diagnoses including diabetes mellitus type two (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness, chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing) heart failure (a condition where the heart cannot pump enough blood to meet the body's needs), hypertension (HTN - high blood pressure), end stage renal disease (ESRD - irreversible kidney failure), and dependance on renal (kidney) dialysis. During a review of Resident 2's Minimum Data Set (MDS-resident assessment tool) dated 12/22/25 indicated Resident 2 had intact cognition (thinking, reasoning, judgement and learning) and required setup or clean-up assistance for eating and required substantial assistance to being dependent on staff for bathing, toileting, oral and personal hygiene, dressing, oral and personal hygiene, and bed mobility. The same MDS further indicated the resident required hemodialysis (HD - a procedure where a patient is hooked up to a machine that cleans their blood of waste and fluid) treatments.During a concurrent interview and record review on 6/26/26 at 12:44 pm with Licensed Vocational Nurse (LVN) 1, Resident 2's Pre-Dialysis Evaluation and Post-Dialysis Evaluation records for March were reviewed. LVN 1 verified the medical record was missing a Post-Dialysis Evaluation for 3/17/26. LVN 1 stated the risk to the resident would be they could miss changes of condition, or medications given during the treatment.During a review of the facility's policy and procedures (P&P) titled Dialysis Management reviewed 6/20/25 indicated, A pre and post dialysis evaluation will be completed by the licensed nurse.All documentation concerning dialysis services and care of the dialysis resident will be maintained in the resident's medical record.

Based on interview and record review, the facility failed to implement an antibiotic stewardship program (a coordinated program that promotes the appropriate use of drugs used to treat infections, including antibiotics), for antibiotic use protocol (official procedure or system of rules) for two of three sample residents (Resident 47 and 14) by failing to ensure Resident 47 and 14 met the urinary tract infection ([UTI]- infection in the urine) criteria (a standard by which something may be decided) prior to starting an antibiotic.This deficient practice had the potential to cause adverse side effects and placed Resident 47 and 14 at risk for antibiotic resistance (when bacteria/germs change in some way that reduces or eliminates the effectiveness of drugs, chemicals, or other agents designed to cure or prevent infections) associated with the use of inappropriate antibiotic therapy.Findings:During a review of Resident 47's admission Records, the admission Records indicated Resident 47 was admitted to the facility on [DATE] with diagnoses including osteomyelitis of vertebra (infection of a spine bone), pressure ulcer of sacral region (a skin wound on the tailbone/lower back caused by long-term pressure), UTI, dysphagia (difficulty swallowing).During a review of Resident 47's Minimum Data Set ([MDS]-a standardized assessment and care screening tool) dated 10/28/2025, the MDS indicated Resident 47 has moderate cognitive impairment, could understand others and make herself understood. The MDS indicated that Resident 47 required substantial/maximal assistance (helper does more than half the effort) with toileting, shower, lower body dressing and personal hygiene.During a concurrent interview and record review on 1/22/2026 at 7:05 a.m. with IPN, records indicated that Resident 47 was prescribed antibiotic treatment on 1/9/2025. The Record indicated the following:Resident 47's Order Summery Report dated 1/9/2025 indicated physician order for cephalexin (antibiotic used to kill bacteria causing infections, particularly in the skin, throat, ears, and urinary tract) 500mg (unit of measurement) 1 capsule by mouth three times a day for urinalysis ([UA]- a simple, common laboratory test that examines a urine sample [pee in a cup] to check for signs of infection) WBC (a blood cell that helps attack infection or injury in the body) >50 for 7 days.Resident 47's Lab Results Report dated 1/8/2026, UA results indicated WBC > 50, Urine Culture (laboratory test that grows bacteria from a urine sample to detect and identify the specific germ causing a UTI) results indicated presence of multi-drug-resistant (bacteria that have become resistant to three or more types of commonly used antibiotics) Escherichia Coli (a type of bacteria commonly found in the intestines of healthy people and animals) in urine.Resident 47's Change in Condition Evaluation dated 1/9/2026, it did not indicate documented signs or symptoms of infection.During an interview on 1/22/2026 at 7:03 a.m. with Infection Prevention Nurse (IPN), the IPN stated that the facility follows an antibiotic stewardship program to ensure antibiotics are prescribed appropriately and only when clinical criteria are met. The IPN stated that the facility uses McGeer criteria (standardized, strict definitions used to identify and track infections [like UTI, pneumonia, or influenza] in long-term care settings) to determine if a resident meets criteria for initiation of antibiotics for infection. The IPN stated McGeer criteria require clinical symptoms of infection, supporting laboratory results and a documented medical diagnosis to be met. The IPN stated if one of the three components is missing, the McGeer criteria are not met, and antibiotic therapy should be reevaluated.The IPN stated that laboratory findings alone do not meet McGeer criteria and that symptoms are required to justify antibiotic use.During a review of Resident 14's admission Records, the admission Records indicated Resident 14 was originally admitted to the facility on [DATE], then readmitted to the facility on [DATE], with diagnoses including metabolic encephalopathy (a reversible brain dysfunction caused by chemical imbalances, toxins, or organ failure (like liver or kidney disease) rather than physical injury), UTI, bacteremia (the presence of bacteria in the bloodstream), type I Diabetes Mellitus ([DM]-a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 14's MDS dated [DATE], the MDS indicated Resident 14 is cognitively intact (has sufficient judgment, planning, organization, self-control) with no significant impairment. The MDS indicated that Resident 14 is dependent (helper does all the effort) with toileting hygiene, shower, lower body dressing, putting on/taking off footwear.During a subsequent interview and record review on 1/22/2026 at 7:15 a.m. with IPN, Resident 14's Order Summary Report dated 1/22/2026 indicated physician order for Macrobid (antibiotic capsule used specifically to treat or prevent bladder infections ) 100 mg 1 capsule by mouth two times a day for UTI for 5 days with a start date 1/19/2025, levofloxacin (a strong, broad-spectrum antibiotic used to treat bacterial infections) 250 mg 2 tablets by mouth one time a day for UTI for 5 days with a start date 1/20/2025.Further record review indicated:No documentation of change in condition related to Resident 14's diagnosis of UTI and antibiotic treatment.No documentation of initiation and implementation of care plan addressing Resident 14's diagnosis of UTI and antibiotic treatment.No documentation of infection control surveillance assessment (the active, ongoing tracking of infections and safety practices in healthcare to prevent outbreaks) related to Resident 14's diagnosis of UTI and antibiotic treatment.The IPN stated that all residents prescribed antibiotics must be included in the surveillance log and assessed as part of the antibiotic stewardship program. The IPN further stated that failure to monitor antibiotic use and document clinical justification does not meet facility protocol for antibiotic stewardship.During an interview on 1/22/2026 at 12:10 p.m. with Director of Nursing (DON), the DON stated that when a resident started on antibiotics, the facility is expected to follow its antibiotic stewardship process, infection control surveillance must be initiated, McGeer criteria must be verified, a change of condition assessment must be completed, and a care plan must be developed and initiated to address the identified infection and treatment. Not completing these actions may result in inappropriate antibiotic use, and potential harm to the resident.During a review of facilities Policies and Procedures (P&P) revised on 5/20/2021, titled Antibiotic Stewardship, indicated The Facility will implement an antibiotic Stewardship Program (ASP) to promote appropriate use of antibiotics optimizing the treatment of infection, reducing the threat of antibiotic resistance, reducing adverse events associated with antibiotic use and Improve outcomes for Residents.

Based on observation, interview and record review, the facility failed to ensure safe provisions of pharmaceuticals services by: Failing to ensure that the medication label matched the physician order for Resident 14.Failing to label medications with expiration dates including two compounded vancomycin HCl (a powerful antibiotic used to treat severe infections caused by bacteria that are resistant to other drugs) intravenous (IV) infusion bags for Resident 42 were not labeled with expiration date and escitalopram (medication to treat depression) for Resident 63 was not labeled with expiration date. These deficient practices had the potential to result in administration of expired medications, reduced therapeutic effectiveness and compromised resident safety and medication errors. Findings: During a review of Resident 14's admission Records, the admission Records indicated Resident 14 was originally admitted to the facility on [DATE], then readmitted to the facility on [DATE], with diagnoses including metabolic encephalopathy (a reversible brain dysfunction caused by chemical imbalances, toxins, or organ failure (like liver or kidney disease) rather than physical injury), UTI, bacteremia (the presence of bacteria in the bloodstream), type I Diabetes Mellitus ([DM]-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 14's Minimum Data Set ([MDS]-a resident assessment tool) dated 11/14/2025, the MDS indicated Resident 14 is cognitively intact (has sufficient judgment, planning, organization, self-control) with no significant impairment. The MDS indicated that Resident 14 is dependent (helper does all the effort) with toileting hygiene, shower, lower body dressing, putting on/taking off footwear. During a review of Resident 14's Order Summary Report dated 1/22/2026 , the order summary report indicated physician order for levofloxacin (a strong, broad-spectrum antibiotic used to treat bacterial infections) 250 mg 2 tablets by mouth one time a day for urinary tract infection (UTI) for 5 days. During a concurrent observation of medication pass and interview on 1/21/2026 at 8:00 a.m. with Licensed Vocational Nurse (LVN) 2, the label on Resident 14's levofloxacin bubble pack sheet indicated levofloxacin 500 mg 1 tablet by mouth one time a day for UTI for 5 days. LVN 2 stated that the physician order and the label on the bubble pack sheet are not matching. LVN 2 stated that she can still administer the medication because the dosage would be the same. LVN 2 then stated that labels on the medication must match the physician order. LVN 2 stated the discrepancy should be communicated with the physician and pharmacy for clarification and correction. LVN 2 further stated if the order and labels are not verified properly, patient could receive double dose, which would lead to medication error and patient harm. 2. a. During a review of Resident 42's admission Records, the admission Records indicated Resident 42 was originally admitted to the facility on [DATE], then readmitted to the facility on [DATE], with diagnoses including pressure ulcer (localized damage to the skin and/o r underlying tissue usually over a bony prominence) of sacral region (area over the tailbone/lower back), osteomyelitis (inflammation of bone or bone marrow, usually due to infection) of vertebra, dysphagia (difficulty swallowing). During a review of Resident 42's MDS dated [DATE] indicated that Resident 42 is cognitively intact with no significant impairment. The MDS indicated that Resident 42 is dependent with toileting hygiene, shower, lower body dressing, putting on/taking off footwear. During a review of Resident 42's Order Summary Report dated 1/15/2026 indicated order for vancomycin HCl 900 mg IV over 90 minute at a rate of 179 ml/hr, every 24 hours. During a concurrent observation of medication room and interview on 1/21/2026 at 11:35 a.m. with LVN 1, it was observed two compound vancomycin IV infusion bags for Resident 42 in refrigerator without expiration dates. LVN 1 stated all medications must be labeled with expiration date. LVN 1 further stated that administering medications without expiration date may cause decreased efficacy and harm the resident. 2. b. During a review of Resident 63's admission Records, the admission Records indicated Resident 63 was admitted to the facility on [DATE] with diagnoses including fibromyalgia (long-term condition that involves widespread body pain), asthma (a condition that causes airways to swell, narrow and fill with mucus), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a concurrent observation of medication cart 1 and interview on 1/21/2026 at 11:50 a.m. with LVN 1, it was observed escitalopram for Resident 63 without expiration date. LVN 1 stated all medications must be labeled with expiration date. Administering medications without expiration date may cause decreased efficacy and harm the residents. During an interview on 1/22/2026 at 12:20 p.m. with Director of Nursing (DON), the DON stated if there is discrepancy between a medication order and the label on the bubble pack, it needs to be addressed immediately. DON stated that the pharmacy must be contacted to obtain a corrected medication matching the physician order. The DON further stated that if the discrepancy is not corrected, it could result in a medication error, potentially leading to reduced medication efficacy. During a review of the facility's policy and procedures (P&P) titled Medication Storage in The Facility updated in 6/20/2025, indicated Facility should assure that infusion therapy labels include the: Resident name, medication name, Date of preparation, Initials of compounder, Ancillary labeling, and Expiration date. The Medication Storage in The Facility P&P indicated Drugs re-packaged by the pharmacy staff will generally carry an expiration date.

Based on observation, interview, and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections or diseases in the healthcare setting) were followed when:Eight of 16 sampled bleach wipe containers' lids were not kept close when not in use.Minimum Data Set Nurse (MDSN) and Certified Nursing Assistant (CNA) 3 did not wear personal protective equipment (PPE-protective items or garments worn to protect the body or clothing from hazards that can cause injury and to protect residents from cross-transmission) before entering the resident's room who was on enhanced barrier precautions (EBP- infection control measures for high-risk residents, to reduce the spread of multidrug-resistant organisms [MDROs]) due to multiple open wounds for two of two sampled residents (Resident 48 and 11.)These failures had the potential to expose the residents to increase risk of infection transmission.Findings: 1.During an observation on 1/21/2026 at 1:30 p.m.on the nursing floor, eight of 16 sampled bleach wipe containers' lids were open in multiple places on the nursing floor throughout the facility. During a concurrent observation and interview on 1/21/2026 at 1:48 p.m. with the Infection Prevention Nurse (IPN), the IPN observed 8 out of 16 bleach wipe containers were open throughout the facility nursing floor. The IPN stated that if the containers are not properly closed, the wipes will not be able to eliminate bacteria, potentially leading to increased risk of infection for residents, visitors, and staff. During a review of the facility's 'Microdot' bleach wipes' manufacturing product label, the label indicated, Keep these wipes in a tightly closed container, when not in use. It also indicated Snap center flap down when finished to retain moisture. During a review of the facility's policy and procedure (P&P) titled, IPC413 Emerging Infectious Diseases, revised 11/6/2023, the P&P indicated, Centers will use appropriate infection prevention and control measures, education strategies, environmental decontamination, and antimicrobial stewardship to mitigate, prevent and manager emergent infectious diseases. 2a. During a record review of Resident 48's admission record indicated Resident 48 was admitted on [DATE] with a diagnoses of cellulitis (a skin infection that causes swelling and redness) of right lower limp, cellulitis of left lower limp, urinary tract infection (UTI- an infection in the bladder/urinary tract), chronic ulcer of other part of right lower leg, and peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs). During Record review of Resident 48's Minimum Data set [MDS- resident assessment tool), dated 12/12/2025 indicated that Resident 48's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was intact. The MDS indicated that Resident 48 needs substantial/maximum assistance (helper does more than half the effort) of toileting, shower, lower body dressing and putting on/taking off footwear. Resident 48 needs supervision or touching assistance for eating, oral hygiene and personal hygiene. During a record review of Resident 48's care plan report titled, Skin Integrity Risk Management dated on 12/5/2025, indicated The resident has potential impairment to skin integrity of the bilateral legs r/t cellulitis with open lesions. During an observation on 1/20/26 at 9:14 a.m., with the MDSN, MDSN entered Resident 48's room without a gown, grabbed the resident's urinal, emptied it in the toilet, and placed it back on the bed, with visibly soiled linens and brown stains. During interview on 1/20/26 at 9:28 a.m. with MDSN, MDSN stated that she only wore gloves to empty Resident 48's urinal and there was no need to wear a gown because the sign outside Resident 48 room does not indicate that staff must wear gown while emptying urinal, MDSN stated she only wear a gown during high contact activities. During a concurrent interview on 1/22/2026 at 12:45 p.m. with the Director of Nurses (DON), DON stated that staff must wear PPE during high contact activities such as bathing, toileting and feeding when caring for residents on EBP. During a review of the facility's policies and procedures titled, Infection Control, revised on 6/20/2025, indicated that the infection control policies and procedures apply equally to all facility staff.control infections in the facility and maintain a safe, sanitary, and comfortable environment for personnel, residents. 2b. During a review of Resident's 11 admission Record, the record indicated the facility admitted the resident on 11/20/25, with diagnoses including but not limited to Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), dysphagia (difficulty swallowing) and failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition and inactivity). During a review of Resident 11's Minimum Data Set (MDS, a standardized care screening and assessment tool), dated 11/27/25, the MDS indicated the resident is dependent (relies on someone else) in completing activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During an observation on 1/20/26 at 10:34 a.m. in Resident 11's room, an EBP sign was posted at the doorway entrance and a cart filled with PPE. During a concurrent observation and interview on 1/21/26 at 7:59 a.m. with CNA 3 in Resident 11's room, CNA 3 was feeding Resident 11. CNA 3 was not wearing a gown or gloves while feeding and holding Resident 11's hand. CNA 3 stated that she saw the EBP sign but forgot to wear PPE. CNA 3 stated the purpose of PPE is to protect residents and staff from the spread of infection. During an interview on 1/21/26 at 10:50 a.m. with Registered Nurse (RN) 1, RN 1 stated staff are supposed to wear a gown and gloves when feeding residents on EBP because it is a high-contact activity. RN 1 stated that failing to wear PPE when indicated can spread infection to medically compromised (a weakened immune system that cannot fight infections as easily as it should) residents. During an interview on 1/22/26 at 12:45 p.m. with the Director of Nursing (DON), the DON stated that PPE for EBP should be worn when helping with ADLs. DON stated ADLs include toileting, mobility and feeding. DON stated that staff are expected to wear PPE to prevent the transmission of pathogens. During a review of the facility's policy and procedure (P&P) titled, Infectious Disease Management, dated 2022, the P&P indicated, Manage patient care according to Center for Disease Control and state/local health department recommendations. During a review of the Los Angeles County Department of Public Heath (LACDPH) document titled, Enhanced Barrier Precautions, dated September 2024, the LACDPH document indicated to wear gloves and a gown for high-contact resident care activities such as dressing, grooming, bathing, changing bed linens and feeding.

Based on interview and record review the facility failed to ensure to provide documented evidence for two of four sample employees (Medical Director and Infection Prevention Nurse (IPN)) Corona virus ([COVID-19] - contagious infectious disease) vaccination status and the provision of education on benefits and potential side effects. This failure had the potential to result in staff and residents contracting COVID-19 which can cause serious illness, hospitalization, and death.Findings: During a concurrent interview and record review on 1/22/2026 at 7:15 a.m., with the IPN 1, employee records (Medical Directors and IPN 2's) indicated no documentation of COVID-19 vaccination status and the provision of education on benefits and potential side effects and offering of the COVID - 19 vaccine. The IPN 1 stated that the facility must maintain documentation related to staff COVID - 19 vaccinations, including COVID - 19 vaccination status, education provided regarding the benefits and potential side effects of the COVID - 19 vaccine, and documentation that the COVID - 19 vaccine was offered. During an interview on 1/22/2026 at 12:10 p.m. with Director of Nursing (DON), the DON stated that all staff, including the Medical Director and IPN 2, are required to have COVID-19 vaccination screening completed upon hire and that ongoing vaccination records must be maintained. The DON stated that COVID - 19 vaccination documentation must be kept current and maintained in both the facility records and individual employee files to ensure compliance with infection prevention requirements and to protect resident and staff safety. During a review of the facility's policy and procedures (P&P) titled, COVID-19 Vaccination Program, reviewed on 6/20/2025, the P&P indicated the following: All Health Care Personnel (HCP) are required to be fully vaccinated (having received primary series of COVID-19 vaccines) and boosted (once booster eligible) against COVID - 19 secondary to the State Public Health Officer Order. Vaccination against COVID-19 is a condition of employment unless the HCP has a medical or religious waiver. For HCP, transcribe all the information from the vaccination card or a copy of the card into the employee's health file as proof they are fully vaccinated.

Based on observation, interview, and record review the facility failed to ensure:Proper resident identification prior to medication administration (MedPass) when licensed vocational nurse (LVN) 1did not check identification (ID) band before MedPass for one of four sampled resident (Resident 66).The physician's orders for pain medication were clarified and accurately implemented for one of one sampled resident (Resident 66.)Controlled substances were separated and secured in accordance with regulatory standards when lorazepam (medication that helps calm anxiety, relax muscles and help with sleep) 2mg/ml oral solution was found in refrigerator in medication room [ROOM NUMBER] stored next to other medications.Controlled substance disposition log was completed in accordance with regulatory requirements and the facility's policy when observed multiple controlled substance disposition logs were missing Director of Nursing's (DON) signatures.These deficient practices had the potential to result in medication errors, including administration of medications to the wrong residents placing residents at risk for adverse outcomes, lack of accountability and traceability for controlled substances, increasing the risk of medication diversion, regulatory noncompliance, potential for Resident 66 to receive inadequate pain management due to inconsistent medication administration.Findings: 1. During a review of Resident 66's admission Records, the admission Records indicated Resident 66 was originally admitted to the facility on [DATE], then readmitted to the facility on [DATE], with diagnoses including hemiplegia (severe weakness or total paralysis of one entire side of the body) and hemiparesis (weakness, numbness, or reduced movement on one side of the body) following cerebral infarction (stroke), hypertension (high blood pressure), severe obesity (having an excessive amount of body fat). During a review of Resident 66's Minimum Data Set ([MDS]-a resident assessment tool) dated 1/19/2026, the MDS indicated Resident 66 has moderate cognitive impairment (a noticeable decline in memory, thinking, or judgment). The MDS indicated that Resident 66 requires Substantial/Maximal assistance (helper does more than half the effort) with toileting hygiene, shower, and requires partial/moderate assistance (helper does less than half the effort) with upper body dressing and personal hygiene. During a concurrent observation of MedPass and interview on 1/21/2026 at 9:05 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 failed to identify Resident 66 prior to medication administration. LVN 1 stated that she did not identify Resident 66's identification (ID) band before administering his medications. LVN 1 stated that residents must be identified before administering medications with two identifiers, such as resident's ID band and computer picture. LVN 1 stated that not checking ID bands can potentially lead to medication error and harm the residents. LVN 1 observed not wearing gloves while assisting Resident 66. LVN 1 stated it is very important to wear gloves when touching pills for medication administration so not to contaminate medication pill when administered to the resident. During an interview on 1/22/2026 at 12:20 p.m. with the DON, the DON stated that before administering any medication, it is essential to identify the resident by checking at least two identifiers, such as the resident's ID band and the resident's photograph in the electronic medical record (EMR). The DON explained that failure to properly identify the resident could result in medication errors, such as administering the wrong medication or dose, and may place the resident at risk for harm or adverse outcomes. The DON stated that during medication administration, LVNs are required to wear gloves. The DON stated that failure to wear gloves may place both residents and staff at risk for contamination. During a review of the facility's policy and procedure (P&P) titled Medication Administration revised on 6/26/2025, the P&P indicated The licensed Nurse will verify the resident's identity before administering the medication using the 6 rights of medication administration. 2. During a review of Resident' 66 admission Record, the admission record indicated Resident 66 was admitted to the facility on [DATE]. Resident 66's diagnoses included but are not limited to right knee replacement, hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), cognitive communication deficit (a communication impairment caused by underlying cognitive issues—such as memory, attention, or executive function deficits—rather than primary language or speech disorders), schizophrenia (a mental illness that is characterized by disturbances in thought), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 66's Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 1/10/2026, the MDS indicated Resident 66 had moderately cognitive impairment. Resident 66 had functional limitation in range of motion on his lower extremity. During a concurrent observation and interview on 1/20/2026 at 9:41 p.m. with Resident 66 in his room, Resident 66 was moaning in pain. Resident 66 stated he did not ask for pain medications because no one helps him, he always tells staff his pain is never taken care of, and nothing is done. During an interview on 1/21/2026 with Resident 66 in his room, Resident 66 reported experiencing severe pain, rating it as a 10 out of 10, and stated that he frequently informs the staff about his unrelieved discomfort. During a review of Resident 66's Physician's Orders, dated 1/21/2026, Resident 66's Physician's Orders indicated Resident 66 had the following pain medication orders as needed for pain: Hydrocodone-Acetaminophen Tablet 10-325 mg (Norco 10), give 1 tablet by mouth as needed for severe pain (8-9) every 4 hours as needed Hydrocodone-Acetaminophen Tablet 5-325 mg (Norco 5), give 1 tablet by mouth as needed for moderate pain (5-7) every 6 hours as needed. During a review of Resident 66's Medication Administration Record (MAR) dated 1/1/2026 – 1/31/2026, the MAR indicated Resident 66 received the following medications 3 hours and 42 minutes apart on 1/17/2026: Hydrocodone-Acetaminophen tablet 10-325 MG; given at 10:56 a.m. Hydrocodone-Acetaminophen tablet 5-325 MG; given at 2:38 p.m. During an interview on 1/21/2026 at 10:54 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated that she could administer a dose of Norco 5 two hours after a given dose regardless of ordered frequency of the medication. During an interview on 1/22/2026 at 9 a.m. with the Pharmacist (PHARM), the PHARM stated that aligning the time frequencies reduces the likelihood of errors and misinterpretations for nursing staff. The PHARM stated that if a resident receives a Norco 10 at 10:56 a.m., the next dose of pain medication should be administered at 2:38 p.m. (6 hours after the previous dose). The PHARM advised that nurses follow the Norco 5 guidelines, which state that doses should be taken every 6 hours to avoid side effects like heavy sedation, confusion, central nervous system depression, and possible overdose. 3. During a concurrent observation of medication room and interview on 1/21/2026 at 11:35 a.m. with LVN 1, it was observed lorazepam oral solution 2mg/ml placed in the refrigerator together with other medications. LVN 1 stated she was unable to identify whether controlled medications were required to be stored separately from other medications in the refrigerator. During a subsequent interview on 1/22/2026 at 12:25 p.m. with the DON, the DON stated that it was acceptable for controlled medications in refrigerator to be placed next to other medications, if they were under two locks. The DON stated only emergency kit medications must be separated and locked separately. 4. During a concurrent review of Controlled Substance Disposition Log (used to track the receipt, use, and disposal of controlled medications) and interview on 1/22/2026 at 12:05 p.m. with the DON, the logs dated 10/2025 through 12/ 2025 were incomplete – specifically, multiple entries were missing DON signatures. The DON explained that when controlled medications are discontinued, licensed nurses bring them to the DON for reconciliation. The DON and the licensed nurse reconcile the medication, document the quantity disposed, date the entry, and sign the Controlled Substance Disposition Log. Meanwhile medications awaiting destruction will then be stored in a double locked drawer in DON's room. Destruction of controlled medications is conducted every 3 months and as needed in the presence of the facility's pharmacist. At that time, both the DON and the pharmacist sign off on the Controlled Substance Disposition Log, documenting the date and quantity of medications destroyed. The DON stated that the multiple Controlled Substance Disposition Logs dated 10/2025-12/2025 were missing DON signatures required to be placed upon destruction of controlled medications. During a review of the facility's policy and procedures (P&P) titled Medication Storage in The Facility revised on 6/20/2025, the P&P indicated Controlled substances that require refrigeration are stored within a locked box within the refrigerator. This box must be attached to the inside of the refrigerator.

Based on interview and record review, the facility failed to obtain written informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for the use of psychotropic medication (chemical substances that affect the brain, modifying mood, thought, emotions and behavior to treat mental illnesses) prior to administering Divalproex (a mood stabilizer medication used for aggression, disruptive behaviors and mood episodes) for one of one sampled resident (Resident 3). This failure resulted in a violation of Resident 3's right to make an informed decision before taking Divalproex and receiving 22 doses of Divalproex. Findings: During a review of Resident 3's admission Record, the record indicated the facility admitted the resident on 4/20/21, with diagnoses including but not limited to schizoaffective disorder (a mental illness that affects thoughts, mood and behavior), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest in activities), and dementia (a progressive state of decline in mental abilities). During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool), dated 12/23/25, the MDS indicated the resident is moderately cognitively impaired (poor decision making and requires increased supervision or cues to complete daily activities). During a review of Resident 3's physician's order, dated 5/1/25, the order indicated to give one tablet of Divalproex 250 milligram (mg, a unit of measure) by mouth one time a day for schizoaffective behavior manifested by aggressive behavior presented as cursing at roommate and staff. During a review of Resident 3's medical records, the medical records did not indicate any documented evidence of informed consent for the use of Divalproex in Informed Consent Documentation or Verification of Informed Consent. During a review of Resident 3's Medication Administration Record (MAR), dated 1/2026, the MAR indicated that Resident 3 received Divalproex every morning from 1/1/26 to 1/22/26, a total of 22 doses. During a concurrent interview and record review on 1/22/26 at 12:16 p.m. with the Director of Nursing (DON), Resident 3's medical record was reviewed. The record indicated no documented evidence of informed consent for the use of Divalproex. The DON stated staff should obtain written informed consent prior to the administration of psychotropic medications. During an interview on 1/22/26 at 3:35 p.m. with Medical Records (MR), MR stated there is no written informed consent for the use of Divalproex in Resident 3's medical record. During a review of the facility's policy and procedures (P&P) titled, Behavior/Psychoactive Medication Management, dated 2022, the P&P indicated, Facility must obtain a resident's written informed consent for treatment using psychoactive drugs and consent renewal every 6 months.

Based on observation, interview and record review, the facility failed to ensure one of three sampled resident (Resident 7) was not offered a gradual dose reduction (GDR, stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) when taking antipsychotic (prescription medications used to treat psychosis) medication to be free from unnecessary medications. This failure had the potential to result in Resident 7 to receive antipsychotic medication without GRD or ongoing evaluation of continued need and placing the resident at risk for adverse medication effects. Findings: During record review of Resident 7's admission record, the admission record indicated Resident 7 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hypothyroidism (thyroid gland isn't producing enough hormones), dementia (a progressive state of decline in mental abilities), and adult failure to thrive. During a record review of Resident 7's Minimum Data set (MDS-a resident assessment tool), dated 10/27/2025 indicated Resident 7's cognition (mental ability decisions of daily living) was intact. The MDS indicated Resident 7 was dependent on personal hygiene, putting on/taking off footwear and showers. The MDS indicated that Resident 7 needed maximal assistance with eating, oral hygiene, toileting, and lower body dressing; however, the facility did not complete the MDS Section D (mood). Staff did not complete the Staff Assessment of Resident 7's mood or document symptom present, symptom frequency, or a total severity score and therefore did not assess and document Resident 7's mood status. During a review of Resident 7's Order Summary Report dated 01/2026 indicated an active order of Risperidone (antipsychotic medication that treats mental health conditions) oral tablet 4 milligram at bedtime, effective 9/18/2025 prescribed for schizoaffective (hallucinations and delusions, and mood disorder symptoms, such as depression) disorder m/b auditory (hearing) hallucination (an experience involving the apparent perception of something not present). During a concurrent interview and record review of Resident 7's electronic medical chart with the Director of Nursing (DON) on 1/22/2026 at 12:11 p.m., the DON stated that the interdisciplinary team (IDT- team members from different departments working together with a common purpose to set goals and make decisions that ensure residents receive the best care) met on 9/26/25 and no GRD was offered to Resident 7. DON stated there are no progress notes from social services or Medical Doctor (MD) indicating that a gradual dose reduction was attempted. DON stated that GRD should be offered to Resident 7 quarterly. DON stated consultant pharmacists comes to the facility and reviewed Resident 7's medication regimen on 9/24/25 and did not make any new recommendations to decrease risperidone. DON states that the Resident 7 did not have a diagnosis of schizophrenia and should have been a trialed for a medication dose reduction. During a review of Resident 7's care plan report titled Resident (Resident 7) uses antipsychotic medication r/t schizophrenia dated on 1/25/2024, indicated the goal, the resident will reduce the use of psychotropic medication through the review date. The care plan intervention indicated, Consult with pharmacy, MD to consider dosage reduction when clinically appropriate at least quarterly .review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy. During a concurrent interview and record review of Resident 7's pharmacist recommendations titled Consultant Pharmacist's medication Regimen Review dated on 9/25/25 with the DON on 1/22/2026 at 12:11 p.m. did not indicate recommendations for gradual dose reduction or continued justification for ongoing use of Risperidone. During a review of the facility's policy and procedures (P&P) titled, Behavior/Psychoactive Medication Management updated 6/20/25, indicated, the licensed nurse will collaborate with the healthcare practitioner, family, resident, and IDT members, to identify the contributing factors related to the resident's mood/behavior and non-medication interventions to be implemented.the IDT will reassess the effectiveness or the psychoactive medication at least quarterly during IDT Care plan meeting or psychoactive behavior management committee.

Based on observation, interview and record review the facility failed to ensure Minimum Data Set(MDS- a resident assessment tool) assessment accurately reflect resident status for one of five sampled residents (Resident 19). This failure had the potential to result in inaccurate assessment of the resident's condition, leading to inappropriate care planning, monitoring and interventions.Findings: During record review of Resident 19's admission record indicated Resident 19 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities) and history of falling. During a record review of the Resident 19's MDS, dated [DATE] indicated Resident 19's cognition (mental ability to make decisions of daily living) was severely impaired. The MDS indicated Resident 19 was dependent (helper does all the efforts. Resident does none of the efforts to complete the activity) of eating, oral hygiene, toileting, shower, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. During a review of Resident 19's Nurses Progress Notes dated 10/29/2025 at 11:54p.m., Licensed Nurse documented that Resident 19 returned from general acute care hospital (GACH) at 11:50p.m. with a right hip fracture (broken bone) from a fall. During a concurrent interview and record review with Registered Nurse (RN) 1 on 1/22/2026 at 7:44 a.m., Resident 19's Clinical admission assessment dated [DATE] timed 6:16p.m. was reviewed. RN 1 stated Resident 19's Clinical admission Assessment was not completed accurately because not all questions were answered including the safety section. RN 1 stated that the assessment is inaccurate because of not properly filling up the questions indicating that Resident 19 is not a high risk for falls. During an interview and record review with Minimum Data Set (MDS) Nurse on 1/22/2026 at 10:40 a.m., Resident 19's of Resident Clinical assessment dated [DATE] was reviewed. MDS nurse stated that Resident 19's re-admission assessment was not completed accurately. Specifically, the assessment section J of the MDS titled, Health Conditions incorrectly addressed the question asking whether the resident had sustained any fractures related to a fall in the 6 months prior to admission/entry or reentry. MDS nurse stated that Resident 19 was re-admitted with a right hip fracture on 11/3/2025 and that the question should have been triggered properly to ensure resident receive the care needed. MDS stated that it was important to accurately assess the residents to be able to provide the proper care they need. During a review of the facility's policy and procedures (P&P) titled Resident Assessment Instrument (RAI) reviewed on 6/20/2025 indicated, The facility will utilize RAI process as the basis for the accurate assessment of each resident's functional capacity and health status.

Based on observation, interview, and record review, the facility failed to meet professional standards of quality for one of four sample residents (Resident 14) when Licensed Vocational Nurse (LVN) 2 was observed crushing medications without a physician's order. This failure had a potential to result in medication ineffectiveness, compromised therapeutic outcomes, and adverse health effects for Resident 14.Findings: During a review of Resident 14's admission Records, the admission Records indicated Resident 14 was originally admitted to the facility on [DATE], then readmitted to the facility on [DATE], with diagnoses including metabolic encephalopathy (a reversible brain dysfunction caused by chemical imbalances, toxins, or organ failure (like liver or kidney disease) rather than physical injury), urinary tract infection (UTI), bacteremia (the presence of bacteria in the bloodstream), type I Diabetes Mellitus ([DM]-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 14's Minimum Data Set ([MDS]-a resident assessment tool) dated 11/14/2025, the MDS indicated Resident 14 is cognitively intact (has sufficient judgment, planning, organization, self-control) with no significant impairment. The MDS indicated that Resident 14 is dependent (helper does all the effort) with toileting hygiene, shower, lower body dressing, putting on/taking off footwear. During a concurrent observation of medication pass and interview on 1/21/2026 at 8:00 a.m. with LVN 2, LVN 2 prepared following medications for Resident 14 scheduled to be administered during morning medication pass:Macrobid (a medication to treat UTI) 100 mg 1 capsule by mouth two times a day for UTI for 5 days,Aripiprazole (a medication to treat mental conditions) 20 mg 1 tablet by mouth one time a day for bipolar disorder (a mental health condition causing severe mood swings),Buspirone (a medication to treat anxiety) 10 mg two tablets by mouth one time a day for anxiety,Gabapentin (a medication that calms overactive nerves to treat nerve pain) 300 mg 1 capsule by mouth three times a day for neuropathic pain (chronic pain caused by damaged or malfunctioning nerves),Metoprolol tartrate (a medication to treat high blood pressure) 25 mg 1 tablet by mouth two times a day for cardiac arrhythmia (abnormal heart rhythm).Vitamin C (a supplement that helps fight infections, heal wounds, and keep tissues healthy) 500 mg 1 tablet by mouth one time a day in the morning for supplement.Levofloxacin 500 mg 1 tablet by mouth one time a day for UTI for 5 days.LVN 2 stated that Resident 14 was on pureed diet (texture-modified food for those who can't handle solid food) and started crushing all above listed tablets and emptying all capsules into medication cups, mixing them with apple sauce. LVN 2 administered all medications to Resident 14. During a concurrent interview on 1/21/2026 at 2:00 p.m. with LVN 2 and record review of Resident 14's physician's order, LVN 2 stated that medications could be crushed with a physician order indicating may crush all crushable medications. LVN 2 stated there was no physician order for May crush all crushable medications. LVN 2 stated there might be medications that should not be crushed, and if they are crushed, the medications may not work as intended for the residents. During a concurrent interview and record review on 1/21/2026 at 2:05 p.m. with Registered Nurse (RN) 1 of Residents 14 physician's orders, the physician order indicated no documentation may crush all crushable medications and no care plan initiated to address Resident 14's needs or preferences for crushed medications. During an interview on 1/22/2026 at 12:30 p.m. with DON, the DON stated that taking medications in a crushed form was acceptable if it was the resident's preference, however there are medications that should not be crushed. The DON stated that physicians need to be aware of resident's preference and an order allowing medications to be crushed must be placed. During a review of the facility's policy and procedures (P&P) titled Medication Administration revised in 6/26/2025, the P&P indicated If the resident has difficulty swallowing pills, the licensed Nurse will notify the physician to discuss the possibility of a different form of the medication i.e. crushed, liquid or suspension. If the medication is to be crushed, a physician order is required.

Based on observation, interview and record review, the facility failed to follow the physician's order for fluid restriction (limits total daily liquid intake) for one of one sampled resident (Resident 4). This failure had the potential to result in inaccurate fluid intake documentation leading to fluid overload (too much fluid in the body) and hospitalization for Resident 4. Findings; During a review of Resident 4's admission Record, dated January 2026, the admission Record indicated the facility admitted the resident on 11/7/25, with diagnoses including but not limited to urinary tract infection (UTI, an infection in the bladder/urinary tract), chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing) and congestive heart failure (CHF, a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 4's Minimum Data Set (MDS, a standardized care screening and an assessment tool), dated 12/22/25, the MDS indicated the resident requires maximum assistance (helper does more than half the efforts to complete a task) with activities of daily living (ADLS, activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 4's physician's order, dated 11/7/25, the order indicated hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidneys have failed) every Tuesday, Thursday and Saturday. During a review of Resident 4's physician's order, dated 12/30/25, the order indicated fluid restriction of 1,000 milliliters (ml, a unit of measure) a day as follows: dietary = 360 ml, nursing 7:00 a.m. to 3:00 p.m. shift = 340 ml, nursing 3:00 p.m. to 11:00 p.m. shift = 200 ml, and nursing 11:00 p.m. to 7:00 a.m. shift = 100 ml. During an interview on 1/21/26 at 1:39 p.m. with Certified Registered Nurse (CNA) 4, CNA 4 stated CNAs are responsible for charting all fluids, including water, juice, milk, coffee and those given during medication administration in Fluid Intake. CNA 4 stated it is important to accurately document fluid intake to prevent fluid overload. During an interview on 1/22/2026 at 9:24 a.m. Licensed Vocational Nurse (LVN) 2, LVN 2 stated duplicate documentation is inaccurate documentation. LVN 2 stated if a shift did not accurately document fluid intake, it would throw off the total recorded fluid intake for the day and could result in going over the ordered fluid restriction amount. During a concurrent interview and record review on 1/22/2026 at 9:28 a.m. with Registered Nurse (RN) 1, Resident 4's Fluid Intake, dated January 2026 was reviewed. The Fluid Intake indicated, on 1/4/2026, Resident 4's total fluid intake was 1,100 ml. RN 1 stated fluid restriction orders were not followed because the total fluid intake exceeded 1,000 ml. RN 1 stated not adhering to fluid restriction can cause edema (swelling of body tissues caused by excess fluid) and shortness of breath. During a concurrent interview and record review on 1/22/2026 at 1:22 p.m. with the Director of Nursing (DON), Resident 4's Fluid Intake, dated January 2026 was reviewed. The Fluid Intake indicated, on 1/4/2026, Resident 4's total fluid intake for the day was 1,100 ml, including the two 500 ml entries at 2:45 p.m. and one 100 ml entry at 5:00 PM. DON stated the entries at 2:45 p.m. were either duplicate documentation or documentation at incorrect time. DON stated staff inaccurately documented and did not follow the fluid restriction order. During a review of the facility's policy and procedures (P&P) titled, Dialysis Management, dated 2022, the P&P indicated, Diet and fluid restrictions will be followed as ordered.

Based on observation, interview, and record review, the facility failed to ensure the following for one of five sampled residents (Resident 21): 1. Resident 21 was assessed for risk of entrapment from bed rails prior to installation.2. Nursing staff implemented physician orders to maintain resident safety for seizure precautions. 3.Resident 21's bed dimensions were appropriate for the resident's size and weight.4. Staff obtained proper consent prior to using bilateral upper and lower side rails for Resident 21. These failures had the potential to result in serious physical injury, including entrapment, restricted movement during a seizure, or falls with injury, due to the use of four side rails (a device that attaches to the side of the bed).Findings: During a record review of Resident 21's admission record indicated Resident 21 was admitted on [DATE] with a diagnoses of seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), hydrocephalus (abnormal buildup of cerebrospinal fluid in the brain leading to damage), and gastro-esophageal reflux disease (GERD-severe acid reflux where stomach acid frequently flows backward into the throat) without esophagitis (swelling of the lining of the esophagus). During a record review of Resident 21's Minimum Data set [MDS-a resident assessment tool), dated 11/21/25 indicated that Resident's cognitive was intact. The MDS indicated that Resident 21 is independent with eating, needs setup or clean up assistance with upper body dressing, requires supervision or touching assistance with oral hygiene, lower body dressing and with personal hygiene. During an observation on 1/21/26 at 10:32 a.m. Resident 21 was observed lying in bed facing the doorway covered with white blanket to Residents 21's shoulder with four side rails up, side rails were not padded, no floor mats on the side of resident 21's bed and the bed was in the low position. During a review of Resident 21's Order Summary Report dated 1/22/2026 indicated physician's orders in effect as of 2/19/2025 for Resident 21 that required:Bilateral padded side rails to decrease potential injury r/t seizure.May order Bilateral side rails up padded and floormat for seizure precaution and fall risk. During a review of Resident 21's medical record on 1/21/2025 at 9:33 a.m. revealed no documentation of alternatives attempted, no documentation of risk of entrapment and no evidence of the resident 21's or representative's informed consent for four bed rail use. There was no care plan addressing bed rail use or potential entrapment. During an interview with Licensed Vocational Nurse 2 (LVN 2) on 1/21/2026 at 10:36 a.m., LVN 2 stated that all four side rails were raised at the family's request while maintenance cleaned Resident 21's floor mats. LVN 2 reported that floor mats and padded side rail covers had been removed for cleaning and no alternative measures were attempted prior to using four side rails. LVN 2 further stated that Resident 21 should have padded side rails to prevent injury during seizures and floor mats due to a history of falls. During an interview and record review with Maintenance Director (MD) on 1/21/2026 at 11:44a.m., MD stated that he was responsible for measuring side rails for all residents upon admission and on a monthly basis. During an interview and record review with Maintenance Director (MD) on 1/21/2026 at 11:44a.m., MD stated that he was responsible for measuring side rails for all residents in the facility upon admission and on a monthly basis. The MD stated that Resident 21's side rails were measured on 12/2/2025; however, he did not measure four side rails. The MD further stated that the side rail measuring log dated 12/3/2025 did not include measurements for the lower side rails because staff had just added them for safety. MD stated that it was important to measure all side rails to prevent any injury, stating that Resident 21 could become entrapped between the rails. During an interview and record review with Registered Nurse 1 (RN 1) on 1/21/2026 at 11:24 a.m., RN 1 stated that there was no care plan initiated for side rails because Resident 21's four side rails were implemented for risk for falls since Resident 21 has a history of falls. During subsequent interview with RN 1 on 1/21/2026 at 11:24 a.m., RN 1 stated that the care plan for at risk for falls did not include Resident 21's four side rails, padded side rails or bilateral floor mats. RN 1 stated that the facility needed to implement other alternatives prior to installing four side rails or any bed rails. RN 1 further stated that it was important to include interventions in Resident21's care plan since it was part of Resident 21's personalized plan of care. RN1 stated that Resident 21's informed consent dated 2/20/2025 indicated bilateral side rails did not include the four side rails. RN 1 further stated that the informed consent was obtained via telephone, and it was incomplete due to missing a second nurse's signature. RN 1 emphasized the importance of assessing residents before side rails are used for safety reasons, as some residents may be at risk of entrapment. During a review of the facility's policy and procedures (P&P) titled, Bed Rails dated 6/20/2025, indicated the licensed nurse will complete the Bed Rail evaluation prior to the use and or installation of any bed rail, upon admission, re-admission, change in bed or mattress, and a change in mobility status. The P&P also indicated a care plan will be developed regarding the use of bed rails.

Based on observation, interview, and record review, the facility failed to ensure that medication error rate was less than five percent (5%). Two (2) medication errors out of twenty-six (26) opportunities resulted in an overall error rate of 7.69%, affecting two of four residents (Residents 14 and 45) observed during medication administration (MedPass) when:The physician order for levofloxacin (a strong, broad-spectrum antibiotic used to treat bacterial infections) for Resident 14 in electronic medical records (EMR) did not match the medication dose and directions listed on the bubble pack label.Licensed Vocational Nurse (LVN) 2 was unable to locate the prescribed strength of Vitamin D3 (supplement that supports bone health) for Resident 45 in medication cart 1, LVN 2 failed to follow up with the physician to clarify the discrepancy and obtain further instructions.These deficient practices increased the risk that Residents 14 and 45 may experience adverse reactions, complications, that could lead to a decline in the residents' condition, harm, or hospitalization.Findings:During a review of Resident 14's admission Records, the admission Records indicated Resident 14 was originally admitted to the facility on [DATE], then readmitted to the facility on [DATE], with diagnoses including metabolic encephalopathy (a reversible brain dysfunction caused by chemical imbalances, toxins, or organ failure (like liver or kidney disease) rather than physical injury), urinary tract infection ([UTI] - infection in the urine), bacteremia (the presence of bacteria in the bloodstream), type I Diabetes Mellitus ([DM]-a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 14's Minimum Data Set ([MDS]-a resident assessment tool) dated 11/14/2025, the MDS indicated Resident 14 is cognitively intact (has sufficient judgment, planning, organization, self-control) with no significant impairment. The MDS indicated that Resident 14 is dependent (helper does all the effort) with toileting hygiene, shower, lower body dressing, putting on/taking off footwear.During a concurrent observation of Med Pass and interview on 1/21/2026 at 8:00 a.m. with LVN 2, LVN 2 prepared following medications for Resident 14 scheduled to be administered during morning MedPass:Macrobid (a medication to treat UTI) 100 mg (unit of measurement) 1 capsule by mouth two (2x) times a day for UTI for 5 days,Aripiprazole (a medication to treat mental conditions) 20 mg 1 tablet by mouth one time a day for bipolar disorder (a mental health condition causing severe mood swings),Buspirone (a medication to treat anxiety) 10 mg two tablets by mouth one time a day for anxiety,Gabapentin (a medication that calms overactive nerves to treat nerve pain) 300 mg 1 capsule by mouth three times a day for neuropathic pain (chronic pain caused by damaged or malfunctioning nerves),Metoprolol tartrate (a medication to treat high blood pressure) 25 mg 1 tablet by mouth two times a day for cardiac arrhythmia (abnormal heart rhythm).Vitamin C (a supplement that helps fight infections, heal wounds, and keep tissues healthy) 500 mg 1 tablet by mouth one time a day in the morning for supplement.Levofloxacin 500 mg 1 tablet by mouth one time a day for UTI for 5 days.During a subsequent interview on 1/21/2026 at 8:00 a.m. with LVN 2, LVN 2 stated levofloxacin label on the bubble pack sheet did not match the physician's order in EMR, the physician order dated 1/22/2026 indicated order for levofloxacin 250 mg 2 tablets by mouth one time a day for UTI for 5 days. LVN 2 stated that she can still administer the medication because the dosage would be the same. LVN 2 stated Resident 14 was on pureed diet (texture-modified food for those who can't handle solid food) and started crushing all above listed tablets and emptying all capsules into medication cups, mixing them with apple sauce. LVN 2 administered all medications to Resident 14.During an interview on 1/21/2026 at 2:00 p.m. with LVN 2, LVN 2 stated that labels on the medication must match the physician order. LVN 2 stated the discrepancy should be communicated with the physician and pharmacy for clarification and correction. LVN 2 stated if the order and labels are not verified properly, patient could receive double dose, which would lead to medication error and patient harm. LVN 2 further stated that medications could be crushed with a physician order indicating may crush medications.During a concurrent interview on 1/21/2026 at 2:00 p.m. and record review with LVN 2, LVN 2 stated physician order did not indicate May crush medications. LVN 2 added there are medications that should not be crushed, and if they are crushed, the medications may not work as intended for the residents.During a review of Resident 45's admission Records, the admission Records indicated Resident 45 was originally admitted to the facility on [DATE], then readmitted to the facility on [DATE], with diagnoses including chronic atrial fibrillation (an irregular and often very rapid heart rhythm), type 2 DM, anemia (a condition where the body does not have enough healthy red blood cells).During a review of Resident 45's MDS dated [DATE], the MDS indicated Resident 45 is cognitively intact, with no significant impairment. The MDS indicated that Resident 45 is independent (completes the activity by themselves with no assistance from a helper) with most of the activities of daily living (ADL).During a concurrent observation of medication administration and interview on 1/21/2026 at 9:30 a.m. with LVN 2, Vitamin D3 125 mcg (5,000 IU), one capsule by mouth, was scheduled to be administered to Resident 45 at 9:00 a.m. LVN 2 was unable to locate the medication in medication cart 1. LVN 2 stated that Vitamin D3 125 mcg was a prescription medication for Resident 45.During a review of Resident 45's electronic medication administration record (eMAR) on 1/21/2026 at 12:30 p.m., the eMAR indicated no documentation of Vitamin D3 administration scheduled at 9:00 a.m. for Resident 45.During a review of Resident 45's Progress notes dated 01/22/2026, Progress notes indicated no documentation of physician notification related to missing medication with instructions on what actions needed to be taken.During an interview on 1/22/2026 at 12:30 p.m. with the Director of Nursing (DON), the DON stated that any discrepancy between a medication order and the label on the bubble pack is an issue that must be addressed immediately. The DON explained that the pharmacy should be contacted to obtain a corrected label. The DON further stated that failure to correct such discrepancies could result in a medication error, potentially reducing the medication's efficacy.The DON also stated that administering medications in crushed form is acceptable if it is the resident's preference; however, certain medications should not be crushed. The DON emphasized that physicians must be informed of the resident's preference, and an order authorizing medications to be crushed must be in place.During a subsequent interview on 1/22/2026 at 12:25 p.m. with DON, the DON stated that if a medication is ordered but not available in the medication cart, the nurse must immediately contact the physician to notify the physician that the medication is unavailable. The DON stated that the nurse must follow the physician's instructions regarding whether the dose can be skipped, delayed or substituted. This process ensures resident safety, prevents missed or inappropriate medication administration.During a review of the facility's policy and procedure (P&P) titled Medication Administration revised in 6/26/2025, the P&P indicated The licensed Nurse will verify the resident's identity before administering the medication using the 6 rights of medication administrationi. Right Resident: Confirm with two identifiers.ii. Right Medication: Verify against the MAR and pharmacy label.iii. Right Dose: Ensure accuracy based on provider order.iv. Right Route: Confirm oral, topical, injection, etc.v. Right Time: Administer within ordered time window.vi. Right Documentation: Immediately document after administration.If the resident has difficulty swallowing pills, the licensed Nurse will notify the physician to discuss the possibility of a different form of the medication i.e. crushed, liquid or suspension. If the medication is to be crushed, a physician order is required.

Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 19) care was not delayed when transportation failed to pick up Resident 19 on 10/28/25 per physician's orders. This failure had the potential to place the resident at risk for delayed treatment and care.Findings: During record review of Resident 19's admission record, the admission record indicated Resident 19 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities) and history of falling. During a record review of the Resident 19's Minimum Data set (MDS-a resident assessment tool), dated 10/17/2025 indicated Resident 19's cognition (mental ability decisions of daily living) was severely impaired. The MDS indicated Resident 19 was dependent (helper does all the efforts. Resident does none of the efforts to complete the activity) of eating, oral hygiene, toileting, shower, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. During a record review of Resident 19's Nursing Progress Notes dated 10/28/2025, the nursing progress notes indicated, MD came to review resident (Resident 19's) chart (medical chart) and assessed resident today with an order to transfer (Resident 19 to a GACH) for further evaluation and treatment due to recent fall. During a record review of Resident 19's Order Summary Report dated 10/28/2025 indicated, May transfer resident (Resident 19) to acute hospital (GACH) for further evaluation r/t (relate to) s/p fall. For possible direct admit to acute hospital. During an interview and record review with the Director of Nursing (DON) on 1/22/2026 at 2:44 p.m., Resident 19's progress notes were reviewed. The DON stated Resident 19 was not transferred to GACH for further evaluation and treatment related to the fall as per MD's orders dated 10/28/2025 because there was transportation delay. The DON stated that licensed nurses are responsible for arranging and coordinating transportation for the residents. The DON stated that when there is a resident direct admit order to a GACH, the facility must wait for bed availability at the GACH. The DON further stated that if the resident is not transferred during certain hours, the facility is required to follow up and inform the MD to communicate and determine if there are any alternative treatments that can be provided while the resident remains in the facility. The DON acknowledged that nursing staff did not document that the MD was notified of the delay in transferring Resident 19 according to MD order dated 10/28/2025. During a phone interview on 1/23/2026 at 3:27 p.m. with Resident 19's DPOA, DPOA stated that the facility informed her that Resident 19 was not transferred to GACH on 10/28/25 because the transportation team did not come get her until the next morning.they did not have the opportunity to get her due to conflict in the schedule. DPOA stated that the facility informed her that they brought in extra staff to assist Resident 19 from falling and implemented bilateral mats. During a review of the facility's policy and procedures (P&P) titled, Change in Condition updated 6/20/25, indicated, a licensed nurse will notify the resident's physician and legal representative when a decision to transfer or discharge the resident from the facility.licensed nurse will document the following: the time the physician was contacted, the method by which he was contacted, the response time, and whether or not orders were received, update care plan to reflect the residents current status.

Based on observation, interview and record review, the facility failed to meet the requirements of no more than four residents per room for 2 of 20 resident rooms (rooms [ROOM NUMBERS]).This failure had the potential to result in inadequate space to provide sufficient nursing care and privacy for the residents.Findings:During a tour of the facility for an unannounced recertification survey visit on 1/22/2026 at 12:57 p.m., Resident rooms [ROOM NUMBERS] were observed to have five residents per room. The residents in rooms [ROOM NUMBERS] were observed to have enough space for residents to move freely inside the room. rooms [ROOM NUMBERS] had adequate space in the room for the residents to operate and use their wheelchairs, walkers, and canes. The room variance did not affect the care and services provided by the nursing staff. During an interview on 1/22/2026 at 12:51 p.m. with the Occupational Therapist (OT) 1, OT 1 stated she can move around the room easily and did not have any obstacles hindering patient care. During an interview on 1/22/2026 at 1:10 p.m. with the Certified Nurse Assistant (CNA 1), CNA 1 stated she can move around the room easily and did not have any obstacles hindering patient care.During an interview on 1/22/2026 at 1:15 p.m. with Resident 35, Resident 35 was asked if he had any concerns regarding his room space, and he stated he did not have any concerns or issues regarding his living space.During a review of the facility's client accommodation analysis form completed on 1/22/2026, the form indicated rooms [ROOM NUMBERS] housed five beds per room.On 1/22/2026, the administrator (ADM) submitted a letter requesting a waiver for rooms with more than four residents per room for the following rooms:room [ROOM NUMBER] with five residentsroom [ROOM NUMBER] with five residents. During the recertification survey on 1/22/2026, staff interviews stated there were no concerns regarding the size of the rooms.During an interview on 1/22/2026, at 1:44 p.m. with the Administrative Assistant (AA), AA stated the facility submitted a written request for the continued room waiver although the room sizes do not impede resident care.

Based on observation, interview and record review, the facility failed to provide at least 80 square feet (sq. ft. -unit of measurement for space) per resident in their bedroom for 17 of 20 resident rooms, (Rooms 4, 5, 6, 7, 8, 9, 10,11, 14, 15, 16, 17, 18, 19, 20, 21, and 22). This failure had the potential to result in inadequate useable living space for all the residents and working space for the health caregivers, which could affect the quality of life for the residents.Findings: During a review of the Request for Room Size Waiver letter submitted by the Administrator, dated 1/22/2026, the letter indicated 17 resident rooms in the facility do not meet the requirement of at least 80 square feet per resident per federal regulation. The letter indicated the rooms do not pose any kind of risk to the care and services the facility provides for the residents. Each room has access to the outside and provides ample sunlight and ventilation. The following rooms provided are less than 80 Sq. Ft. pr resident: Room Size (length and width) Floor Area (square feet) #of beds 4 14 ft. x 10 ft. 140 Sq. Ft. 2 5 14 ft. x 10 ft. 140 Sq. Ft. 26 14 ft. x 10 ft. 140 Sq. Ft. 2 7 14 ft. x 10 ft. 140 Sq. Ft. 2 8 14 ft. x 10 ft. 140 Sq. Ft. 2 9 14 ft. x 10 ft. 140 Sq. Ft. 2 10 20 ft. x 10 ft. 200 Sq. Ft. 3 11 20 ft. x 10 ft. 200 Sq. Ft. 3 14 20 ft. x 10 ft. 200 Sq. Ft. 3 15 20 ft. x 10 ft. 200 Sq. Ft. 3 16 20 ft. x 10 ft. 200 Sq. Ft. 3 17 20 ft. x 10 ft. 200 Sq. Ft. 3 18 20 ft. x 10 ft. 200 Sq. Ft. 3 19 20 ft. x 10 ft. 200 Sq. Ft. 3 20 20 ft. x 10 ft. 200 Sq. Ft. 3 21 20 ft. x 10 ft. 200 Sq. Ft. 3 22 20 ft. x 10 ft. 200 Sq. Ft. 3 According to the federal regulation, the minimum square footage for a two bedroom is at least 160 sq. ft and three bedrooms are at least 240 sq. ft. During multiple observations of the residents' rooms from 1/20/2026-1/22/2026, the residents had ample space to move freely inside the rooms. There were sufficient spaces to provide freedom of movement for the residents and for nursing staff to provide care for the residents. There were also sufficient spaces for bedside tables, side tables and resident care equipment. During an interview on 1/22/2026 at 12:51 p.m. with the Occupational Therapist (OT) 1, OT 1 stated she can move around the room easily and did not have any obstacles hindering patient care. During a concurrent observation and interview on 1/22/2026, at 12:57 p.m., with the Maintenance Director (MD), the MD used a tape measurer to measure the size of the room from the window to the door for the length, then measuring from wall to the start of the closet horizontally for the width. The MD stated, this is how I measure to verify the size of the rooms, there are no complaints about the size of the rooms, and the staff and residents can move around with no issues. During an interview on 1/22/2026 at 1:10 p.m. with the Certified Nurse Assistant (CNA 1), CNA 1 stated she can move around the room easily and did not have any obstacles hindering patient care. During an interview on 1/22/2026 at 1:15 p.m. with Resident 35, Resident 35 was asked if he had any concerns regarding his room space, and he confirmed that he did not have any concerns or issues regarding his living space. During an interview on 1/22/2026, at 1:44 p.m. with the Administrative Assistant (AA), AA stated the facility submitted a written request for the continued room waiver although the room sizes do not impede resident care.

Based on interview and record review, facility failed to provide necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care to one of four sampled resident (Resident 1), by failing to address behavioral health care needs and implementing a person-centered care plan when Resident 1 unrealistic demands according to facility's policy and procedure (P&P) titled, Behavior/Psychotropic Drug Management . This deficient practice had the potential to negatively affect the delivery of behavioral health care and services to Resident 1. Cross Reference F745 Findings: During a review of the Resident 1's Admission Record, it indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including type II diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of the Minimum Data Set (MDS - resident assessment tool) dated 2/7/2025, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were mildly impaired. The MDS indicated Resident 1 required maximal assistance to total dependent from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS also indicated, Resident 1 experienced moderate depression in half or more of the days while in the facility. During a review of Resident 1's History and Physical (H&P) dated 2/2/2025, the H&P indicated, Resident 1 can understand and make own medical decisions. During a review of Resident 1's Care Plan (CP) for mood problem related to major depression, initiated on 2/10/2025, the CP indicated a goal of, Resident (1) will have improved mood state happier, calmer appearance, no signs and symptoms (s/sx) of depression. During a review of Resident 1's Medical Record as of 3/26/2025, there was no CP develop regarding Resident 1's behavior of unrealistic demands and requests. During a review of Resident 1's Psychosocial Note, dated 3/20/2025 by Psychiatrist 1 (PSYCH1), the Psychosocial Note indicated, The primary goal for the session was to explore and improve the client's (Resident 1) interpersonal interactions, particularly with the staff at the skilled nursing facility where she resides. The client (Resident 1), diagnosed with bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), is in current episodes of depression, and it is crucial to address her mood and emotional state, which influence her behavior towards others. During a review of Resident 1's Progress Notes by Social Services Director (SSD), dated 3/25/2025, the Progress Notes indicated, I (SSD) advised patient (Resident 1) that unfortunately, we cannot accommodate her (Resident 1)'s needs due to her demands, she is max (maximum) assist with Hoyer Lift (a mechanical device used to lift and/or transfer a person from place to place), and she is demanding to be up by 6 a.m. She (Resident 1) is also asking to have her laundry done on a daily basis, she also complains of having all her belongings brought to her room, which is a lot of boxes . We have tried to find a facility that will meet her needs, but she has declined every single facility that has accepted her based on her (Resident 1) needs. During an interview with Resident 1 on 3/26/2025 at 12:03 p.m., Resident 1 stated, SSD was very rude when he (SSD) approached her, and he (SSD) asked her, when are you leaving? . Resident 1 stated, she felt like she was being kicked out . Resident 1 stated, she is particular on the place where she would like to stay, she does not want to go elsewhere and would like to stay in the facility. Resident 1 further stated, she understands that she can be demanding but it's because she is picky with the place she wanted to stay. Resident stated, she felt bad that they are trying to send her out elsewhere because of her demands. During an interview with Certified Nursing Assistant 1 (CNA 1) on 3/26/2025 at 12:18 p.m., CNA 1 stated, Resident 1 liked to be up early in the morning after breakfast at around 9:30 a.m. CNA 1 stated, Resident 1 is nice to her, and she (Resident 1) was friendly with staff. CNA 1 stated, Resident 1 are particular on her likes and dislikes, but she (CNA 1) understands because it is residents' rights. During an interview with SSD on 3/26/2025 at 1:02 p.m., SSD stated, Resident 1 have high demands such as wanting to get out of bed early at 6 a.m., she (Resident 1) wanted her laundry to be done daily, and she (Resident 1) wanted all her belongings in her room. SSD stated, they are not able accommodate her needs because of her high demands so he (SSD) inquired into other skilled nursing facility (SNF) that may accommodate her needs. SSD stated, Resident 1 declined to be transferred to another SNFs. When asked what residents' rights are when it comes to their freedom of choice, SSD was not able to answer. SSD stated, there was no IDT meeting conducted in preparation of Resident 1's discharge planning. SSD stated, he does not know about the facility's policy on discharge and transfer of residents. SSD further stated, there was nothing wrong on how he approached Resident 1 regarding transferring her (Resident 1) to other SNFs because of her high demands. During a concurrent interview and record reviews with Registered Nurse (RN 1) on 3/26/2025 at 1:33 p.m., RN 1 stated, she explained to Resident 1, and Resident 1 understood about not being able to store all her belongings in her room for her safety and others. RN 1 stated, if Resident 1 requested to be out of bed early in the morning, staff need to accommodate her needs and if they are not able to get Resident 1 up early, staff need to explain it to Resident 1. RN 1 stated, Resident 1 also understood that they are not able to wash her clothes daily because the laundry is done in the facility for only twice a week. RN 1 reviewed SSD's notes on 3/25/2025 and stated, the facility can accommodate Resident 1's needs and they should not transfer Resident 1 because of high demands . RN 1 stated, if staff talked to Resident 1 in a manner where they do not feel secured and disrespected, Resident 1 may feel that she is not wanted and neglected which Resident 1 may be very sensitive because of her diagnosis of major depressive disorder. During a review of the facility's policy and procedures (P&P) titled, Behavior/Psychotropic Drug Management, reviewed and approved by facility on 6/28/2024, the P&P indicated, It is the policy of this Facility to provide person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being . If an in-house resident manifests a change in his/her mood or behavior symptoms, the licensed Nurse will conduct an assessment of the resident's mood and behavior status utilizing the Change of Condition process.

Based on interview and record review, the facility failed to provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being to one out of four sampled residents (Resident 1), by failing to promote individualized, non-pharmacological approaches to care that meet the mental and psychosocial needs. This deficient practice placed Resident 1 in psychosocial distress. Findings: During a review of the Resident 1's Admission Record, it indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including type II diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of the Minimum Data Set (MDS - resident assessment tool) dated 2/7/2025, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were mildly impaired. The MDS indicated Resident 1 required maximal assistance to total dependent from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS also indicated, Resident 1 experienced moderate depression in half or more of the days while in the facility. During a review of Resident 1's History and Physical (H&P) dated 2/2/2025, the H&P indicated, Resident 1 can understand and make own medical decisions. During a review of Resident 1's Care Plan (CP) for mood problem related to major depression, initiated on 2/10/2025, the CP indicated a goal of, Resident (1) will have improved mood state happier, calmer appearance, no signs and symptoms (s/sx) of depression. During a review of Resident 1's Medical Record as of 3/26/2025, there was no CP develop regarding Resident 1's behavior of unrealistic demands and requests. During a review of Resident 1's Psychosocial Note, dated 3/20/2025 by Psychiatrist 1 (PSYCH1), the Psychosocial Note indicated, The primary goal for the session was to explore and improve the client's (Resident 1) interpersonal interactions, particularly with the staff at the skilled nursing facility where she resides. The client (Resident 1), diagnosed with bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), is in current episodes of depression, and it is crucial to address her mood and emotional state, which influence her behavior towards others. During a review of Resident 1's Progress Notes by Social Services Director (SSD), dated 3/25/2025, the Progress Notes indicated, I (SSD) advised patient (Resident 1) that unfortunately, we cannot accommodate her (Resident 1)'s needs due to her demands, she is max (maximum) assist with Hoyer Lift (a mechanical device used to lift and/or transfer a person from place to place), and she is demanding to be up by 6 a.m. She (Resident 1) is also asking to have her laundry done on a daily basis, she also complains of having all her belongings brought to her room, which is a lot of boxes . We have tried to find a facility that will meet her needs, but she has declined every single facility that has accepted her based on her (Resident 1) needs. During an interview with Resident 1 on 3/26/2025 at 12:03 p.m., Resident 1 stated, SSD was very rude when he (SSD) approached her, and he (SSD) asked her, when are you leaving? . Resident 1 stated, she felt like she was being kicked out . Resident 1 stated, she is particular on the place where she would like to stay, she does not want to go elsewhere and would like to stay in the facility. Resident 1 further stated, she understands that she can be demanding but it's because she is picky with the place she wanted to stay. Resident stated, she felt bad that they are trying to send her out elsewhere because of her demands. During an interview with Certified Nursing Assistant 1 (CNA 1) on 3/26/2025 at 12:18 p.m., CNA 1 stated, Resident 1 liked to be up early in the morning after breakfast at around 9:30 a.m. CNA 1 stated, Resident 1 is nice to her, and she (Resident 1) was friendly with staff. CNA 1 stated, Resident 1 are particular on her likes and dislikes, but she (CNA 1) understands because it is residents' rights. During an interview with SSD on 3/26/2025 at 1:02 p.m., SSD stated, Resident 1 have high demands such as wanting to get out of bed early at 6 a.m., she (Resident 1) wanted her laundry to be done daily, and she (Resident 1) wanted all her belongings in her room. SSD stated, they are not able accommodate her needs because of her high demands so he (SSD) inquired into other skilled nursing facility (SNF) that may accommodate her needs. SSD stated, Resident 1 declined to be transferred to another SNFs. When asked what residents' rights are when it comes to their freedom of choice, SSD was not able to answer. SSD stated, there was no IDT meeting conducted in preparation of Resident 1's discharge planning. SSD stated, he does not know about the facility's policy on discharge and transfer of residents. SSD further stated, there was nothing wrong on how he approached Resident 1 regarding transferring her (Resident 1) to other SNFs because of her high demands. During a concurrent interview and record reviews with Registered Nurse (RN 1) on 3/26/2025 at 1:33 p.m., RN 1 stated, she explained to Resident 1, and Resident 1 understood about not being able to store all her belongings in her room for her safety and others. RN 1 stated, if Resident 1 requested to be out of bed early in the morning, staff need to accommodate her needs and if they are not able to get Resident 1 up early, staff need to explain it to Resident 1. RN 1 stated, Resident 1 also understood that they are not able to wash her clothes daily because the laundry is done in the facility for only twice a week. RN 1 reviewed SSD's notes on 3/25/2025 and stated, the facility can accommodate Resident 1's needs and they should not transfer Resident 1 because of high demands . RN 1 stated, if staff talked to Resident 1 in a manner where they do not feel secured and disrespected, Resident 1 may feel that she is not wanted and neglected which Resident 1 may be very sensitive because of her diagnosis of major depressive disorder. During an interview with Administrator (ADM) on 3/26/2025 at 4:19 p.m., ADM stated, a follow-up in-services with a Social Services Consultant will be provided to the SSD to ensure that the facility is providing appropriate accommodation and needs of all residents. During a review of the facility's Job Description (JD) titled, Social Service Coordinator , date signed by SSD on 4/20/2023, the JD indicated, Qualifications: Good written and verbal communication skills; Good interpersonal skill . Principal Responsibilities: Ensure the residents' psychosocial and concrete needs are identified and met in accordance with federal, state and company requirements. Customer Service: Presents professional image to consumers through dress, behavior and speech. Adheres to company standards for resolving consumer concerns. Ensures that all consumer/ resident rights are protected.

Based on interview and record review, the facility failed to provide a sufficient preparation and orientation for one of four sampled residents, (Resident) 1 with a safe and orderly discharge planning by failing to: 1. Complete an Interdisciplinary Team (IDT - a group of dedicated healthcare professionals who work to bring knowledge together to help residents receive the care they need) meeting regarding Resident 1's discharge planning. 2. Ensure the discharge planning was necessary, not because Resident 1 demanded of wanting to get up early and requested of laundry services. 3. Honor Resident 1's rights to be treated with kindness, respect and dignity. These deficient practices resulted in incomplete and ineffective discharge planning that may lead to lack of necessary care after discharge. Findings: During a review of the Resident 1's Admission Record, it indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including type II diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of the Minimum Data Set (MDS - resident assessment tool) dated 2/7/2025, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were mildly impaired. The MDS indicated Resident 1 required maximal assistance to total dependent from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS also indicated, Resident 1 experienced moderate depression in half or more of the days while in the facility. During a review of Resident 1's History and Physical (H&P) dated 2/2/2025, the H&P indicated, Resident 1 can understand and make own medical decisions. During a review of Resident 1's Care Plan (CP) for mood problem related to major depression, initiated on 2/10/2025, the CP indicated a goal of, Resident (1) will have improved mood state happier, calmer appearance, no signs and symptoms (s/sx) of depression. During a review of Resident 1's Psychosocial Note, dated 3/20/2025 by Psychiatrist 1 (PSYCH1), the Psychosocial Note indicated, The primary goal for the session was to explore and improve the client's (Resident 1) interpersonal interactions, particularly with the staff at the skilled nursing facility where she resides. The client (Resident 1), diagnosed with bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), is in current episodes of depression, and it is crucial to address her mood and emotional state, which influence her behavior towards others. During a review of Resident 1's Progress Notes by Social Services Director (SSD), dated 3/25/2025, the Progress Notes indicated, I (SSD) advised patient (Resident 1) that unfortunately, we cannot accommodate her (Resident 1)'s needs due to her demands, she is max (maximum) assist with Hoyer Lift (a mechanical device used to lift and/or transfer a person from place to place), and she is demanding to be up by 6 a.m. She (Resident 1) is also asking to have her laundry done on a daily basis, she also complains of having all her belongings brought to her room, which is a lot of boxes . We have tried to find a facility that will meet her needs, but she has declined every single facility that has accepted her based on her (Resident 1) needs. During a review of Resident 1's Medical Record as of 3/26/2025, there was no IDT team meeting in preparation of Resident 1's discharge planning. During an interview with Resident 1 on 3/26/2025 at 12:03 p.m., Resident 1 stated, SSD was very rude when he (SSD) approached her, and he (SSD) asked her, when are you leaving? . Resident 1 stated, she felt like she was being kicked out . Resident 1 stated, she is particular on the place where she would like to stay, she does not want to go else where and would like to stay in the facility. Resident 1 further stated, she wanted to see where they put her belongings that was sent from her previous facility where she resided, but she was told it was placed somewhere else, and they (facility) can not store it in her room. Resident 1 further stated, she understands that she can be demanding but it's because she is picky with the place she wanted to stay. Resident stated, she felt bad that they are trying to send her out elsewhere because of her demands. During an interview with Certified Nursing Assistant 1 (CNA 1) on 3/26/2025 at 12:18 p.m., CNA 1 stated, Resident 1 liked to be up early in the morning after breakfast at around 9:30 a.m. CNA 1 stated, Resident 1 is nice to her, and she (Resident 1) was friendly with staff. CNA 1 stated, Resident 1 are particular on her likes and dislikes, but she (CNA 1) understands because it is residents' rights. During an interview with SSD on 3/26/2025 at 1:02 p.m., SSD stated, Resident 1 have high demands such as wanting to get out of bed early at 6 a.m., she (Resident 1) wanted her laundry to be done daily, and she (Resident 1) wanted all her belongings in her room. SSD stated, they are not able accommodate her needs because of her high demands so he (SSD) inquired into other skilled nursing facility (SNF) that may accommodate her needs. SSD stated, Resident 1 declined to be transferred to another SNFs. When asked what residents' rights are when it comes to their freedom of choice, SSD was not able to answer. SSD stated, there was no IDT meeting conducted in preparation of Resident 1's discharge planning. SSD stated, he does not know about the facility's policy on discharge and transfer of residents. SSD further stated, there was nothing wrong on how he approached Resident 1 regarding transferring her (Resident 1) to other SNFs because of her high demands. During a concurrent interview and record reviews with Registered Nurse (RN 1) on 3/26/2025 at 1:33 p.m., RN 1 stated, she explained to Resident 1, and Resident 1 understood about not being able to store all her belongings in her room for her safety and others. RN 1 stated, if Resident 1 requested to be out of bed early in the morning, staff need to accommodate her needs and if they are not able to get Resident 1 up early, staff need to explain it to Resident 1. RN 1 stated, Resident 1 also understood that they are not able to wash her clothes daily because the laundry is done in the facility for only twice a week. RN 1 reviewed SSD's notes on 3/25/2025 and stated, the facility can accommodate Resident 1's needs and they should not transfer Resident 1 because of high demands . RN 1 stated, if staff talked to Resident 1 in a manner where they do not feel secured and disrespected, Resident 1 may feel that she is not wanted and neglected which Resident 1 may be very sensitive because of her diagnosis of major depressive disorder. During a review of the facility's policy and procedure (P&P), titled, Discharge and Transfer of Residents, reviewed and approved by facility on 6/28/2024, the P&P indicated that, To ensure that discharge planning is complete and appropriate, and that necessary information is communicated to the continuing care provider . The Facility may transfer or discharge a resident with an order from the resident's physician for: The discharge is necessary for the welfare of the resident, and needs cannot be met in the facility; The Resident's health has improved significantly and services provided by the facility are no longer required . A. Prior to discharging the resident, Nursing Staff/IDT will prepare a Discharge Summary/Post Discharge Plan of Care and will document the summary in the resident's medical record. During a review of the facility's P&P titled, Resident's Rights , reviewed and approved on 6/28/2024, the P&P indicated, The facility will promote and protect those rights. Residents have freedom of choice, as much as possible, about how they wish to live their everyday lives and receive care, subject to the Facility's rules and regulations and applicable state and federal laws governing the protection of resident health and safety . Employees are to treat all residents with kindness, respect, and dignity and honor the exercise of residents' rights.

Based on observation, interview, and record review the facility failed to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity in full recognition of his or her individuality when two (2) of 13 sampled residents (Resident 2 and Resident 42) did not get their meals at the dining table at the same time. This failure had the potential to result in psychosocial distress and frustration for Resident 2 and Resident 42. Findings: During a review of Resident 2's Admission Record, the admission record indicated the facility admitted Resident 2 on 12/12/2022 with diagnoses including, but not limited to, chronic obstructive pulmonary disease ([COPD] a common lung disease that makes it difficult to breathe, dysphagia (difficulty swallowing) and type 2 diabetes (a common condition that occurs when the body does not use insulin properly, resulting in high blood sugar levels.) During a review of Resident 2's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/17/2024, the MDS indicated Resident 2 was severely cognitively impaired (process of thinking and reasoning) skills for daily decision making. The MDS indicated Resident 2 required set-up and cleaning assistance when eating. During a review of Resident 2's Order Summary Report, dated 11/11/2024, the order summary report indicated Resident 2 was ordered a no added salt([NAS] no salt packet served on the tray), soft mechanical chopped texture (diet consist of soft, chopped foods) with thin liquid (fluids with no restriction) consistency. During an observation on 11/17/2024 at 12:33 p.m. in the residents' dining room, the first food cart arrived in the dining room. Observed that there were 13 residents were seated in the dining room. Observed seven (7) residents got their meals while six (6) residents waited. During an interview on 11/17/2024 at 12:34 p.m. with Resident 2, Resident 2 stated she has been waiting and she was hungry. During an observation on 11/17/2024 at 12:35 p.m., the next cart arrived but did not have the trays for three (3) residents. During an interview on 11/17/2024 at 12:45 p.m. with Licensed Vocation Nurse 3 (LVN 3), LVN 3 stated they (facility) did not serve the trays at the same time today and it was not their usual process. LVN 3 stated there was a mix up with some of the tray and they were looking for the resident's tray. LVN 3 stated they could do better and communicate with the kitchen so they could serve the residents at the same time. LVN 3 stated resident's food could be unhappy for not getting their food at the same time and their food could be cold. During an observation on 11/17/2024 at 12:48p.m., Resident 2 was served food. During an observation on 11/17/2024 at 12:51 p.m., Resident 42 was served food. During an interview on 11/17/2024 at 12:54 p.m. with Director of Nursing (DON), DON stated she expected the food cart to be in the dining room for lunch at 12:15 and she saw some residents did not get their food hence she tried to figure out where the trays were. DON stated their process was to distribute the food to the residents at the same time so that residents would not feel deprived of something or felt neglected. During a review of the facility's Policies and Procedures (P&P) titled Resident Rights - Personal Property, dated 6/28/2024, the P&P indicated, Purpose: To ensure the quality of life of all residents by allowing residents to create a home-like environme.

Based on interview and record review, the facility failed to ensure one of two residents (Resident 1) was not administered Glipizide (a medication for diabetes mellitus [DM-high blood glucose/sugar levels]) on 2/9/2023. Resident 1 did not have DM and did not have an order to receive Glipizide. This deficient practice resulted in Resident 1 having altered mental status (AMS - a change in mental status that can be life threatening), diaphoresis (excessive sweating), and seizure activity (sudden uncontrolled body movements) on 2/9/2023. Resident 1's blood glucose level was 24 (below 40 is considered severe hypoglycemia [severely low blood sugar], a life-threatening and needs immediate medical treatment, if not treated can result in a coma and/or death. Normal blood glucose range is 70 to 99) milligrams (mg- unit of measurement) per deciliter (dL- unit of measurement). Resident 1 was treated at a general acute care hospital (GACH) for hypoglycemia (a condition in which blood glucose level is lower than the standard range). On 4/3/2023, at 12:30 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death of a resident) was called in the presence of the Administrator because of the seriousness related to the facility's failure to ensure one of two residents (Resident 1) was not administered Glipizide on 2/9/2023. Resident 1 had cognitive impairment (Problems with a person's ability to think, learn, remember, use judgement, and make decisions) and did not have diabetes mellitus. Resident 1 did not have an order to receive Glipizide. On 2/9/2023, at 4:40 p.m., Resident 1, noted with AMS, diaphoresis and seizure like activity manifested by constant jerking (sudden involuntary twitching of a muscle or group of muscles). Resident 1's blood glucose level was 24 mg/dl. On 2/9/2023, at 4:43 p.m., Resident 1 was transferred to a local GACH emergency department for further evaluation and care. Resident 1 tested positive for Glipizide during GACH emergency room blood draw for hypoglycemic agents (medications that lower blood sugar) screen (test will detect the drug at physiologically significant concentrations) on 2/9/2023. On 4/4/2023, at 5.15 p.m., the facility provided acceptable IJ Removal Plan (interventions to correct the deficient practice). While onsite, the survey team confirmed implementation of the IJ corrective actions through observation, interview, and record review, and the SSA removed the IJ in the presence of the Director of Nursing (DON), facility manager, and two facility consultants. A review of the IJ removal plan included: The DON immediately provided education to 15 of 21 licensed nurses on the facility's policy and procedures for medication administration. The DON verified the licensed nurses' competencies on medication administration. The DON, the Director of Staff development (DSD) or designee will educate the licensed nurses who are not scheduled to work or are on leave of absence, upon the licensed nurses return to work and prior to active duty to ensure safe medication administration to the residents. The validation of medication administration competencies will be completed through the monitoring system established through medication administration observation of licensed nurses. A licensed pharmacist will educate the licensed nurses on the importance of correct medication administration to residents with emphasis on administering medications to the right residents. The licensed pharmacist will educate the licensed nurses on the effects associated with administering medications not ordered for a resident including oral hypoglycemic agents which would cause hypoglycemia to a resident. The DON will investigate medication error(s) and complete the medication error report. The DON will communicate the medication error to the resident's attending Physician and the facility's Medical Director. Findings: A review of Resident 1's admission record indicated the facility originally admitted Resident 1 on 6/7/2022 and readmitted Resident 1 on 1/23/2023 with diagnoses including Parkinson's disease (a progressive disease of the nervous system marked by tremors, muscular rigidity, and slow movements) and dementia (progressive or persistent loss of intellectual functioning with memory and abstract thinking impairment), urinary calculi (kidney stones), and chronic kidney disease (the presence of either kidney damage or decreased kidney function for three or more months). The admission record did not indicate Resident 1 had DM. A review of Resident 1's Medication Administration Record (MAR) for the month of 2/2023, did not indicate Resident 1 was on any medications for DM. A review of Resident 1's facility progress notes dated 2/9/203 timed at 4 p.m., indicated, on 2/9/2023 at 4 p.m., Resident 1 had a change of condition (COC - a deterioration in health, mental, or psychosocial status which can be life threatening) exhibited by AMS, seizure episode, and a blood sugar of 24 mg/dl. A review of Resident 1's Change of Condition form dated 2/9/2023 timed at 4:40 p.m., indicated Resident 1 was noted with AMS, diaphoresis and seizure like activity manifested by constant jerking. Resident 1's blood glucose level was checked and resulted at 24 mg/dL. The Medical Doctor 1 (MD 1) was notified and gave an order to transfer Resident 1 to a local GACH emergency department. A review of Resident 1's GACH Emergency Department (ED) Provider Note dated 2/9/2023, indicated Resident 1 presented with AMS and low blood sugar. Resident 1 was administered glucose and felt better. The ED provider note indicated Resident 1 had numerous episodes of hypoglycemia in the ED and was placed on D5 (Dextrose in water - hydration fluid) intravenously (IV - inside a vein). The ED provider note indicated the reason for Resident 1's hypoglycemia was unknown. GACH admitted Resident 1 for further work-up (evaluation). A review of Resident 1's GACH hypoglycemic agent laboratory records dated 2/9/2023, indicated Resident 1's blood tested Positive for Glipizide (reference value of negative to 5ng/ml [normal liters per minute - unit of measurement]). A review of the facility's document titled Glucotrol (Glipizide) Tablet dated 9/2008, indicated, Glucotrol is an adjunct (optional) to diet and exercise to improve blood glucose levels in adults with type 2 DM. The primary mode of action is to stimulate insulin (a hormone [A substance made by in the body and circulate in the bloodstream to control actions of certain cells or organs] that helps control blood sugar) released from the . pancreas (an organ in the body that produces insulin). The document indicated that blood sugar control persists in some patients for up to 24 hours after a single dose . The half-life (time it takes for a drug's active substance in the body to reduce by half) of elimination (remove) ranges from two to four hours . The metabolism (the physical and chemical processes in the body that convert or use energy) and excretion of Glucotrol may be slowed in patients with impaired renal (When the kidneys [An organ that removes waste and extra water from the blood or keep body chemicals in balance] stop working) . Under hypoglycemia section, indicated that, Renal (kidney) insufficiency may cause elevated (raised blood levels of Glucotrol . increases the of serious hypoglycemic (low blood sugar) reactions. A review of Resident 1's Minimum Data Set (MDS-a standardized assessment care screening tool) dated 3/10/2023, indicated Resident 1 had severely impaired (very hard time remembering things, making decisions, concentrating, or learning) cognition (mental ability to make decisions of daily living). The MDS indicated Resident 1 required extensive staff assist with bed mobility, eating, dressing and toileting. A review of Resident 3's (Resident 1's roommate) admission record indicated the facility originally admitted Resident 3 on 6/12/2020 and readmitted Resident 1 on 2/20/2021 with diagnoses including chronic obstructive pulmonary disease (COPD - condition involving blockage of the airways causing difficulty breathing), DM, hypertension (HTN- high blood pressure), cognitive communication deficit (difficulty thinking and how someone uses language) and seizures (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal activity in the brain). A review of Resident 3's MDS dated [DATE], indicated Resident 3 had severely impaired cognition and required extensive staff assist with bed mobility, eating, dressing and toileting. A review of Resident 3's Order Summary Report dated 12/8/2021, indicated Resident 3 to receive Glipizide 10 mg give one tablet by mouth one time a day at 6:30 a.m. before breakfast and five (5) mg tablet by mouth in the evening before dinner. A review of Resident 3's MAR for the month of 2/2023 timed at 6:30 a.m., indicated Resident 3 to receive Glipizide 10mg at 6:30 a.m. before breakfast. On 3/23/2023 at 11:30 a.m., during an interview, MD 1 confirmed and stated Resident 1 was admitted at a GACH for hypoglycemia related to Glipizide. MD 1 confirmed and stated Resident 1 did not have a history of DM and was not prescribed Glipizide. MD 1 stated he suspected Resident 1 received Resident 3's (roommate) Glipizide by mistake. MD 1 stated he notified the facility's DON that Resident 1 received Resident 3's Glipizide. MD 1 stated, We may see some initial confusion followed by lethargy and diaphoresis over a four-hour time frame, when asked what could happen if Glipizide was administered to a person with no diagnosis of diabetes. On 3/28/2023 at 10:04 a.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) confirmed and stated he was the medication nurse on 2/9/2023 between the hours of 6 a.m. and 7:30 a.m. LVN 1 stated he was certain he administered Glipizide to Resident 3 and not to Resident 1. LVN 1 further added he will no longer work night shift because his blood pressure was affecting his short-term memory (The capacity to hold a small amount of information available for a short period of time). LVN 1 stated he medicated the correct resident because prior to administering medication, he (LVN 1) makes sure he has the correct resident by calling the resident's name and checks the resident's medication against the physician's order. LVN 1 stated the facility was aware that Resident 1's blood tested positive for Glipizide. On 3/28/2023 3:09 p.m., during an interview, Registered Nurse 1 (RN 1) confirmed and stated that on 2/9/2023 between 3:45 p.m. and 4 p.m., Resident 1 had a COC. RN 1 stated Resident 1's shoulders were jerking on and off but Resident 1 remained alert. RN 1 stated Resident 1's vital signs (blood pressure, temperature, heart rate and respiratory rate) were checked and were within normal limits. RN 1 stated Resident 1's blood glucose level was 24mg/dl and Resident 1 received glucagon (medication to correct hypoglycemia/increase the blood sugar). RN 1 stated Resident 1 was transported to a GACH via 911 services (universal telephone number the gives the public direct access to the Public Safety. Answering point where emergency services such as the fire department, police or paramedics can be dispatched to a location) on 2/9/2023 at 4:43 p.m. RN 1 stated Resident 1's blood collected at the GACH, tested positive for Glipizide. A review of the facility's policy and procedures titled, Medication Errors, dated 7/2018, indicated, upon discovery of an error, notification will immediately be given to the director of nursing services and the administrator.The director of nursing services or his/her designee will investigate the error to determine the cause.

Based on observations, interviews, and record reviews, the facility failed to provide services needed to prevent or treat pressures ulcers (PU, an area of the skin that died because the patient laid or sat on that area of skin so long that blood stopped flowing to that area of skin) and vascular ulcers ([NAME], when an area of skin dies because blood vessels do not allow blood to circulate to that area of skin) for four of four sampled residents (Residents 1, 5, 15, and 17) when: a). The facility did not ensure that licensed nursing staff (LNS) assessed Residents 1 and 5's level of risk for developing pressures ulcers, according to the facility's policy, b). The facility did not ensure LNS assessed Residents 1, 5, 15 and 17's PUs and VUs on a weekly basis, according to the facility's policy and professional standards of practice, c). The facility did not ensure LNS fully implemented Residents 1, 5, 15, and 17's care plans for skin and pressure wound care, d). The facility did not ensure LNS entered Medical Doctor (MD) 7's orders for PU and [NAME] treatments, laboratory services, and turning and repositioning into the medical records of Residents 1, 5, 15 and 17, or that LNS documented when or if MD 7's orders were performed. These deficient practices resulted in or could have contributed to the following: - Resident (R) 1 had a Stage 4 PU (Stage 4 pressure ulcers extend even deeper, exposing underlying muscle, tendon, cartilage, or bone), throughout more than 160 days in the facility - R 5 had three PUs throughout more than 166 days in the facility and in that time R 5 developed at least four new PUs - R 15 had a Stage 2 PU (At stage 2, the skin breaks open, wears away, or forms an ulcer, which is usually tender and painful) throughout more than 66 days in the facility and in that time developed two new wounds: a PU on the right leg and a PU on the left heel. -R 17 had a Stage 4 PU throughout more than 119 days in the facility and during that time R 17 developed a new PU. These deficient practices had the potential to result in Residents 1, 5, 15, and 17 experiencing prolonged pain, infections, hospitalization s, and deaths. On [DATE] at 4:56 PM, the State Survey Agency (the Department) called an Immediate Jeopardy situation (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM) and Regional Quality Management Consultant (RQM) with regards to failure to ensure Residents 1, 5, 14, 15, 16, and 17 were free of neglect and received the care needed to prevent the development facility acquired pressure ulcers and to heal existing pressure ulcers. On [DATE] at 1:10 PM, the RQM provided the Department with a Plan of Action (POA) which included the following summarized actions: 1. On [DATE], the RQM completed Braden Scale Risk Assessments (BSRA, a tool for measuring a resident's risk for developing pressure ulcers) for all residents and Weekly Skin Assessments for all residents that have pressure ulcers. 2. On [DATE], RQM completed a review of all Wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. On [DATE], RQM and Resource Nurse (RNN) initiated in-services to all nursing staff regarding the facility's comprehensive skin assessment and wound care program which includes the following: a). How often to conduct and how to document a Braden Risk Assessment for all residents b). How to develop and document an individualized skin care plan for all residents c). How to implement and document interventions according to the resident's care plan d). When and how to document a Weekly Skin Evaluation Form for all residents e). When and how and how to document resident skin assessments, perform wound treatments, and when, how, and who will audit skin and wound related documentation f). When, how often, and how to complete Weekly Pressure Injury and Non-Pressure Injury /Ulcer Progress Reports and where to put the documents On [DATE] at 3:28 PM, after confirming the facility's implementation of the immediate corrective actions, the Department accepted the POA and removed the Immediate Jeopardy while onsite, in the presence of ADM and Director of Nursing (DON). Cross reference F600 Findings: A review of R 1's Face Sheet (Admission Record) indicated, R 1 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R 1's care plan titled, Skin-Short Term Pressure Ulcer, dated [DATE], indicated. Site of Pressure Ulcer: Sacral .Stage IV .Approach .Administer medications and treatments as ordered and monitor effectiveness .Turning and Repositioning as scheduled. A review of R 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated [DATE], indicated, R 1's needed extensive assistance from staff with moving in his bed. A review of R 1's care plan titled, Skin, dated [DATE], indicated, Resident at risk for skin break/ulcer formation .Approach .Administer medication and treatments as ordered and monitor for effectiveness/delayed healing .reposition with care rounds. A review of R 1's Wound Care Evaluation and Treatment, dated [DATE], indicated, Plan .Turn patient every 2 hours and avoid direct pressure to the ulcer site . A review of R 1's history and physical examination [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R 1's care plan titled, Activities of Daily Living, dated [DATE], indicated, R 1 needed assistance with bed mobility .Turn and reposition as ordered. A review of R 5 Face Sheet, dated [DATE], indicated, R 5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R 5's MDS, dated [DATE], indicated, R 5's ability to remember words and answer questions was severely impaired (limits an individual ' s physical or mental ability to perform basic work activities on a sustained basis) and totally dependent on staff to move in bed and to transfer in and out of bed. a. A review of R 5's Wound Care Evaluation and Treatment dated [DATE], indicated as of [DATE], R 5 had an unstageable PU (a PU that is covered by a dark dead skin that prevents a healthcare provider from seeing what is underneath) on each heel and on the right side of the right lower leg. A review of R 5's Wound Assessment and Plan, dated [DATE], indicated R 5 had developed an eighth PU on the left buttock, which MD 7 noted to be a Stage 1 PU (An area of skin that has poor blood circulation from a patient laying or sitting on that area of skin for a long period of time, but has not died or broken). A review of R 5's Wound Assessment and Plan dated [DATE], indicated R 5's Stage 1 PU on the left buttock had broken open and became a Stage 2 PU (A PU that has broken open and a healthcare provider can see down past the top layer of skin but not completely through the skin). A review of R 5's Wound Assessment and Plan, dated [DATE], indicated R 5 had the three unstageable PUs on both heels and the right side of the right leg, approximately five months since MD 11's Wound Care Evaluation and Treatment dated [DATE], and in that time R 5 developed four additional Pus: a Stage 4 PU on the left lower leg, and unstageable PUs on the right ankle, on the right big toe, and on the left foot, for a total of seven PUs. A review of R 15's Face Sheet, dated [DATE], indicated R 15 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R 15's Resident Baseline Evaluation, dated [DATE], indicated, R 15 was admitted to the facility with four wounds: a). A Stage 2 PU on the sacral area that was open and measured 4 cm by 4 cm, b). A wound on the right foot that was open and measured 1 cm long and 1 cm wide, c). A wound on the back side of the left lower leg that was open and measured 13 cm long and by 4 cm wide, and d). A wound on the left lower leg that was covered with black scab and measured 4 cm long and 2 cm wide. A review of R 15's H & P dated [DATE], indicated R 15 had wounds on both feet, severe peripheral vessel disease (a disease of the blood vessels that stops blood from circulating through some of the blood vessels), and had the capacity to understand and make decisions. A review of R 15's MDS, dated [DATE], indicated R 15's was cognitively intact, needed extensive assistance from staff to move in bed and to transfer in and out of bed and had one Stage 2 PU and two VUs. A review of R 15's Interfacility Transport Report, dated [DATE], indicated, the facility transferred R 15 to a general acute care hospital (GACH) on [DATE], and the GACH documented a PU on R 15's right leg, and a PU on his left heel. A review of R 15's Wound Assessment and Plan dated [DATE], indicated: a). R 15 still had the Stage 2 PU on the sacral area, b). The wound on the right foot had become so deep MD 7 could see past the skin and down to the Muscle/Tendon/Fascia, c). The wound on the back side of the left lower leg that measured 10 cm long and 4 cm wide had become so deep MD 7 could see past the skin and down to the fat Layer, beneath the skin, d). R 15 developed a new wound on the left foot that was so deep MD 7 could see all the way down to the bone. A review of R 17's Face Sheet, dated [DATE], indicated, R 17 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of R 17's H & P dated [DATE], indicated R 17 could understand and make decisions and had a Stage 3 PU on the sacral area. A review of R 17's Wound Care Evaluation and Treatment dated [DATE], indicated, R 17 had a Stage 4 PU on the sacral area. A review of R 17's MDS, dated [DATE], indicated R 17 was totally dependent on staff to move in bed, needed at least two staff to transfer in and out of bed, and had one Stage 2 PU, one Stage 4 PU, and one unstageable PU. A review of R 17's Wound Assessment and Plan dated [DATE], indicated, R 17 had the Stage 4 PU throughout the approximately 42 days since MD 11's evaluation on [DATE], and R 17 developed a new unstageable PU (Refers to an ulcer that has full thickness tissue loss but is either covered by extensive necrotic tissue or by an eschar [is dead tissue that falls off (sheds) from healthy skin]) on the left heel. A review of R 17's Wound Assessment and Plan dated [DATE], indicated, R 17 had the Stage 4 PU on the sacral area throughout approximately 118 days in the facility and had unstageable PU on the left heel throughout the approximately 69 days since MD 7 noted first noted it. On [DATE] at 11:45 a.m., during an interview, RQM stated R 15's Resident Baseline Evaluation dated [DATE], did not indicate R 15 had a PU on the right leg or a PU on the left heel when the facility admitted R 15. The RQM further stated R 15 must have developed the PUs on the right lower leg and left heel after admission. On [DATE] at 3:45 p.m., during an observation and a concurrent interview on [DATE] at 3:45 PM, R 15 had: a wound on the sacral area that was pink and dark red and measured approximately 2.75 cm long and 2.75 cm wide, that RNS stated was a stage 2 PU, a wound on the right foot that was approximately 1.5 cm long and 1 cm wide that RNS stated was deep enough to see past the lowest layer of skin, a wound on the back side of left lower leg that was broken, pink, and yellow, and measured 10 cm long and 3.5 cm wide that RNS said was a [NAME], a wound on the left heel that was approximately 2 cm long and 2 cm wide that was open, dark, and had a small greyish area toward the center RNS said was bone, and a wound on the right side of the right lower leg that was pink, and reddish that the RNS was a Stage 1 PU. On [DATE] at 4:00 p.m., during an interview, RQM stated according to facility's policy, the LNS are supposed to complete a BSRA for every resident upon their admission, then once a week for three more weeks, and then at least once quarterly (every three months) and whenever the resident has a change in condition. The RQM further stated if the LNS does not complete a BSRA for a resident according to facility's policy, the resident may not receive the services they need to prevent them from developing PUs or to prevent their existing PU(s) from worsening, both of which could be painful, become infected, and or result in hospitalization s and deaths. On [DATE] at 4:05 p.m., during an interview and a concurrent record review with RQM, R 1's BSRA dated [DATE] was reviewed. The BSRA indicted the LNS first completed a BSRA for R 1's on [DATE], 20 days after R 1 was admitted to the facility. The LNS did not complete another BSRA for R 1 until approximately 90 days later, on [DATE]. The RQM further stated the LNS did not complete a BSRA for R 1 until 20 days after admitting R 1, and then not for another 90 days on [DATE]. The RQM further stated the LNS should have completed the BSRA at the time of R 1's admission to the facility, once a week for three more weeks, and then at least once quarterly, according to facility's policy. On [DATE] at 4:10 p.m., during an interview and a concurrent record review of R 5's BSRA, dated [DATE], indicates the LNS completed only one BSRA for R 5 between the time of admission and [DATE] when the LNS completed the second BSRA. RQM stated the LNS should have completed a BSRA for R 5 once a week for four weeks after R 5's admission but did not do so. RQM further stated the LNS did not complete another BSRA for R 5 until [DATE], more than 90 days after admitting R 5 to the facility. On [DATE] at 11:15 a.m., during an observation and a concurrent interview with Registered Nurse Supervisor (RNS), R 5 had seven PUs, unstageable PUs on the right and left heels, on the right side of the right leg, on the right side of the right ankle, on the right big toe and on the left foot, and a Stage 4 PU on the left lower leg. RNS 1 confirmed the findings and stated R 5's three PUs on the right and left heels and on the right side of the right leg, that were documented on [DATE] had not healed and that R 5 had developed five more PUs since [DATE], four of which, had not healed. On [DATE] at 11:48 a.m., during an observation and a concurrent interview with R 17 and RNS, R 17 had a Stage 4 PU on the sacral area and an unstageable PU on the left heel. R 17 stated the Stage 4 PU was painful. RNS stated R 17 had a Stage 4 PU on the sacral area since his admission and wound on the left heel that was an unstageable PU that has not healed yet. On [DATE] at 3:30 p.m., during an interview with Licensed Vocational Nurse 5 (LVN 5), LVN 5 stated prior to about a week ago, the facility had not trained her regarding its policy for competing BSRA for residents. On [DATE] at 3:35 p.m., during an interview, LVN 6 stated prior to about a week ago, the facility had not trained her regarding its policy for competing BSRA for residents. On [DATE] at 3:40 p.m., during an interview, LVN 7 stated prior to about a week ago, the facility had not trained her regarding its policy for competing BSRA for residents. b). On [DATE] at 4:15 p.m., during an interview, the RQM stated the Weekly Pressure Injury/Ulcer Progress Reports enable LNS and doctors to understand how a resident's wound is changing, improving or worsening, and responding to treatments over time. The RQM further stated without the weekly assessments, LNS and healthcare providers may not be able to provide the best care for the resident's PUs, which could result in the PU worsening and becoming more painful and or infected, which could lead to hospitalization s, and death. The RQM confirmed the findings and stated the LNS staff did not complete Weekly Pressure Injury/Ulcer Progress Reports (WPIUPRs) for Rs 1, 5, 15 and 17 on a weekly basis. The RQM further stated the facility's policy required weekly PU and [NAME] assessments. On [DATE] at 4:20 p.m., during an interview and a concurrent record review of R 1's WPIUPRs, dated [DATE], [DATE], [DATE], and [DATE], was reviewed. The WPIUPRs indicated incomplete with multiple blank spaces. RQM stated R 1's WPIUPRs were incomplete and missing important information the LNS should have completed. Four WPIUPRs was completed for R 1 since admitted to the facility on [DATE], (approximately 20 weeks). On [DATE] at 4:25 p.m., during an interview and a concurrent record review of R 5's WPIUPRs, dated [DATE], [DATE], and [DATE] was reviewed. The WPIUPRs indicated multiple spaces meant for information such as, color, drainage, and whether a wound had necrosis or not were blank, even though R 5 had multiple PUs that did or could have had those characteristics. The RQM stated R 5's WPIUPRs dated [DATE], [DATE], and [DATE] were incomplete and missing information that the LNS should not have left blank. The RQM confirmed the findings and stated, The LNS should have written not applicable or checked 'no', if the wound did not have those characteristic, instead of leaving the space blank. RQM further stated the LNS should have completed a WPIUPR, for each of R 5's PUs, every week since R 5's admission on [DATE] (approximately 28 weeks ago) but did not start completing WPIUPRs for R 5 until [DATE]. On [DATE] at 4:27 p.m., during an interview and a concurrent record review of R 15 WPIUPRs was reviewed. R 15 had two WPIUPRs that were not dated and indicated the words, Sacral Stage 2, and Left Lower Leg. There was no documentation regarding R 15's PU and VUs. The RQM confirmed the findings and stated R 15's WPIUPRs were totally incomplete. The RQM further stated they are not acceptable. The RQM further stated the LNS should have completed a WPIUPR for each of R 15's wounds every week from the time of admission to the week R 15 died on [DATE] (approximately 11 weeks). On [DATE] at 4:30 p.m., during an interview and a concurrent record review of R 17's WPIUPRs, dated [DATE] and [DATE] was reviewed. The WPIUPRs indicated the LNS attempted to complete WPIUPRs for R 17 on [DATE] and [DATE], even though R 17 was admitted to the facility on [DATE] with a Stage 3 PU. R 17's WPIUPRs dated [DATE] and [DATE] were missing important information such as when R 17's Stage 4 PU on the sacral area was first noted, descriptions of its color, and what interventions were in place to treat it. The RQM stated there was no indication of a WPIUPR for R 17's unstageable PU on the left heel. The RQM stated the LNS should have started completing WPIUPRs for R 17's Stage 4 PU at the time the facility admitted R 17 on [DATE]. The RQM further stated the LNS should have completed a WPIUPRs every week for both of R 17's PUs and filled out the WPIUPRs completely. On [DATE] at 11:35 a.m., during an interview, the Medical Record Director (MRD) stated the facility does not have WPIUPR for R 5 other than the WPIUPRs dated [DATE], [DATE], and [DATE]. On [DATE] at 11:45 a.m., during an interview, MRD stated the facility does not have WPIUPR for R 15 other than the two undated WPIUPRs that were incomplete. On [DATE] at 3:30 p.m., during an interview, LVN 5 stated prior to about a week ago the facility had not trained her regarding its policy for competing WPIUPRs for residents with PUs and VUs. On [DATE] at 3:35 p.m., during an interview, LVN 6 stated prior to about a week ago the facility had not trained her regarding its policy for competing WPIUPRs for residents with PUs and VUs. On [DATE] at 3: 40 p.m., during an interview, LVN 7 stated that prior to about a week ago the facility had not trained her regarding its policy for competing WPIUPRs for residents with PUs and VUs. C). A review of R 1's Wound Assessment and Plans, dated [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], all indicated regular repositioning in bed. A review of R 5's Resident Care Plan Skin, dated [DATE] indicated, Resident at risk for skin break/ulcer formation .Administer medication and treatment as ordered. A review of R 5's Resident Care Plan Activities of Daily Living, dated [DATE], indicated, Resident needs assistance with: Bed mobility .Turn and reposition as ordered. A review of R 5's Wound Assessment and Plans, dated [DATE], [DATE], [DATE], [DATE], and [DATE], all indicated, regular repositioning in bed. A review of 15's Resident Care Plan Skin, dated [DATE] indicated, Resident at risk for skin break/ulcer formation .Administer medication and treatment as ordered .Care and reposition with care rounds. A review of R 15's Resident Care Plan Skin-Short Term Pressure Ulcer, dated [DATE], indicated, Site of pressure ulcer: sacral .Stage II .Administer medications and treatment as ordered .Turning and repositioning as scheduled. A review of R 15's Wound Assessment and Plan, dated [DATE], indicated, regular repositing in bed. A review of R 17's Resident Care Plan Skin-Short Term Pressure Ulcer, dated [DATE], indicated: Site of pressure ulcer: sacrum Stage IV .Administer medications and treatment as ordered .Turning and repositing as scheduled; site of pressure ulcer: Left buttock Stage II .Administer medications and treatment as ordered .Turning and repositing as scheduled, site of pressure ulcer: left heel .Administer medications and treatment as ordered .Turning and repositing as scheduled. A review of R 17's Wound Care Evaluation & Treatments, dated [DATE] and [DATE], both indicated, Turn patient every 2 hours and avoid direct pressure to ulcer site . On [DATE] at 3:10 p.m., during an interview, the Director of Staff Development (DSD) stated without regular turning and repositing, residents could develop PUs that could cause a lot of pain, become infected, and result in the resident's hospitalization s and deaths. The DSD stated the facility does not have a written lesson plan for training staff on a turning and repositing program, even though many resident care plans include turning and repositing as an intervention for the prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 3:00 p.m., during an interview with RQM stated the purpose of resident care plans was to document medical problems a resident had and what medical problems a resident was at risk for developing, and what the nursing staff did to treat those medical problems and prevent future medical problems. The RQM stated without accurate and detailed care plans, that were also followed by LNS, residents may not have received the care they needed and could have developed facility acquired Pus, all of which could have resulted in hospitalization s and deaths. The RQM further stated some of those medical problem could have been prevented if LNS developed, updated, and followed the care plans correctly. The RQM stated a commonly understood professional nursing standard of practice, regarding residents who cannot reposition themselves in bed or in chairs, is for nursing staff to develop care plans that include turning and repositioning the residents at least every two hours to prevent the residents from developing Pus. The RQM further stated without regular turning and repositing, a resident could develop PUs that could be painful and infected which could result in a resident's hospitalization and death. The RQM further stated a commonly understood professional nursing standard of practice was to include the completion of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The RQM further stated the facility did not have a written policy or procedure specifically detailing a program for turning and repositioning residents who could not turn and reposition themselves, did not have a lesson plan for training nursing staff about a turning and repositing program, and did not have a specific document with which nursing staff may document each time they turn and reposition residents. The RQM stated, We don't have anything like that. On [DATE] at 3:15 p.m., during an interview, RQM stated the facility has no documentation of each time nursing staff turned and repositioned R 1, even though two different doctors gave such orders and two of R 1's care plans included following physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RQM confirmed the findings and stated the LNS did not follow the care plans for R 1's skin and wound care. On [DATE] at 3:17 p.m., during an interview, RQM stated the facility has no documentation of each time nursing staff turned and repositioned R 5, even though MD 7 gave such an order and R 5's Resident Care Plan Skin included following physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 3:20 p.m., during an interview, the RQM stated the facility had no documentation of each time nursing staff turned and repositioned R 15, even though MD 7 gave such the order to do so, and two of R 15's care plan included interventions such as following physician orders, reposition with care rounds, and turning and repositioning as ordered. On [DATE] at 3:23 p.m., during an interview and a concurrent record review R 17's Resident Care Plan Skin, dated [DATE] was reviewed. The care plan indicated, Resident at risk for skin break/ulcer formation .Administer medications and treatment as ordered .Care and reposition with care rounds .Float heels as tolerated . The RQM stated floating heels meant the nursing staff will ensure a pillow or other soft object is between R 17's heels and the bed, so that blood can circulate to the skin of the heels and help heal R 17's PUs. On [DATE] at 3:25 p.m., during an interview and a concurrent record review, R 17's Wound Assessment and Plans dated [DATE], [DATE], and [DATE] was reviewed. The Wound Assessment and Plans, indicated, Off load wounds as tolerated. The RQM stated, off load wounds as tolerated, meant putting something soft underneath the wounds so that blood can circulate to the wound and help the wound to heal. On [DATE] at 3:27 p.m., during an interview, RQM stated the facility has no documentation of if or when nursing staff turned and repositioned R 17 or off-loaded R 17's PUs, even though MD 11 ordered the nursing staff to do so, and four of R 17's care plans included following physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 3:30 p.m., during an interview, the RNN stated without regular turning and repositing, a resident could develop painful PUs that could become infected and result in a resident's hospitalization and death. The RNN stated the facility had no form of documentation that records when and how often nursing staff turned and repositioned residents, even though Rs 1, 5, 15, and 17 all had care plans for skin care and wound prevention that included turning and repositing resident every two hours as a part of their care plans. The RNN stated the facility does not have a written policy and procedures describing a turning and repositioning program. On [DATE] at 3:15 p.m., during an interview, the DSD confirmed the findings and stated the facility had no documentation of a written policy and procedures or lesson plan specifically for training staff how often to turn and reposition residents and how to document each time the nursing staff did so. On [DATE] at 3:30 p.m., during an interview, LVN 5 stated she does not know of a specific, Q (every) 2 hour turning and repositioning program, or that the facility trained her regarding any such program. On [DATE] at 3:35 p.m., during an interview, LVN 6 stated she was registry LVN, and does not know of a specific Q2 hour turning and repositioning program, or if the facility trained her regarding any such program. On [DATE] at 3:40 p.m., during an interview, LVN 7 stated she does not know of a specific, Q2 hour turning and repositioning program, or that the facility trained her regarding any such program. On [DATE] at 3:45 p.m., during an interview, Certified Nursing Assistant 10 (CNA 10), stated she does not know of a specific, Q 2 hour turning and repositioning program, or that the facility trained her regarding any such program. On [DATE] at 3:50 p.m., during an interview, CNA 11 stated she does not know of a specific, Q2 hour turning and repositioning program, or that the facility trained her regarding any such program. On [DATE] at 3:55 p.m., during an interview, CNA 12 stated she does not know of a specific, Q (every) 2 hour turning and repositioning program, or that the facility trained her regarding any such program. d). A review of R 1's Wound Care Evaluation and Treatment, dated [DATE], indicated, Plan: .Turn patient every 2 hours and avoid direct pressure to the ulcer site .Low air loss mattress (LALM, a type of inflatable mattress that cushions the skin and helps to prevent PUs), Orders: Apply [MEDICATION(S)] to ulcer and cover with [MEDICATION(S)] daily. A review of R 1's Wound Assessment and Plans, dated [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], all indicated, Regular repositioning in bed . The Wound Assessment and Plan dated [DATE], also indicated, Place [MEDICATION(S)] moistened 4x4 gauaze loosely into wound opening 2) apply dermafungal barrier cream to periwound skin. On [DATE] at 3:20 p.m., during an interview, the DSD stated a commonly understood professional nursing standard of practice was for LNS to ensure that all physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . DSD further stated if the LNS does not correctly enter physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DSD further stated this could result in the resident's medical problem getting worse or the resident developing new medical problems, all of which could result in the resident's hospitalization and death. The DSD further stated the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observation, interview, and record review the facility failed to ensure six of 17 sampled residents (Residents 1, 5, 14, 15, 16, and 17) were free of neglect when the facility failed to ensure: a) Licensed Nursing Staff (LNS) assessed Residents 1, 5, 15 and 17's pressure ulcers (PU, injury to skin and underlying tissue due to prolonged pressure over a bony structure) on a weekly basis, according to the facility's policy and procedures and professional standards of practice, b). LNS fully implemented Residents 1, 5, 15, and 17's care plans for skin and pressure wound treatments. c). LNS entered Medical Doctor (MD) 7's orders for PU and turning and repositioning into the medical records of Residents 1, 5, 15 and 17, or LNS documented when or if MD 7's orders were performed, d). Performed and documented the turning and repositioning of Residents 1, 5, and 15, and the off-loading (to minimizing or removing weight placed on the foot to help prevent and heal ulcers) of Resident 17's PUs, as ordered by their physicians, e). Staff administered the anti-anxiety medication [MEDICATION(S)] (A medication used to treat ADHD [Attention-deficit/[CONDITION(S)] disorder, A chronic condition including attention difficulty, [CONDITION(S)], and impulsiveness] and anxiety) to Resident 14 for 11 days and pain medication to Resident 16 for approximately 12 hours, as ordered by his physician, and f). Residents 1, 5, 15, and 17 received all the wound treatments ordered by their physicians throughout the months of 4/2021 and 5/2021. These deficient practices resulted in or could have contributed to the following: 1) Resident (R) 1 had a facility acquired Stage 4 PU (Stage 4 pressure ulcers extend even deeper, exposing underlying muscle, tendon, cartilage, or bone) 2) R 5 had three more facility acquired PUs and in that time R 5 developed additional PUs: a Stage 4 PU on the left lower leg, and unstageable (Refers to an ulcer that has full thickness tissue loss but is either covered by extensive necrotic tissue or by an eschar [is dead tissue that falls off (sheds) from healthy skin]). PUs on the right ankle, on the right big toe, and on the left foot, for a total of seven Pus. 3) R 14 stated he was uncomfortable and fearful of going to the general acute care hospital (GACH) after he did not receive his medication, [MEDICATION(S)]. 4) R 15 had a Stage 2 PU (At stage 2, the skin breaks open, wears away, or forms an ulcer, which is usually tender and painful) and developed two facility acquired PUs on the right leg and the left heel. 5) R 16 stated he was in pain overnight when staff did not give him his pain medication when he requested for his medication. 6) R 17 had a Stage 4 PU and a facility acquired unstageable PU. On 7/8/2021 at 4:56 PM, the State Survey Agency (the Department) called an Immediate Jeopardy situation (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM) and Regional Quality Management Consultant (RQM) with regards to failure to ensure Residents 1, 5, 14, 15, 16, and 17 were free of neglect due to inability to provide the care and treatment needed to prevent the development facility acquired pressure ulcers and to heal existing pressure ulcers, administered pain medication and anti-anxiety medication as ordered by the physician. On 7/9/2021 at 1:10 PM, the RQM provided the Department with a Plan of Action (POA) which included the following summarized actions: 1. On 7/9/21, the RQM completed Braden Scale Risk Assessments (BSRA, a tool for measuring a resident's risk for developing pressure ulcers) for all residents and Weekly Skin Assessments for all residents that have pressure ulcers. 2. On 7/8/21, RQM completed a review of all Wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. On 7/8/21, RQM and Resource Nurse (RNN) initiated in-services to all nursing staff regarding the facility's comprehensive skin assessment and wound care program which includes the following: a). How often to conduct and how to document a Braden Risk Assessment for all residents b). How to develop and document an individualized skin care plan for all residents c). How to implement and document interventions according to the resident's care plan d). When and how to document a Weekly Skin Evaluation Form for all residents e). When and how and how to document resident skin assessments, perform wound treatments, and when, how, and who will audit skin and wound related documentation f). When, how often, and how to complete Weekly Pressure Injury and Non-Pressure Injury /Ulcer Progress Reports and where to put the documents On 7/9/2021 at 3:28 PM, after confirming the facility's implementation of the immediate corrective actions, the Department accepted the POA and removed the Immediate Jeopardy while onsite, in the presence of ADM and Director of Nursing (DON). Cross reference F686 Findings: 1.) A review of R 1's Face Sheet (Admission Record) indicated, R 1 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R 1's history and physical examination [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/25/21, indicated, R 1's needed extensive assistance from staff with moving in his bed. On 5/23/21, at 4:00 p.m., during an interview with the RQM and a concurrent record review of R 1's Treatment Administration Record (TAR) for the month of 4/2021, the TAR indicated sacral (is at the bottom of the spine and lies between the fifth segment of the lumbar spine [L5] and the coccyx [tailbone]) pressure injury-stage 3 (SPIS3, the sore gets worse and extends into the tissue beneath the skin, forming a small crater [hole]) Cleanse with NS (normal saline), pat dry. Apply [MEDICATION(S)] (help in the management of acute, chronic, and stalled wounds and [CONDITION(S)] to assist in safe and effective removal of necrotic [dead] tissue) and cover with dry dressing daily for 30 days, then reassess. The TAR further indicated there were 11 blank spaces where Licensed Nursing Staff (LNS) should have signed their initials if they had carried out the physician orders. The TAR further indicated areas for the LNS to indicate they had ensured R 1 was wearing Prevalon boots (comfortably offload the heel and reduce pressure) and the Low air loss mattress (LALM, a type of inflatable mattress that cushions the skin and helps to prevent PUs) was working correctly. However, there were approximately 107 spaces where LNS should have signed their initials if they carried out the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The RQM stated the blank spaces indicated no LNS had carried out MD 6's orders regarding R 1's SPIS3, Prevalon boots, or LALM. RQM further stated the commonly known standard of practice was for the LNS to sign their name and initials on the TAR when they had carried out an order. The RQM further stated, a commonly known nursing professional standard was, If it wasn't charted, it wasn't done. The RQM confirmed the findings and stated if LNS does not ensure R 1 was wearing the Prevalon boots and the LALM was working properly as ordered by the physician, R 1 could develop new PUs and R 1's SPIS3 could get worse and could result in R 1 developing infections, being hospitalized , and dying. On 5/23/2021 at 4:05 p.m., during an interview with the RQM, and a concurrent record review of R 1's Physician and Telephone Orders (PTO), dated 5/12/2021, indicated, sacral-coccyx-region stage 4 pressure injury (SCRS4PI, a Stage 4 PU on the area of skin on the upper-middle part of the buttocks): irrigate with NS, pat dry, apply medical honey gel, cover with a foam dressing QD (daily) .for 30 days, then reevaluate. The PTO further indicated, Monitor pain, before, during, and after wound care. The PTO further indicated, R 1 had discolorations on his upper right and left arms and the facility staff was to monitor the skin of R 1's upper right and left arms for, skin breakdown every shift for 30 days then re-eval. RQM stated R 1's SPIS3 had worsened and become the SCRS4PI MD 6 wrote a treatment order for on 5/12/21. On 5/23/2021, at 4:07 p.m., during an interview and a concurrent record review with RQM, R 1's TAR for the month of 5/2021 was reviewed. The TAR indicated, there were 40 blank spaces next to MD 6's order to monitor R 1's pain before, during, and after wound care for R1's SCRS4PI and ten blank spaces next to the order to treat R 1's SCRS4PI. RQM stated LNS should have signed their initials in the ten spaces next to the treatment order and recorded R 1's pain assessment scores in the 40 blank spaces if they had carried out MD 6's treatment order and the order to monitor R 1's pain before, during, and after, caring for R 1's SCRS4PI between 5/12/21 and 5/27/21, but did not do so. RQM further stated the TAR indicated no LNS carried out MD 6's orders regarding the monitoring of R 1's pain before, during, and after caring for his SCRS4PI for 14 days. The RQM further stated the multiple missed treatments and pain monitoring indicated by the TAR may count as neglect, if the LNS did not actually do the treatments. On 5/28/2021 at 3:05 p.m., during an interview and a concurrent record review with the Medical Record Director (MRD), R 1's PTO dated 5/27/21, was reviewed. The PTO indicated, on 5/27/21, MD 6 ordered the facility to discontinue all previous orders regarding the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The MRD stated the LNS should have carried out MD 6's orders to treat R 1's SCRS4PI and monitor his pain from 5/12/21, every day, until 5/27/21, a total of 14 days. On 5/28/2021, at 4:05 p.m., during an interview and a concurrent record review of R 1's BSRA, dated 2/11/2021 was reviewed. The BSRA indicated, the LNS first completed a BSRA for R 1's on 2/11/2021, 20 days after R 1 was admitted to the facility. There was no other BSRA completed R 1 until approximately 90 days later, on 5/13/21. The RQM confirmed the findings and stated the LNS should have completed the BSRA at the time of R 1's admission to the facility, once a week for three more weeks, and then at least once quarterly. 2.) A review of R 5 Face Sheet, dated 5/19/21, indicated, R 5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R 5's MDS, dated [DATE], indicated, R 5's ability to remember words and answer questions was severely impaired (limits an individual ' s physical or mental ability to perform basic work activities on a sustained basis) and totally dependent on staff to move in bed and to transfer in and out of bed. On 5/21/2021 at 3:10 p.m., during an interview with the RQM and a concurrent record review, 5's TAR for the month of 5/2021, which had numerous blank spaces next to the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A date-stamped copy of the TAR was reviewed with the RQM. The Surveyor date stamped a copy of the TAR with a stamp reading, Received May 21, 2021. RQM 1 stated R 1's TAR for the month of 5/2021 indicated: a). 29 blank areas next to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] b). 29 blank spaces next to the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] c). 29 blank spaces next to the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] d). 15 blank spaces next to the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] e). 15 blank spaces next to the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] f). 86 blank spaces next to the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The RQM stated the spaces were where LNS should have signed their initials if they had carried out the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/28/2021 at 4:10 p.m., during an interview and a concurrent record review with RQM, R 5's BSRA, dated 1/16/21 was reviewed. The BSRA indicated the LNS completed only one BSRA for R 5 between the time of admission and 4/28/21 when the LNS completed the second BSRA. The RQM confirmed the findings and stated LNS should have completed a BSRA for R 5 once a week for four weeks after R 5's admission but did not do so. RQM stated the LNS did not complete another BSRA for R 5 until 4/28/21, more than 90 days after admitting R 5 to the facility. 3.) A review of R 14's Face Sheet dated 5/19/21, indicated R 14 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R 14's H & P, dated 5/11/21, indicated R 14 had the capacity to understand and make decisions. A review of R 14's MDS, dated [DATE], indicated R 14's was cognitively intact and needed extensive assistance from staff to move in bed and to transfer in and out of bed. A review of R 14's Physician Orders, for the month of 5/2021, indicated, [MEDICATION(S)] 10 milligram (mg- unit of measurement) tablet. Take 1 tab PO (by mouth) daily for ADHD. A review of R 14's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/23/2021 at 4:52 p.m., during an interview, R 14 stated he repeatedly asked for the medication [MEDICATION(S)], starting on 5/8/21. R 14 stated, several times .I went out to the medication cart and asked for it. I went to the nursing desk to ask for it .the answer was either, the doctor hadn't ordered that, or the pharmacy hadn't sent it yet and I knew there was something more to it than that because the doctor (MD 5) told me he ordered it for me because my anxiety is so bad. R 14 further stated, On the 4th (5/4/21) my heart started pounding hard and I started having chest pain and they sent me to a hospital, which was scary because I was scared of getting Covid-19 [Coronavirus, is a disease caused by [CONDITION(S)]-CoV-2 that can trigger a respiratory tract infection which can affect the upper respiratory tract (sinuses, nose, and throat) or lower respiratory tract (windpipe and lungs]. When I came back from the hospital, they (the LNS) wouldn't give me the medication for my anxiety. R 14 further started I asked for it after I got back from the hospital but nobody followed up about it (the medication [MEDICATION(S)]) until I guess the 19th (5/19/21), because that was when I finally got it (the medication [MEDICATION(S)]). 4.) A review of R 15's Face Sheet, dated 5/19/21, indicated R 15 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R 15's H & P, dated 5/2/21, indicated R 15 had the capacity to understand and make decisions. A review of R 15's MDS, dated [DATE], indicated R 15's was cognitively intact and totally dependent on staff to move in bed and to transfer in and out of bed. A review of R 15's PTO dated 4/7/21, indicated, - Sacral Stage 2 Pressure Injury - Cleanse with NS, pat dry, apply [MEDICATION(S)] and cover daily for 30 days then reassess, - Right (R) lateral (refers to the outer side of the body part) side of the foot - open wound - cleanse wound with NS, pat dry, apply [MEDICATION(S)] solution (for minor cuts, scrapes & [CONDITION(S)] to help prevent infections before they start) and cover daily for 30 days then reassess, - Left (L) lower leg posterior side - open wound cleanse with NS, pat dry, apply [MEDICATION(S)] and cover daily and wrap with kerliex (bandage to cushion and protect wound areas) secure with tape QD (daily) for 30 days then reassess, and - R lower leg posterior site - open wound cleanse with NS, pat dry, and apply [MEDICATION(S)] and cover with Dry Dressing (DD) and wrap with kerliex secure with tape daily foe 30 days then reassess. A review of R 15's PTO written by Nurse Practitioner (NP), dated 5/11/21, indicated: - Pressure ulcer coccyx - Cleanse with NS, pat dry, apply [MEDICATION(S)] foam dressing, - L (Left) great toe PU - cleanse with NS pat dry, Paint with [MEDICATION(S)], dry dressing - daily and PRN (as needed), - BLE (Bilateral lower extremities) - cleanse with NS, pat dry, paint with [MEDICATION(S)] to black eschar (Dead tissue that eventually sloughs off healthy skin after an injury), - Silvadine (Is a white cream that reduces bacteria and helps remove dead tissue from your wound) dressing to open areas posterior LE (Lower extremities). Cover dry dressing with kerliex every daily and PRN. On 5/17/2021 at 1:07 p.m., during an interview and a concurrent record review with the MDR, R 15's Wound Assessment and Plan dated 5/11/2021 was reviewed. The Wound Assessment and Plan indicated MD 7 evaluated R 15 and wrote new orders for her wound treatments, however, MRD stated the facility had no documentation of LNS entering MD 7's orders into R 15's electronic medical record computer or transcribing them onto R 15's Treatment Administration Record (TAR) for the month of 5/2021. The MRD further stated the LNS should have entered MD 7's orders and transcribed them onto R 15's TAR. On 7/12/2021 at 1:12 p.m., during an interview with the Director of Staff Development (DSD), stated the blank spaces next to the wound care orders on the TAR of R 15 for the month of 5/2021, indicated LNS only performed R 15's wound treatments on three of the 31 days they should have performed the treatments. The DSD further stated if the LNS did not perform the treatments, it could qualify as neglect. The DSD further stated, that is total unacceptable. On 7/15/2021 at 1:00 p.m., during an interview and a concurrent record review with the MRD, R 15's Wound Assessment and Plan dated 5/11/2021, was reviewed. R 15's Wound Assessment indicated MD 7 evaluated R 15 and wrote new orders for her wound treatments. MRD further stated MD 7's orders discontinued MD 13's previous orders as of 5/11/2021. The MRD further stated during the approximately 11 days between 5/1/21 (the date R 15 returned to the facility), and 5/11/2021 (the day MD 7 wrote new wound treatment orders), the LNS should have been carrying out MD 13's from 4/7/2021, for treating R 15's wounds. The MRD stated the facility had no documentation of the LNS doing so. On 7/15/2021 at 1:03 p.m., during an interview and a concurrent record review with the MRD, R 15's TAR for the month of 5/2021 was reviewed. There was no indication the LNS had performed any treatments for R 15's wounds between 5/1/2021 and 5/12/2021, approximately 11 days. The MRD confirmed the findings and stated R 15's TAR for the month of 5/2021, did not indicate any LNS performed any treatments for R 15's wounds between 5/1/2021 and 5/12/2021 approximately 11 days. On 7/15/2021 at 1:05 p.m., during an interview and a concurrent record review with the MRD, R 15's PTO dated 5/2/2021 was reviewed. R 15's PTO indicated, for the facility to arrange a wound consult, however, no wound consult was done until MD 7 evaluated R 15 on 5/22/2021, approximately 20 days after MD 5 ordered the wound consult. The MRD stated MD 5 ordered the facility to arrange a, wound consult, however, no wound consult was done until MD 7 evaluated R 15 on 5/22/21, approximately 20 days after MD 5 ordered the wound consult. The MRD further stated R 15 should have received the wound consult sooner than 20 days after MD 5 wrote the order. On 7/15/2021 at 1:07 p.m., during an interview and a concurrent record review with MRD, R 15's TAR for the month of 5/2021 was reviewed. The TAR indicated next to each order were 16 blank spaces where the LNS should have signed their initials if they had performed the orders. R 15's TAR for the month of 5/2021 did not indicate any LNS performed any of MD 7's or NP 2's wound treatment orders, for approximately 14 days between 5/11/2021 and 5/31/2021, for a total of 64 missed treatments. The MRD confirmed the findings and stated R 15's TAR for the month of 5/2021, did not indicate any LNS performed any of MD 7's or NP 2's wound treatment orders, for approximately 14 days between 5/11/2021 and 5/31/2021, for a total of approximately 64 missed treatments. The MRD further stated the LNS should have carried out either the doctors' orders or the NP's orders through 5/2021. The MRD further stated doing nothing might possibly be considered as neglect. The MRD further stated if the LNS were confused about treatment orders they should know to ask someone in leadership. 5.) A review of R 16's Face Sheet, dated 5/19/21, indicated R 16 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R 16's H & P dated 5/21/21, indicated, R 16 had the capacity to understand and make decisions. A review of R 16's MDS, dated [DATE], indicated R 16 was cognitively intact, needed extensive assistance from staff to move in bed, transfer in and out of bed, and in and out of his wheelchair. On 5/21/2021 at 1:15 p.m., during an interview, R 16 stated, he needed a lot of help to get up and into my wheelchair because of my ankle. R 16 further stated on the night the facility admitted him, his left ankle was hurting terribly, and that he repeatedly asked staff for pain medication. R 16 further stated, When they brought me and put in bed, there was a lot of moving and my ankle hurt with all the moving around, I asked for a pain pill, however, they were all so busy I don't think anyone heard me. R 16 further started he got the pain pill the next morning. R 16 further stated, I was hurting in the night, I could barely sleep, I started wondering if they could take care of me. R 16 further They were busy running around, I used my call light, but they didn't come for a while. R 16 further stated, They came after a while, I don't remember how long, but I still didn't get my pain pill, so it wasn't any help when they came, I gave up till the morning because I thought the doctor or somebody would come. On 5/21/2021 at 1:22 p.m., during an interview, the RQM stated R 16's medical record did not have any documentation of R 16 vital signs, pain levels, or assessments documented by Licensed Nursing Staff (LNS), at the time the LNS admitted R 16 to the facility. The RQM acknowledged and stated R 16 could have been in pain because of he recently had surgery on his ankle. 6.) A review of R 17's Face Sheet, dated 5/19/21, indicated, R 17 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of R 17's H & P, dated 3/5/21, indicated R 17 could understand and make decisions. A review of R 17s MDS, dated [DATE], indicated R 17 was totally dependent on staff to move in bed, needed at least two staff to transfer in and out of bed. The MDS further indicated R 17 had one Stage 2 PUs and one unstageable PU on the left heel. A review of R 17's Wound Care Evaluation and Treatment, dated 3/17/2021, indicated, Pressure ulcer of sacral region Stage 4 .Orders: Apply wet to dry with half strength Dakin's solution (To cleanse wounds in order to prevent infection) to ulcer cover with four by four (4 X4 )gauze (Help protect minor cuts and scrapes) gauze ABD (abdominal) and kerlix perform daily. On 7/1/2021 at 11:48 a.m., during an observation of R17's PU and a concurrent interview with the Registered Nurse Supervisor (RNS) and R 17, R 17 had a Stage 4 PU on the sacral area and an unstageable PU on the left heel. R 17 stated the Stage 4 PU was painful. The RNS stated, R 17 had a Stage 4 PU on the sacral area since his admission and wound on the left heel that was an unstageable PU that hasn't healed yet. On 7/15/2021 at 1:15 p.m., during an interview and a concurrent record review with MRD, R 17's TAR for the month of 4/2021 was reviewed. The TAR indicated there are eight blank spaces where LNS should have signed their initials if they had completed the treatment. The MRD confirmed the findings and stated next to the order are eight blank spaces that indicate no LNS performed R 17's wound treatment on those eight days. The MRD further stated this could be considered neglect. On 7/15/2021 at 1:17 p.m., during an interview and a concurrent record review with the MRD, R 17's Wound Assessment and Plan undated was reviewed. R 17's Wound Assessment and Plan indicated MD 7 wrote new orders for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . MRD further stated no LNS entered MD 7's orders into the electronic medical record or transcribed the order onto R 17's TAR for the month of 5/2021. The MRD further stated, The LNS definitely should have transcribed the orders and entered them into the computer but did not. On 7/15/2021 at 1:20 p.m., during an interview and a concurrent record review for R 17's TAR for the month of 5/2021 was reviewed. The TAR indicated the order given by MD 11 for R 17's sacral region stage 4 PU on 3/17/2021, and 13 spaces where LNS signed their initials indicating they had performed the treatment ordered by MD 11. However, the order given by MD 11 should have been discontinued on 4/22/2021, when MD 7 wrote new wound treatment orders. The MRD stated the facility had no documentation of orders for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Furthermore, R 17's 5/2021 TAR indicated 18 spaces with no LNS initials which indicates no LNS performed R 17's sacral region stage 4 PU treatments on those days. MRD further stated R 17's 5/2021 TAR indicated 18 spaces with no LNS initials which indicates no LNS performed treatments to R 17's sacral region stage 4 PU on those 18 days. The MRD further stated this could be considered as neglect. On 7/15/2021, at 3:30 p.m., during an interview with Licensed Vocational Nurse 5 (LVN 5), LVN 5 stated, prior to about a week ago, the facility had not trained her regarding its policy for completing BSRA for residents. On 7/15/2021 at 3:35 p.m., during an interview, LVN 6 stated prior to about a week ago, the facility had not trained her regarding its policy for completing a BSRA for residents. On 7/15/2021 at 3:40 p.m., during an interview, LVN 7 stated prior to about a week ago, the facility had not trained her regarding its policy for completing BSRA for residents. A review of the facility's policy and procedures, titled, Abuse - Prevention, Screening, & Training Program, dated 7/2018, indicated, Purpose To address the health, safety, welfare, dignity, and respect of residents by preventing abuse, neglect .and mistreatment .The Facility does not condone any form of resident abuse, neglect .and develops Facility policies, procedures, training programs, and screening and prevention systems to promote an environment free from abuse, neglect .and mistreatment .Definitions: .Neglect and deprivation of goods and services by staff are defined as failure to provide goods and services necessary to attain or maintain physical, mental, and psychosocial well-being and avoid physical harm, pain, mental anguish, or emotional distress . A review of the facility's policy and procedures, titled Resident Abuse - Recognizing Signs and Symptoms, dated 1/1/12, indicated, Purpose To ensure that Facility Staff recognize signs and symptoms of resident abuse, neglect and mistreatment and participate in preventing such abuse .The Facility provides training to Facility Staff to enable the identification of resident abuse, neglect or mistreatment.

Based on interview and record review, the facility failed to ensure one of 17 sampled residents (Resident 16) was provided pain management during the first 12 hours from admission after a recent surgery (date and name of surgery not indicated), to repair a broken ankle. On 5/17/2021, after Resident 16 was admitted at 9 p.m., having pain on his left ankle, he did not receive pain management and pain medication until 12 hours later This deficient practice resulted in Resident 16 having uncontrolled pain to the left ankle from 5/17/2021 to 5/18/2021. Findings: A review of Resident 16's Face Sheet indicated the facility admitted the resident on 5/17/2021 from a General Acute Care Hospital (GACH) with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 16's transferring (GACH's) Emergency Documentation dated 5/17/2021, indicated the resident had a cast on his left ankle because his bones near his left ankle had previously broken (fractured) and were still healing. A review of Resident 16's Physician's Telephone Order, dated 5/17/2021 and timed at 9:00 p.m., indicated, the facility admitted the resident at 9:00 p.m. A review of Resident 16's Physician's Telephone order, dated 5/17/2021, timed at 10:27 p.m., indicated to give Oxycodone-Acetaminophen (is a combination medicine used to relieve moderate to severe pain) 5-325 milligram (mg, unit of measurement) one to two tablets, by mouth, every six hours as needed for moderate to severe pain. Not to exceed eight tablets a day, for pain management. A review of Resident 16's Physician's Telephone Order, dated 5/18/2021, timed at 12:00 a.m., indicated to administer Oxycodone [MEDICATION(S)] (HCL) (is used to help relieve moderate to severe pain. Oxycodone belongs to a class of drugs known as opioid analgesics. It works in the brain to change how the body feels and responds to pain. It is used for the relief of moderate to severe pain) 30 mg tablet, by mouth, three times a day, for pain management. A review of Resident 16's History and Physical exam (H&P) completed by the attending physician on 5/21/2021, indicated the resident had the capacity to understand and make decisions. Resident 16 underwent surgery to repair his left foot fracture and had a medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident 16's Minimum Data Set (MDS - standardized assessment and care-screening tool) dated 5/24/2021, indicated the resident had no memory problem, was able to communicate needs and required extensive assistance from staff to move in bed, transfer in and out of bed, and in and out of his wheelchair. On 5/21/2021 at 1:15 p.m., during an interview, Resident 16 stated he needed a lot of help to get up and into the wheelchair because of his left ankle. Resident 16 stated that on the night of his admission to the facility, his left ankle was hurting terribly and he repeatedly asked Licensed Nurse Staff for pain medication. Resident 16 added, When they brought me and put me in bed, there was a lot of moving and my ankle hurt with all the moving around, I asked for a pain pill, however, they were all so busy I don't think anyone heard me. I was hurting in the night, I could barely sleep, I started wondering if they could take care of me. They were busy running around, I used my call light, but they didn't come for a while. I don't remember how long, but I still didn't get my pain pill, so it wasn't any help when they came, I gave up until the morning because I thought the doctor, or somebody would come. Resident 16 further started he got the pain pill the next morning. On 5/21/2021 at 1:22 p.m., during an interview, the Regional Quality Manager (RQM) stated Resident 16's medical record did not have any documentation of pain level assessments by the licensed nurses at the time of admission, on 5/17/2021. The RQM acknowledged and stated Resident 16 could have been in pain because of his recent ankle surgery. On 5/21/2021 at 2:43 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated the facility admitted the resident on the night of 5/17/2021, at around 8:00 or 8:30 p.m. and on that day, the facility had registry (staffing agency contracted to provide temporary nursing staff) licensed nurses who were not trained on admission of residents. LVN 1 stated the facility's electronic medical record system was not working and she (LVN 1) could not document Resident 16's pain levels or anything else, so I wrote it all on a piece of paper . I don't know where the paper went. I don't remember if he was in pain . He could have been in pain because he had the surgery on his ankle, but I don't remember if he was because we were all so busy . On 5/21/2021 at 6:15 p.m., during an interview, LVN 2 stated that on the night of 5/17/2021, when the facility admitted Resident 16, I think we only had three nursing assistants that night . It was very busy, and I was running around a lot . that night we definitely needed more help . On 7/9/2021 at 1:28 p.m., during an interview with Director of Staff Development (DSD) and concurrent review of Resident 16's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The first dose of Oxycodone HCL 30 mg was administered to Resident 16 on 5/18/2021 at 9:00 a.m., which was approximately 12 hours from the ordered time (12 a.m.). The DSD stated the licensed nurses should have given pain medication timely (as ordered). The DSD further stated the Emergency Medication Kit (E-kit) contained eight tablets of Oxycodone-Acetaminophen 5-325. On 7/20/2021, at 1:39 p.m., during an interview, the facility's Medical Director stated he was not aware Resident 16 was not given pain medication for 12 hours from 5/17/2021, the time the medication was ordered. A review of the facility's policy titled, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .g., Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . X. Orders pertaining to other health disciplines will be transcribed onto that discipline's appropriate communication system. A review of the facility's policy and procedures titled, Medication - Administration, dated 1/1/2012, the RQM was unable to provide an updated policy, indicated, Purpose To ensure the accurate administration of medication for residents in the facility . ii. Medications and treatments will be administered as prescribed . A review of the facility's policy and procedures titled, Pain Management with revised date of November 2012, the RQM was unable to provide an updated policy, indicated, Facility Staff will help the resident attain or maintain their highest level of well-being while working to prevent or manage the resident's pain to the extent possible. The Licensed Nurse will administer pain medication as ordered and document medication administered on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on interview and record review the facility failed to ensure two of 17 sampled residents (Residents 14 and 16) were free of significant medication errors by: 1. Not administering Resident 14 the medication [MEDICATION(S)] (medication that contains a combination of [MEDICATION(S)] and [MEDICATION(S)] which are central nervous system stimulants that affect chemicals in the brain and nerves that contribute to [CONDITION(S)] and impulse control. [MEDICATION(S)] helps to improve concentration and focus) 10 milligrams (mg- unit of measurement) tablet, 11 days (From 5/8/2021 through 5/19/2021) after the physician ordered the medication. 2. Not administering Resident 16 Oxycodone with acetaminophen (is a combination medicine used to relieve moderate to severe pain) 5-325 mg as soon as possible and not 14.5 hours later. These deficient practices resulted in Resident 14 to have signs of withdrawal from [MEDICATION(S)] manifested by increased anxiety. For Resident 16 resulted in uncontrolled pain to the left ankle. Findings: 1. A review of Resident 14's Admission Record (Face Sheet) indicated the facility admitted the resident 4/28/2021 with a re-admitted d 5/8/2021. Resident 14's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 14's Licensed Personnel Progress Notes, dated 5/4/2021, indicated the resident complained of chest pain and the facility transferred the resident to a General Acute Care Hospital (GACH). A review of Resident 14's Licensed Personnel Progress Notes, dated 5/8/2021 Indicated the resident returned to the facility on [DATE]. A review of Resident 14's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 14's History and Physical (H&P) exam completed by the attending physician on 5/11/2021, indicated the resident had the capacity to understand and make decisions. A review of Resident 14's Minimum Data Set (MDS, standardized assessment and care-planning tool) dated 5/15/2021, indicated the resident had no memory problems, was able to communicate needs, and needed extensive assistance from staff to move in bed and to transfer in and out of bed. A review of Resident 14's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/23/2021 at 4:52 p.m., during an interview, Resident 14 stated he repeatedly asked for the medication [MEDICATION(S)], starting on 5/8/2021. Resident 14 stated, several times .I went out to the medication cart and asked for it. I went to the nursing desk to ask for it .the answer was either, the doctor hadn't ordered that, or the pharmacy hadn't sent it yet and I knew there was something more to it than that because the doctor told me he ordered it for me because my anxiety is so bad. Resident 14 further stated that after he finally received the medication [MEDICATION(S)], Hell yes it worked. A few hours after I finally got it ([MEDICATION(S)]) I felt [NAME] better, like a different man. According to the medication manufacturer's warnings and side effects, stopping [MEDICATION(S)] suddenly can cause unpleasant withdrawal symptoms, including intense craving for [MEDICATION(S)], trouble sleeping, depression, sluggishness, anxiety and irritability, and panic attacks. On 5/23/2021 at 5:05 p.m., during an interview, the Regional Quality Management Consultant (RQM) stated she did not know why it took so long for the facility to get Resident 14's [MEDICATION(S)] from the pharmacy. RQM acknowledged not giving Resident 14 his ordered [MEDICATION(S)] for 11 days was a significant medication error. On 7/20/2021, at 1:39 p.m., during an interview, the facility's Medical Director stated he was not aware Resident 14 was not given [MEDICATION(S)] for 11 days. 2. A review of Resident 16's Face Sheet indicated the facility admitted the resident on 5/17/2021 from a GACH with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 16's transferring GACH's Emergency Documentation dated 5/17/2021, indicated the resident had a cast on his left ankle because his bones near his left ankle had previously broken (fractured) and were still healing. A review of Resident 16's Physician's Telephone Order, dated 5/17/2021 and timed at 9:00 p.m., indicated, the facility admitted the resident at 9:00 p.m. A review of Resident 16's Physician's Telephone order, dated 5/17/2021, timed at 10:27 p.m., indicated to give Oxycodone-Acetaminophen 5-325 mg one to two tablets, by mouth, every six hours as needed for moderate to severe pain. Not to exceed eight tablets a day, for pain management. A review of Resident 16's Physician's Telephone Order, dated 5/18/2021, timed at 12:00 a.m., indicated to administer Oxycodone [MEDICATION(S)] (is used to help relieve moderate to severe pain. Oxycodone belongs to a class of drugs known as opioid analgesics. It works in the brain to change how the body feels and responds to pain. It is used for the relief of moderate to severe pain) 30 mg tablet, by mouth, three times a day, for pain management. A review of Resident 16's H&P completed by the attending physician on 5/21/2021, indicated the resident had the capacity to understand and make decisions. Resident 16 underwent surgery to repair the is left foot fracture and had a medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident 16's MDS dated [DATE], indicated the resident had no memory problem, was able to communicate needs and required extensive assistance from staff to move in bed, transfer in and out of bed, and in and out of his wheelchair. On 5/21/2021 at 1:15 p.m., during an interview, Resident 16 stated he needed a lot of help to get up and into the wheelchair because of his left ankle. Resident 16 stated that on the night of his admission to the facility, his left ankle was hurting terribly and he repeatedly asked staff for pain medication. Resident 16 added, When they brought me and put me in bed, there was a lot of moving and my ankle hurt with all the moving around, I asked for a pain pill, however, they were all so busy I don't think anyone heard me. I was hurting in the night, I could barely sleep, I started wondering if they could take care of me. They were busy running around, I used my call light, but they didn't come for a while. I don't remember how long, but I still didn't get my pain pill, so it wasn't any help when they came, I gave up until the morning because I thought the doctor, or somebody would come. Resident 16 further started he got the pain pill the next morning. On 5/21/2021 at 1:22 p.m., during an interview, RQM stated Resident 16's medical record did not have any documentation of pain level assessments by the licensed nurses at the time of admission. RQM acknowledged and stated Resident 16 could have been in pain because of his recent ankle surgery. On 5/21/2021 at 2:43 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated the facility admitted the resident on the night of 5/17/2021, at around 8:00 or 8:30 p.m. and on that day, the facility had registry (staffing agency contracted to provide temporary nursing staff) licensed nurses who were not trained on admission of residents. LVN 1 stated the facility's electronic medical record system was not working and she (LVN 1) could not document Resident 16's pain levels or anything else, so I wrote it all on a piece of paper . I don't know where the paper went. I don't remember if he was in pain . He could have been in pain because he had the surgery on his ankle, but I don't remember if he was because we were all so busy . On 5/21/2021 at 6:15 p.m., during an interview, LVN 2 stated that on the night of 5/17/2021, when the facility admitted Resident 16, I think we only had three nursing assistants that night . It was very busy, and I was running around a lot . that night we definitely needed more help . On 7/9/2021 at 1:28 p.m., during an interview with Director of Staff Development (DSD) and concurrent review of Resident 16's MAR for the month of 5/2021, DSD stated that based on the documentation, the first dose of Oxycodone-Acetaminophen 5-325 was given to resident on 5/18/2021 at 1:00 p.m., which was 14.5 hours from the ordered date and time (5/17/2021 at 10:27 p.m.). The first dose of Oxycodone HCL 30 mg was administered to Resident 16 on 5/18/2021 at 9:00 a.m., which was 12 hours from the ordered time (12 a.m.) DSD stated the licensed nurses should have given pain medication timely. DSD stated the Emergency Medication Kit (E-kit) contains eight tablets of Oxycodone-Acetaminophen 5-325. On 7/20/2021, at 1:39 p.m., during an interview, the facility's Medical Director stated he was not aware Resident 16 was not given pain medication for 12 hours. A review of the facility's policy titled, Medication - Administration, dated 1/1/2012, indicated, Purpose To ensure the accurate administration of medication for residents in the facility . ii. Medications and treatments will be administered as prescribed . A request was made on 7/20/2021 for an updated policy regarding medication administration, the RQM was unable to provide one.

Based on observation, interview and record review, the facility's staff members (CNA 1, LVN 1, LVN 2, dietary staff 1, dietary staff 2, the physical therapist and physical therapist aide, consultant wound surgeon, housekeeper staff 1, housekeeper staff 2, and laundry staff 1), failed to follow standard infection control practices to prevent the potential transmission and spread of infection in the facility while providing care for 7 out of 18 sampled residents (2, 6, 14, 15, 16, 17, 18 ) by failing to: 1. Ensure certified nursing assistant 1 (CNA 1), licensed vocational nurse 1 (LVN 1), dietary staff 1, dietary staff 2, and laundry staff 1, washed their hands before and after providing care to Resident 2, and before leaving Resident 2's contact isolation room; and to wash their hands after taking off their personal protective equipment ((PPE) refers to protective clothing, gloves, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection) used during the provision of care for Resident 2; 2. Ensure the Physical Therapist ((PT)-a professional who uses treatment techniques to promote (help) the ability to move, reduce pain, restore function, and prevent disability ) and the therapist's aide, made sure the mechanical lift was sanitized (to make something free from dirt, infection or disease) after transferring Resident 2, who was on contact isolation precautions, before the lift was taken to another resident's room. 3. Ensure LVN 1 sanitized the blood pressure cuff and the stethoscope, after checking Resident 15, 16, and 17's blood pressure, and to not re-use the same instruments to check Resident 2's blood pressure, who was on contact isolation, and would not place both instruments in the medication cart for storage. 4. Ensure a consulting wound surgeon washed his hands after leaving Resident 2's contact isolation room, and before putting on PPE and entering into Resident 14's contact isolation room, and after measuring Resident 14's pressures ulcer, after removing his PPE and leaving the facility. 5. Ensure dietary staff 1 and dietary Staff 2 washed their hands after handling trash and immediately after entering the kitchen. 6. Ensure housekeeping staff 1 and housekeeping staff a) Prepared the sanitizing solution at the correct concentration in order to kill[DIAGNOSES REDACTED] spores; and were able to verbalize knowledge on the preparation of sanitizing solution with the correct concentration; b) Ensure a bottle of bleach would not be taken to the isolation room and then placed back into the cleaning cart for transport for the use in other residents rooms, c) Ensure a graduate cylinder to flush urinals would not be stored on top of the flush pipe in the bathroom, d) Ensure to provide laundry staff member with PPE to be available for their use when handling soiled clothing. 7. Ensure laundry staff 1 washed and dried the residents' personal clothing at the required temperature to kill[DIAGNOSES REDACTED] spores and prepared the sanitizing solution at the correct concentration in the washing machine. 8. Ensure all laundry and housekeeping staff were trained on proper infection control practices. 9. Ennsure the rinse cups that were being used to rinse resident's urinals were not stored on bathroom commode or on top of the toilet flush pipe in order to prevent potential disease transmission. 10. Ensure LVN 2 washed her hands before preparing Resident 6's wound care supplies and would not touch the back of the PPE gown while providing treatment to Resident 2's a pressure ulcer(localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear). 11. Ensure Resident 2's family member was educated about the contact isolation precautions and handwashing. 12. Ensure the laundry area were equipped with hand washing facilities for the use of laundry staff members after handling, processing, transporting and storing residents' soiled clothes to prevent contamination and transmission of infection. These deficient practices had the potential to spread infections throughout the facility to residents, staff, and visitors and placed residents at risk of developing foodborne illnesses. During survey there were 49 residents at the facility. Two residents out of 49 residents were on contact isolation for[DIAGNOSES REDACTED]. Findings: a. During an observation, on April 12, 2016, at 10:35 a.m., Resident 2's room had a posted Isolation Precautions warning sign (signs to protect and inform patients, their families, visitors and healthcare workers, and to stop germs from spreading across a healthcare setting) because of Clostridium difficile infection ((C-diff) a spore-forming bacillus that causes inflammation of the colon producing watery diarrhea, abdominal pain, fever, and loss of appetite. The people who have illnesses or conditions requiring prolonged use of antibiotics, and the elderly, are at greater risk of acquiring this disease. The[DIAGNOSES REDACTED] is shed in the feces. Healthcare workers can spread the bacteria to patients or contaminate surfaces through hand contact. Any surface, device, or material, e.g., toilets, bathing tubs, and electronic rectal thermometers, that becomes contaminated with feces may serve as a reservoir for the spores that can live for long periods on surfaces). A review of Resident 2's clinical records indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. colon), sepsis (blood infection), urinary tract infection ((UTI) infection of the urine), sacral pressure ulcer (the triangle bone below the back bone) with osteo[DIAGNOSES REDACTED] (inflammation of bone or bone marrow, usually due to infection), a peripherally inserted central catheter (PICC line through an intravenous access that can be used for extended antibiotic therapy), with multidrug-resistant organisms (bacteria that cannot be killed by the antibiotics commonly used to treat infections caused by these bacteria) that included [MEDICATION NAME] resistant [MEDICATION NAME] (VRE) infection in stool/rectum, methicilin resistant streptococcus auerus (MRSA) infection, and extended spectrum beta lactamase (ESBL) of the nares (nose) infections. A review of the care plan dated March 18, 2016, indicated Resident 2 required contact isolation precautions because the resident was colonized with MDRO, VRE of stool/rectum, MRSA of nares, and ESBL. The goal was to observe and maintain the contact isolation precautions every shift. The interventions were to follow contact isolation protocol as directed and to educate resident/family regarding contact isolation precautions. A review of the Minimum Data Set (MDS), a standardized assessment and a care screening tool, dated March 30, 2016, indicated Resident 2 was alert and oriented, required total assistance from staff for bed mobility, extensive assistance for dressing, and hygiene. The resident was incontinent (lost control) of bowel, and had an urinary suprapubic catheter (a thin tube used to drain urine from the bladder in to a bag). On April 18, 2016, there was an order to place Resident 2 on contact isolation (used for infections, diseases, or germs that are spread by touching the patient or items in the room) due to colonizing (the infected person may have no signs or symptoms of infection while still having the potential to infect others) of multi-resistant organisms (MDRO- bacteria that cannot be killed by the antibiotics commonly used to treat infections caused by these bacteria) for[DIAGNOSES REDACTED] colitis, and to arrange an appointment with the infectious diseases doctor when the resident would finish the antibiotic therapy (in five weeks). During an observation, on April 12, 2016, at 10:35 a.m., Laundry staff 1 was observed coming out of a resident's room and entered in to Resident 2's room. Laundry staff 1 was observed putting on a disposable gown and gloves without first washing her hands. Laundry staff 1 started to put the laundered clothes in Resident 2's closet. She was observed touching Resident 2's table, closet, and curtains, while going back and forth to the rolling garment rack. When finished, Laundry staff 1 was observed removing her gown and gloves, and take the rolling garment rack to another room and continued putting other residents clothes away without first washing her hands. During an observation, on April 12, 2016, at 12:35 p.m., the Physical Therapist and a therapy aide, transferred Resident 2 using a mechanical lift. When finished, they were observed placing the mechanical lift outside of Resident 2's room without sanitizing the lift. They both removed their gowns and gloves, then touched the nurses station counter top before washing their hands at the station. The mechanical lift was then taken by another staff member into another residents room. During an observation on April 12, 2016, at 3:50 p.m., LVN 1 and CNA 1 turned and pulled Resident 2 up in bed. LVN 1 and CNA 1 were observed leaving Resident 2's isolation room without washing their hands. Both were observed using a sanitizer that was placed outside the resident's door. On April 13, 2016, at 11 a.m., the housekeeper was observed using a spray bottle filled with a small amount of solution marked 'bleach.' The housekeeper was observed taking this spray bottle with bleach out of her cleaning cart into Resident 2's room and placed it on top of the table. She then brought it out and without sanitizing the bottles surface, placed it back in her cart. The housekeeper was observed taking the same spray bottle in to several other resident's rooms. a. A review of the physician's orders [REDACTED]. 1. On March 24, 2016, there was an order for [REDACTED]. 2. On March 28, 2016, there was an order for [REDACTED]. 3. On April 14, 2016, there was an order for [REDACTED]. 4. On April 17, 2016, there was an order for [REDACTED]. On April 13, 2016, at 3 p.m., during a treatment observation for Resident 2's sacral (tailbone) pressure ulcer, LVN 2 kept pulling up her PPE gown and her uniform because the back of her gown was not tied. Before leaving the room LVN 2 took her gown and gloves off, and instead of washing her hands, she used the sanitizer that was outside of the room. At the same time the resident's family member was observed entering the room without washing his hands before putting on gown and gloves. After leaving the room, the family member was observed taking the PPE off, and without washing his hands came to the nurse's station where he asked for a pen. At the same time the Director of Nursing (DON) was informed about the Surveyor's observations. The DON stated that was the first time she's ever seen him. The family member left the facility without being educated about the contact isolation precautions, and how to protect himself against the[DIAGNOSES REDACTED] infection. On April 13, 2016, at 3:20 p.m., during an interview, the DON stated all staff must wash their hands prior to entering a resident's room and after taking their PPE off. The DON stated she was not sure and could not find documented evidence to ensure Resident 2's family member was ever educated about[DIAGNOSES REDACTED] and or contact isolation precautions. b. A review of Resident 14's clinical records indicated the resident was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. According to the care plan for contact isolation dated February 16, 2016, indicated Resident 14 required contact isolation due to[DIAGNOSES REDACTED] and VRE in the urine. The intervention was to follow contact isolation protocol as directed, and to educate the resident/family regarding contact isolation precautions. A review of the Minimum Data Set (MDS), a standardized assessment and care screening tool, dated February 26, 2016, indicated Resident 14 was alert and oriented, required extensive assistance from staff for bed mobility, transfer, toilet use, personal hygiene, and was always incontinent of bowel and bladder. According to the physician's orders [REDACTED]. The order also included treatment for [REDACTED]. A review of the physician's orders [REDACTED]. 1. Ertapenem (antibiotic) intravenous for sepsis (the body's overwhelming and life-threatening response to an infection which can lead to tissue damage, organ failure, and death), 2. [MEDICATION NAME] Proxetril (antibiotic) 200 milligram (mg) tablet by mouth for sepsis. During an observation on April 14, 2016, at 4:30 p.m., a wound surgeon was observed leaving Resident 2's room after measuring Resident 2's pressure ulcer, without washing his hands first. The surgeon was observed using the sanitizer outside of the resident's room. The surgeon then walked down the hallway to another residents room, come back, and used sanitizer on his hands before putting on PPEs and then entered Resident 14's room. He then measured Resident 14's pressure ulcer, removed his PPEs and left the facility without washing his hands. On April 14, 2016, at 5 p.m., in an interview with the DSD, who also was the infection control nurse, the DSD stated the surgeon was not instructed about the proper infection control practices prior to entering the two isolation rooms. c. On April 13, 2016, at 8:50 a.m., or a.m., during the medication pass observation LVN 1 was observed checking Resident 15 and Resident 16's blood pressure. LVN 1 cleaned the stethoscope (a medical instrument for listening to the action of someone's heart or breathing) with an alcohol pad, and sanitized the blood pressure cuff (a device that measures blood pressure composed of an inflatable rubber cuff wrapped around the arm) using a chlorine bleach cloth wipe. LVN 1 then placed the stethoscope and the blood pressure cuff over her neck and shoulder where it was touching her bare neck, hair and clothing. LVN 1 then put both of the instruments over Resident 15's bare arms in order to check the blood pressure. LVN 1 then placed the same instruments in the medication cart without sanitizing them first. LVN 1 then checked Resident 17's blood pressure with the same stethoscope and blood pressure cuff without sanitizing them first. Resident 17 was observed touching his urinal that contained urine, before touching his bed remote. LVN 1 then touched the bed remote control, then touched the medicine cups top edges without sanitizing or washing her hands first. Resident 17 was observed putting his mouth on the medicine cups top edges where it was touched by LVN 1's unwashed hands. On the same day at 10:10 a.m., while pouring Resident 18's medications, LVN 3 was observed touching the lid of the trash canister on the medication cart, twice. LVN 3 was observed not sanitizing or washing her hands prior to pouring the rest of the medications. On the same day at 2 p.m., in the presence of the director of staff development (DSD), LVN 1 stated she had a blood pressure cuff and a stethoscope for Resident 2. LVN 1 then pulled both instruments out of her medication cart where she was storing them. Concurrently, the DSD stated these instruments were for personal use and had to be stored in a resident's room, in the drawer, and discarded after a resident's discharge. The DSD stated they should have never been mixed with the other resident's medications. c. On April 14, 2016, at 8:55 a.m., during in an interview with Housekeeper 1, she stated she used a mixture of chlorine and water in a bottle to clean the rooms. When asked how she measured the concentration of that mixture, she stated I use only a small amount of bleach. When asked for the specific formula/concentration used, she referred to the Housekeeper Staff 2. There was no formula/concentration available. Concurrently, the Housekeeping Staff 2 was asked how the facility was cleaning the isolation rooms. He stated they used a medication cup (approximately 16 ounces) to measure one or two cups of bleach to two gallons of water (pointing to a 3/4 level on a 36 quart mop bucket). Housekeeping Staff 2 verbalized a lack of knowledge on how to prepare the sanitizing solution mixture of 9:1 ratio (9 parts water, and one part chlorine). Housekeeping Staff 2 stated he did not train all of his housekeeping and laundry staff about the[DIAGNOSES REDACTED] infection and the proper cleaning and sanitizing of the isolation rooms. On April 15, 2016, at 8 p.m., during the environmental observation tour, that included the laundry area, accompanied by the Housekeeping Staff 2, the facility used a household washer and dryer to wash the resident's clothing, rags, and mop heads. The washer was observed on medium setting and contained wet rags and mop heads. The Housekeeping Staff 2 stated they had just washed those items using chlorine that was pumped in to the machine when the machine was turned on. He then took a hose and put it in the washing machine saying that was how the chlorine was added to the wash. The housekeeping supervisor pointed to a gage, and stated the temperature of the water was 150 degrees Fahrenheit. The water temperature in the machine registered at 150 degrees Fahrenheit. He was asked if there was enough chlorine added to the machine, he stated yes. However, when an active chlorine test strip (test strips that react to chlorine and produce a specific color change) was used to measure the amount of chlorine in water, it indicated zero chlorine parts per million (PPM). The Housekeeping Staff 2, stated he did not know why there was no chlorine in the machine. d. According to Resident 6's admission record, the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the physician's orders [REDACTED]. During the treatment observation on April 13, 2016, at 10:10 a.m., the treatment nurse LVN 2 was observed preparing supplies for Resident 6's deep tissue injury care without washing her hands or putting gloves on. LVN 2 was observed also not washing her hands after touching keys, touching treatment cart, opening and closing drawers and touching the wound care supplies she was preparing for the treatment. The wound care supply included: 1. Stack of 4.0 inches by 4.0 inches gauze. 2. Eight clear plastic cups. 3. Tongue blades. 4. Zinc Oxide paste. During an interview with LVN 2 in the presence of the DON on April 15, 2016 at 7:45 a.m., LVN 2 stated she washed her hands initially, however she confirmed touching keys, touching the treatment cart, opening and closing drawers and proceed to prepare wound care supplies without washing her hands or using gloves. e. On April 14, 2016, at 1:20 p.m., a dietary staff 1 was observed outside the facility emptying trash in a large trash bin. Dietary staff 1 was observed returning back inside the facility and to walk in the kitchen without washing his hands. Next, dietary staff 1 was observed placing a hairnet on, touching a backpack and placing a small bowl on the counter. On April 14, 2016, at 1:20 p.m., a dietary staff 2 was observed outside the facility around a large trash bin. Dietary staff 2 was observed returning back inside the facility and walking into the kitchen without washing his hands. Then he was observed placing a hairnet on and placing a resident's tray on the tray cart. On April 14, 1:30 p.m., during an interview, both dietary staff members stated, the facility's policy was to place a hairnet on and to wash hands upon entering the kitchen. On April 14, 1:35 p.m., during an interview, the dietary supervisor stated, the facility's policy was to place a hairnet on and to wash their hands upon entering the kitchen. A review of the facility dietary in-service dated February 24, 2016, titled Food Procurement, Storage, Preparation, Serve-Sanitary ( hand washing, hair net) indicate both dietary staff members attended the in-service. A review of the facility's policy and procedure for hand washing, revised December 20, 1994, indicated hand washing would be performed before and after wearing gloves, before and after residents care, after handling contaminated articles, and before caring for susceptible residents. According to the California Department of Public Health Joint Infection Control Prevention and Control Guidelines, Enhanced Standard Precautions (ESP), 2010, the standard precautions presumes that all body fluids including moist body fluids (blood, excretions, secretions, non-intact skin and mucous membranes) from all patients/residents are colonized or infected with one or more transmissible infectious viruses and/or bacteria (MRSA, VRE,[DIAGNOSES REDACTED]). In addition to hand hygiene, the standard precautions require gowns, gloves masks, and face shields when health care personnel (HCP) anticipates that their hands, clothes, and or mucous membranes of the eyes, nose, mouth, or skin on the face will be exposed to blood or body fluids. All facility staff should be educated, specially when observations indicate that employees are not in compliance with the facility hand hygiene procedures. Visitors, volunteers, and residents should also be educated and instructed in hand hygiene procedures. The essential elements of the hand hygiene education program should include expectations of the facility administrative staff (i.e. monitoring compliance with procedure). Each HCP, volunteer, and visitor should periodically be required to verbally and physically demonstrate the proper technique and indications for hand hygiene including alcohol-based products and soap and water. The infection prevention professional or other designated person specifically trained to observe for and document compliance with the hand hygiene procedures should, at least every 2-3 weeks and on all shifts, discretely observe HCP including physicians, physician assistants, and nurse practitioners as well as ancillary staff, volunteers, and visitors. Non-compliance should be immediately addressed. Each employee, resident, and visitors should be trained in the use of the specific hand hygiene products that include the instructions for the use of the alcohol-based hand hygiene products. The HCP, visitors, and volunteers must wash their hands with soap and water after contact with intact and non-intact skin, clothing, and environmental surfaces or residents. Environmental sanitation is as important since regardless of the original site of the infection or colonization infectious agents (C-diff) can contaminate all or parts of the patient's skin surface, especially those sites that are moist. The bacteria are then shed in the skin cells onto environmental surfaces such as bedrails and table tops in the patient's immediate environment. These organisms can survive on dry environmental surfaces from several hours to many weeks and serve as a source of hand, glove, and clothing contamination. Use an Environmental Protection Agency (EPA) registered detergent/disinfectant in all resident care areas. The manufacture's recommendations for amount, dilution, and contact time should be followed. The 1:9 (one part of bleach to nine part of water) dilution of 5.25% sodium [MEDICATION NAME] (household beach) and water freshly mixed daily should be used to disinfect the rooms. Use a clean cloth saturated with properly diluted disinfecting solution for each residents' area of the room. Clean and disinfect multiple-resident use equipment (lifts, blood pressure cuffs) between each patient use. Laundry wash water temperatures maintained at or above 160 degrees Fahrenheit (F) (71 degrees Celsius (C)). Alternately, low temperature washing at 71-77 F (22-25 C) plus 125 parts-per-million (ppmP chlorine bleach rinse has been found to be effective. If the later recommendation is implemented the use of chlorine bleach should be carefully monitored. Wear gowns, and gloves when in contact with linens visibly soiled with blood, excretions and secretions. Ensure that employees assigned to the laundry service wear PPE including moisture repelling gowns and gloves when handling and sorting soiled linens, and periodically observe employees assigned to the laundry for compliance with facility policies and procedures including PPE, and laundry wash water temperature. The outcome surveillance is the ongoing, systematic collection, analysis, interpretation, and dissemination of data to all HCP related to the occurrence of healthcare-associated infections (HAI) in long term care facility (LTCF). The facility's infection prevention program should review the current definitions of infections for surveillance in LTCF and adopt develop a structured method by which data is collected, analyzed, and reported to the infection control and/or quality improvement committee. According to the Center for Disease Control (CDC) a healthcare workers have to use gloves when entering patients' rooms and during patient care, and to perform hand hygiene after removing gloves. Because alcohol does not kill Clostridium difficile spores, use of soap and water is more efficacious than alcohol-based hand rubs. f. On April 12, 2016, at 3:35 p.m., during the tour of the facility's interior environment the surveyor in the presence of the maintenance supervisor observed graduated rinse cups were left and stored in room [ROOM NUMBER], bathroom commode and on top of the toilet flush pipes in residents' bathroom [ROOM NUMBER], 6, 7, 8, 9, 10, 11 12, 14, 15, 16. 17, 18, 19, 20, 21, 22, 23 and 24. During an interview on the same date at 3:45 p.m., the staff developer stated that the graduated rinse cups are use for rinsing resident urinals. g. During the tours of the laundry areas on the same dates (4/13/16 and 4/14/16), the surveyor observed that the facility laundry room and laundry area was not equipped with hand washing facilities for the use of laundry staff members after handling, sorting and transporting residents' soiled clothes to prevent contamination and transmission of infection. During an interview on April 14, 2016, at 9:15 a.m., the assigned laundry staff member stated that she used hand sanitizer and proceeded to wash her hands in upstairs bathroom after handling and sorting soiled clothes because the laundry was not equipped with hand washing facilities. A review of the facility Laundry Department Infection Control Policy and Practices indicated that the following precautionary procedures must be followed by laundry employees to prevent the spread of infectious diseases to other staff members: * Employees in the soiled areas shall wear gloves when handling soiled linens. * SANITIZE and WASH HANDS AND ADHERE TO HAND WASHING PROCEDURES.