Every finding on record at Pelican Ridge Post Acute

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to follow their pharmaceutical procedures for one of 28 final sampled residents (Resident 9) and four nonsampled residents (Resident 20, 52, 107, and 154). * LVN 1 failed to prepare the correct physician's order dosage for Resident 9's gabapentin (medication to treat nerve pain) solution. This failure had the potential to negatively affect the resident's health condition. * The facility failed to reconcile Residents 20, 52, and 107's controlled medications with the MAR. * The facility failed to accurately enter the physician's order for Resident 154's hydrocodone-acetaminophen (a controlled pain medication) into the EHR prior to removing the medication from the facility's ADDS, and administering it to the resident. In addition, the facility failed to administer Resident 154's metoprolol tartrate (a medication for HTN) and pantoprazole (a medication to reduce stomach acid) as ordered. These failures had the potential for a negative outcome in the residents' clinical status due to medications not being administered as ordered by the physician, or appropriately transcribed, and inaccurate accounting of controlled mediations, as well as a delay in identifying potential drug diversion of controlled medications.Findings: 1. Review of the facility's P&P titled IIA2: Medication Administration – General Guidelines revised 10/2017 showed medications are administered as ordered by the physician. Once the medications are administered, the administration is documented on the MAR. Review of the facility's P&P titled IC3: Medication Ordering and Receiving Medications From the Dispensing Pharmacy revised 1/2022 showed new medications may be removed from the facility's emergency drug supply while pending pharmacy delivery. Medical record review for Resident 154 was initiated on 8/20/26. Resident 154 was admitted to the facility on [DATE]. a. Review of Resident 154's Order Summary Report showed the following physician's orders: - a discontinued order dated 8/19/26, for hydrocodone-acetaminophen 10-325 mg, administer one tablet by mouth every six hours PRN for severe pain; - a discontinued order dated 8/19/26, for hydrocodone-ibuprofen 10-200 mg, administer one tablet by mouth every four hours PRN for severe pain; and - an active order dated 8/19/26, for hydrocodone-acetaminophen 10-325 mg, administer one tablet by mouth every four hours PRN for severe pain. The order was later discontinued on 8/19/26. Review of Resident 154's Order Audit Reports (undated) showed the following: - the hydrocodone-acetaminophen 10-325 mg for every six hours PRN was ordered on 8/19/26 at 1447 hours. The order was discontinued on 8/19/26 at 2238 hours; - the hydrocodone-ibuprofen 10-200 mg for every four hours PRN was ordered on 8/19/26 at 2235 hours. The order was discontinued on 8/20/26 at 0324 hours; and - the hydrocodone-acetaminophen 10-325 mg for every four hours PRN was ordered on 8/20/26 at 0709 hours. The order was still active. Review of Resident 154's Progress Note dated 8/19/26 at 2245 hours, showed hydrocodone-acetaminophen 10-325 mg was retrieved form the ADDS and administered to the resident at 2245 hours. There was no active order to administer the medication. Review of Resident 154's Progress Note dated 8/20/26 at 0336 hours, showed hydrocodone-acetaminophen 10-325 mg was retrieved form the ADDS and administered to the resident at 0335 hours. There was no active order for the medication. On 8/20/26 at 1024 hours, an interview and concurrent medical record review for Resident 154 was conducted with LVN 4. LVN 4 stated the night nurse informed her she (the night nurse) entered the resident's hydrocodone-acetaminophen 10-325 mg to be administered every four hours PRN incorrectly, and accidentally ordered it as hydrocodone-ibuprofen 10-200 mg to be administered every four hours PRN. On 8/20/26 at 1045 hours, an interview and concurrent facility document review was conducted with RN 5. RN 5 stated the process was to use the facility's cell phone to text and communicate with the physicians when new residents were admitted . RN 5 stated the physician would usually continue the acute care hospital treatment orders and if the staff needed clarification for anything, they could text the medication details for clarification. Review of the facility's cell phone texts to Physician 1 showed the following: - dated 8/19/26 at 1507 hours, the physician was notified the resident had arrived at the facility; - dated 8/19/26 at 2234 hours, a facility staff notified the physician Resident 154 was crying in pain and asked if the PRN hydrocodone 10 mg could be increased from every six hours to every four hours. The physician replied and approved the change. The text did not specify if the medication was for hydrocodone only, or as a combined medication with acetaminophen or ibuprofen; - dated 8/20/26 at 0711 hours, the facility staff informed the physician staff accidentally entered the wrong pain medication into the orders. RN 5 stated the LVN meant to change the hydrocodone-acetaminophen 10-325 mg order from every six hours to every four hours, however when entering the new order into the EHR, she selected the incorrect medication. On 8/20/26 at 1110 hours, an interview and concurrent medical record review for Resident 154 was conducted with the DON. The DON reviewed Resident 154's medical record, and the pharmacy ADDS transaction report. The DON was notified of the facility staff's texts to the physician and the hydrocodone-ibuprofen medication being incorrectly ordered. The DON stated the resident original order for the hydrocodone-acetaminophen 10-325 mg every six hours PRN was supposed to be changed to every four hours PRN, and verified the hydrocodone-ibuprofen medication should not have been entered in the EHR as an order. The DON reviewed the resident's medical record and verified the nurses progress notes showed the resident received hydrocodone-acetaminophen 10-325 mg and failed to ensure there was a current order before the medications were administered. b. On 8/19/26 at 1037 hours, during an inspection of Medication Room A with the DON, an ADDS was observed. The DON stated the ADDS was used as an emergency drug supply, and contained controlled medications, blood pressure medications, antibiotics, and some routinely used medications to be available for new admissions. The DON showed a binder next to the ADDS with a formulary list of the ADDS contents. Review of the facility's ADDS formulary list (undated) showed the metoprolol tartrate medication was available in the form of 25 mg tablets. Review of Resident 15's MAR for August 2026 showed a physician's order dated 8/19/26, for metoprolol tartrate 50 mg by mouth twice a day, hold for SBP less than 110 mmHg or a heart rate less than 60 BPM. The MAR showed the medication was scheduled to be administered on 8/19/26 at 1700 hours. The MAR showed a Chart Code of 6 for other/see progress notes and was digitally signed by LVN 6. Review of Resident 154's progress notes failed to show why the metoprolol medication was not administered to the resident. On 8/20/26 at 1402 hours, an interview and concurrent medical record review for Resident 154 was conducted with the QA Nurse. The QA Nurse reviewed Resident 154's medical record and verified the MAR showed a chart code of 6 for the metoprolol tartrate 50 mg to be administered 8/19/27 at 1700 hours. The QA Nurse stated code 6 typically meant the medication was not administered. The QA Nurse verified there was no progress note to show why the medication was not administered. The QA nurse then called LVN 6, and stated the LVN did not administer the medication because it was not delivered yet from the pharmacy. LVN 6 then reviewed the facility's ADDS formulary list and verified the medication was available in 25 mg tablets. The QA Nurse reviewed the resident's vital signs and verified the resident's BP and heart rate were not below the medication's hold parameters, and two tablets should have been removed from the ADDS and administered to the resident. c. Review of Resident 15's MAR for August 2026 showed a physician's order dated 8/19/26, for pantoprazole sodium delayed release 40 mg by mouth daily for GERD. The MAR showed the medication was scheduled to be administered on 8/20/26 at 0900 hours. The MAR showed a Chart Code of 6 for other/see progress notes and was digitally signed by LVN 4. Review of Resident 154's Order – Administration Note dated 8/20/26 at 0953 hours, showed the LVN was unable to locate the medication. On 8/20/26 at 1024 hours, an interview and concurrent medical record review for Resident 154 was conducted with LVN 4. LVN 4 stated she was unable to administer Resident 154's pantoprazole sodium medication as scheduled because she could not find it. LVN 4 stated she called the pharmacy and they stated it was delivered and signed for last night. On 8/20/26 at 1400 hours, a follow-up interview was conducted with LVN 4. LVN 4 stated she located the pantoprazole sodium medication in the medication cart, in a different section. 2. Review of the facility's P&P titled Controlled Medications dated 4/2008 showed when a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the MAR includes the date and time of administration, amount administered, signature of the nurse administering the dose on the accountability record at the time the medication is removed from the supply, and initials of the nurse administering the dose on the MAR after the medication is administered. a. Medical record review for Resident 52 was initiated on 8/18/26. Resident 52 was admitted to the facility on [DATE], readmitted on [DATE]. Review of Resident 52's H&P examination dated 2/18/26, showed Resident 52 had the capacity to understand and make decisions. Review of Resident 52's MDS assessment dated [DATE], showed Resident 52's BIMS score was 13, indicating intact cognition. Review of Resident 52's Order Summary Report showed physician's order dated 7/19/26, for tramadol (opioid analgesics) 50 mg, give 1.5 tablets by mouth every eight hours as needed for severe pain and document nonpharmacological interventions. Review of the facility's Antibiotic or Controlled Drug Record (undated) showed Resident 52's tramadol 50 mg medication was signed out on 8/7/26 at 2217 hours. Review of Resident 52's MAR for August 2026 failed to show documented evidence the tramadol tablet 50 mg medication was administered to Resident 52 on 8/7/26 at 2217 hours. On 8/19/26 at 1111 hours, an interview and concurrent review of the controlled medication reconciliation for Resident 52's tramadol 50 mg was reviewed with LVN 2. LVN 2 verified the above findings. b. Medical record review for Resident 20 was initiated on 8/18/26. Resident 20 was admitted to the facility on [DATE], readmitted on [DATE]. Review of Resident 20's H&P examination dated 6/23/26, showed Resident 20 had no capacity to understand and make decisions. Review of Resident 20's Order Summary Report showed physician's order dated 6/28/26, for hydrocodone-acetaminophen (opioid analgesics) oral tablet 10-325 mg, give one tablet by mouth every 6 hours as needed for moderate to severe pain and document nonpharmacological interventions. Review of Resident 20's MDS assessment dated [DATE], showed Resident 20's BIMS score was 10, indicating moderate cognitive impairment. Review of the facility's Antibiotic or Controlled Drug Record (undated) showed Resident 20's hydrocodone-acetaminophen oral tablet 10-325 mg was signed out on 8/17/26 at 0930 hours. Review of Resident 20's MAR for August 2026 failed to show documented evidence the hydrocodone-acetaminophen tablet 10-325 mg medication was administered to Resident 20 on 8/17/26 at 0930 hours. On 8/19/26 at 1152 hours, an interview and concurrent review of the controlled medication reconciliation for Resident 20's hydrocodone-acetaminophen 10-325 mg was reviewed with LVN 2. LVN 2 verified the above findings. c. Medical record review for Resident 107 was initiated on 8/19/26. Resident 107 was admitted to the facility on [DATE]. Review of Resident 107's Order Summary Report showed physician's order dated 8/4/26, for tramadol 50 mg give one tablet by mouth every 24 hours as needed for moderate-severe pain for 14 days and document nonpharmacological interventions. Review of Resident 107's MDS assessment dated [DATE], showed Resident 107's BIMS score was 12 indicating moderate cognitive impairment. Review of the facility's Antibiotic or Controlled Drug Record (undated) showed Resident 107's tramadol 50 mg medication was signed out on 8/15/26 at 0001 hours. Review of Resident 107's MAR for August 2026 failed to show documented evidence the tramadol 50 mg medication was administered to Resident 107 on 8/15/26 at 0001 hours. On 8/19/26 at 1530 hours, an interview and concurrent review of the controlled medication reconciliation for Resident 107's tramadol tablet 50 mg was reviewed with RN 4. RN 4 verified the above findings. On 8/20/26 at 1335 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 3. Review of the facility's P&P titled Medication Administration dated 10/2017 showed when administering potent medications on liquid or those requiring precise measurement, such as digoxin, devices provided by the manufacturer or obtained from the provider pharmacy like oral syringes are used to allow accurate measurement of doses. Medical record review for Resident 9 was initiated on 8/18/26. Resident 9 was admitted to the facility on [DATE]. Review of Resident 9's H&P examination dated 7/29/26, showed Resident 9 had no capacity to make decisions. Review of Resident 9's MDS assessment dated [DATE], showed Resident 9's BIMS score was 4, indicating severe cognitive impairment. Review of Resident 9's Order Summary Report showed an order dated 7/28/26, for gabapentin oral solution 300 mg/6 ml, give 6 ml via GT three times a day. On 8/18/26 at 0818 hours, a medication administration observation for Resident 9 and concurrent interview was conducted with LVN 1. LVN 1 stated Resident 9's medications had to be administered via the GT. LVN 1 prepared the 6 ml of gabapentin 600 mg in a measuring cup, however LVN 1 did not use the syringe to measure how much medication was poured in the medication cup. The medication cup did not have a mark to indicate how much gabapentin medication was poured, but it appeared to be closer to 7 ml. LVN 1 stated she intended to administer the above medication, however the surveyor intervened before the medications were administered. LVN 1 was informed of the error and measured the correct dose of gabapentin with the syringe. On 8/18/26 at 0934 hours, an interview was conducted with LVN 1. LVN 1 stated she should administer the correct dose by using a syringe to measure the liquid medication accurately. LVN 1 stated licensed nurses must follow physician's orders.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmaceutical services to ensure proper storage, labeling, and disposal of the medications. * The keys for Medication Carts C and D were improperly stored inside of three-ring binders on top of each cart. * The destroyed medication incinerator's lid was not secured, resulting in medications previously destroyed and deemed unusable being accessible in their original intact form. * An opened PPD vial was not dated when opened. * The facility failed to ensure a topical medication in Treatment Cart A was labeled and dated with the open date. * The facility failed to ensure oral and topical medications were free from white liquid residue and labeled with an open date in Medication Cart H. * There were three topical medication stored on Resident 150's window sill. These failures had the potential to negatively impact on the residents' well-being, and the potential for the medications to lose stability and effectiveness.Findings: Review of the facility's P&P titled IE4: Medication Destruction revised 10/2017 showed the discontinued medications are destroyed and placed in a proper waste container. Non-controlled medication destruction is done in the presence of two nurses. Review of the facility's P&P titled ID1: Storage of Medications revised 1/2025 showed only licensed nurses, pharmacy personnel, and those lawfully authorized are allowed access to medications. Medication carts are locked or attended by persons with authorized access. 1. On 8/18/26 at 0522 hours, a medication administration observation was conducted with LVN 12. LVN 12 stated on the night shift (2300-0700 hours), LVN 12 split Medication Cart D between two nurses. LVN 12 retrieved Tramadol (a controlled medication for pain) from Medication Cart D (located by a doorway next to Resident Room D), placed the medication cart keys under the front cover of a three-ring binder on top of the medication cart, and then went to Medication Cart C located in front of the Resident Room D's doorway. LVN 12 removed the medication from the cart, locked the cart, administered the medications, came back to the medication cart, unlocked it, retrieved blood sugar testing supplies, locked the medication cart, placed the keys for Medication Cart 3 under the front cover of a three-ring binder on top of the medication cart, and went into a resident room for a blood sugar check. A female staff in a polo shirt was observed walking in the hallway and opened a door and entered the dietary department at the end of the hallway (with one resident room between Resident Room D before the hallway ended and went around the corner). At 0539 hours, LVN 12 returned to the cart and stated the medication cart keys were either stored in the binder or kept in the nurses' possession. LVN 12 verified the keys to Medication Carts 3 and 4 were currently stored in the binders located on top of each medication cart. On 8/18/26 at 0725 hours, an interview was conducted with the DON. The DON stated the medications cart keys should not be stored in the medication cart binders, and should always be in the nurse's possession. 2. On 8/19/26 at 1037 hours, an inspection of Medication Room A was conducted with the DON. The following was observed:- The destroyed medication incinerator's lid was not secured. Inside were multiple intact pills, capsule, and tablets in a usable form. There was some dark brown granules observed on the side of the container. In addition, a sealed plastic bag was in the incinerator with multiple intact white capsules. The DON stated there were coffee grounds placed in the incinerator to ensure the medications were unusable until the container was picked up to be properly discarded, but verified the medications observed did not have any coffee grounds observed on them and they were easily retrievable and usable; and- an opened PPD vial located in the medication refrigerator was not dated when opened. The vial label showed to discard once opened for 30 days. The DON verified the vial should have been dated when it was opened. 3. Review of the facility's P&P titled Medication Storage in the Facility dated 4/2008 showed the following: - orally administered medications are kept separate from externally used medications and treatments such as suppositories, ointments, creams, vaginal products, etc. Eye medications are stored separately by facility policy; - outdated contaminated, or deteriorated medications, and those in containers that are cracked, soiled, or without closures are immediately removed from inventory, disposed of according to procedures for medication disposal and reordered from the pharmacy; - medication storage areas are kept clean, well-lit, and free of clutter and extreme temperatures and humidity; and - medication storage conditions are monitored on a routine basis and corrective action taken if problems are identified. On 8/19/26 at 1044 hours, an inspection of Treatment Cart A was conducted with LVN 4. There was one tube of isosorb ointment (anti-infective) 10 gm observed without a label or dated with the opened date. LVN 4 verified the above findings. 4. On 8/18/26 at 0818 hours, a medication administration observation was conducted with LVN 1. LVN 1 stated Resident 9's medications had to be administered via the GT. A bottle of Liquacel (protein supplement) was observed without a opened date labeled on the bottle. LVN 1 verified the above findings. On 8/19/26 at 1458 hours, an inspection of Medication Cart H was conducted with RN 4. The following was observed: - a bottle of aspirin (anti-platelet) enteric-coated 81 mg was not labeled with an opened date; - a tube of diclofenac gel (nonsteroidal anti-inflammatory drug) 1% was not labeled with an opened date; and - a bottle of vancomycin (antibiotic) liquid had white sticky liquid and white liquid residue in the syringe. RN 4 verified the above findings. RN 4 stated the licensed nurses must label house supply medications or supplements after opening. In addition, the licensed nurses must clean the liquid bottles after each use and dispose of any unclean syringes. On 8/20/26 at 1335 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 5. On 8/17/26 at 0907 hours, an observation and concurrent interview was conducted in Resident 150's room. Resident 150 was awake and lying in bed. Resident 150's bedside window sill had the following topical medications: - one tube of diclofenac sodium 1.76 ounce topical gel (arthritis pain reliever); - one 3 ounce bottle of miconazole nitrate 2% powder (antifungal powder; and - one 2.6 ounce tube of Arnicare gel (for pain relief). Resident 150 stated the medications on the windowsill were his. Resident 150 stated he did not use the medications at his home; his wife and some CNAs got it for him. On 8/17/26 at 0910 hours, an observation and concurrent interview was conducted with CNA 7 in Resident 150's room. CNA 7 verified there were three medications stored on the resident's windowsill and further verified they belonged to Resident 150. On 8/17/26 at 1050 hours, an observation and concurrent interview was conducted with LVN 6. LVN 6 verified there were three medications stored on Resident 150's bedside windowsill. LVN 6 verified the medications should not have been there. On 8/20/26 at 1426 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure food safety and sanitation guidelines were followed. * The facility failed to ensure 30 individual boxes of milk was discarded after their expiration date. * The facility failed to ensure food preparation equipment was properly air-dried before storage. * The facility failed to ensure Dietary Aide 1 performed handwashing after removing hand mittens. These failures posed the risk of food-borne illnesses in highly susceptible resident population of 133 facility residents who received food prepared in the facility kitchen. Findings: Review of the facility's Total by Diet Texture dated 8/17/26, showed 133 of 140 residents consumed food prepared in the facility kitchen. 1. Review of the facility's P&P titled Food Safety and Food Storage revised 11/4/24, show it is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state and local authorities. Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety. Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms. On 8/17/26 at 0801 hours, during the initial tour of the kitchen, an observation and concurrent interview was conducted with the DSS. 30 individual boxes of Alta Dena reduced fat milk with an expiration date of 8/13/26, were observed in the walk-in freezer. The DSS verified the expiration date. 2. According to the USDA Food Code 2022, 4-901.11, Equipment and Utensils, Air-Drying Required, after cleaning and sanitizing, equipment and utensils shall be air-dried or used after adequate draining before getting in contact with food. According to the USDA Food Code 2022, 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles, cleaned equipment and utensils shall be stored in a self-draining position that allows air drying. On 8/17/26 at 0801 hours, during the initial tour of the kitchen, an observation and concurrent interview was conducted with the DSS. Six aluminum trays were observed stored wet and stacked on top of one another. The DSS verified the trays had not been air-dried. 3. Review of the facility's P&P titled Food Safety and Food Storage revised 11/4/24, showed the staff shall adhere to safe hygienic practices to prevent contamination of food from hands or physical objects. The staff shall wash hands according to the facility procedures. On 8/18/26 at 1215 hours, an observation and concurrent interview was conducted with Dietary Aide 1. Dietary Aide 1 was observed removing hand mittens after placing a container of sauce from the over into the hot steamer. Dietary Aide 1 then immediately assisted with tray line preparation without washing hands. Dietary Aide 1 acknowledged he should have washed his hands after removing the hand mittens. On 8/20/26 at 1026 hours, an interview was conducted with the DSS and Regional Clinical Consultant. The DSS and Regional Clinical Consultant were informed and acknowledged the above findings.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to establish and maintain the infection control program and practices designed to help prevent the development and transmission of diseases and infections. * The facility failed to ensure the clean folded pillowcases and blankets were not stored with potentially contaminated items in the clean area of the laundry. * The facility failed to ensure the newly washed blankets were stored in a clean and covered space in the laundry room. * The facility failed to ensure the laundry room was free from accumulated dusts on the exterior of the standing air conditioner, the exterior of the three washing machines, and on the floor. * The facility failed to ensure the Legionella testing was followed, and the monthly boiler inspection indicated what was done during the inspection. * The facility failed to ensure Resident 140's urinal was not placed on top of the overbed table with the water pitcher. * The facility failed to ensure the staff was wearing the proper PPE (Personal Protective Equipment) when performing the high-contact care for Resident 12 who was on Enhanced Barrier Precautions (EBP). These failures placed the residents at risk for infections and not control/prevent potential transmission of communicable diseases to other residents throughout the facility. Findings: Review of the facility's P&P titled Infection Control and Prevention Program dated 12/19/22, showed this facility has established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards. Further review of facility's P&P showed the laundry, and direct care staff shall handle, store, process and transport linens to prevent the spread of infection. Linens will be stored on all resident care units on covered carts, shelves, in bins, drawers or linen closets., 1. a. On 8/18/26 at 0819 hours, a tour of the laundry room and concurrent interview was conducted with Laundry Staff 1 with the Central Supply Room Designee. A clean linen folding table on the right side of the room was observed with a cell phone, eyeglasses, and a used paper towel touching the folded pillowcases and folded blankets. Laundry Staff 1 verified the clean laundry were touching her cell phone, eyeglasses, and used paper towel. Laundry Staff 1 stated I'm sorry, I will wash this again, and removed the phone, eyeglasses and used paper towel from the clean linen folding table. 1. b. On 8/18/26 at 0819 hours, while the tour of the laundry room and concurrent interview with Laundry Staff 1 with the Central Supply Room Designee was being conducted, on the left side of the room folded blankets were stored outside and on top of the linen cart touching the wall and almost near the ceiling. Residents' clothes were also observed in a hanger on top of a black container. Laundry Staff 1 verified the folded blankets that were stored outside and on top of the linen cart touching the wall and almost near the ceiling. Laundry staff 1 stated those blankets are washed and clean. When Laundry Staff 1 was asked where the blankets should be stored, Laundry Staff 1 responded blankets should be inside the clean cart, covered. 1. c. On 8/18/26 at 0819 hours, while the tour of the laundry room and concurrent interview with Laundry Staff 1 with the Central Supply Room Designee was being conducted, the standing air conditioner next to the clean linen folding table was observed dusty on the exterior front and back, including the filter, which was visibly full of thick accumulation of dusts. In addition, the exterior of the three washing machines had accumulations of dusts in the front and back areas. Furthermore, the floor of the laundry room was observed dusty. Laundry Staff 1 verified the above findings and stated she tried to clean the laundry room when she finished taking care of the linens and clothes. Laundry Staff 1 further stated another shift came in the afternoon and they cleaned. On 8/18/26 at 1030 hours, a follow-up inspection of the laundry room and interview was conducted with the Housekeeping, Maintenance, and Laundry Manager. The Housekeeping, Maintenance, and Laundry Manager acknowledged the above findings and stated they will re-inservice the staff regarding the handling of the clean linens, and blankets, the remind staff they have a drawer to place their things and not the clean linen folding table, and their things should not touch the clean linens, clothes; and will make sure the laundry room was cleaned regularly. 2. Review of the facility's P&P titled Legionella Surveillance dated 12/19/22, showed it is the policy of the facility to establish primary and secondary strategies for the prevention and control of legionella infections. The following were also outlined as follows: - Legionella surveillance is one component of the facility's water management plans for reducing the risk of legionella and other opportunistic pathogens in the facility's water systems. - under physical controls: cooling towers and potable water systems shall be routinely maintained, - under temperature controls: cold water shall be stored and distributed below 68 degrees F and hot water shall be stored above 140 degrees F and circulated at a minimum return temperature of 124 degrees F. Review of the Water Management Report dated 8/16/26, showed the Infection Prevention and Control Department has established and documented a comprehensive Water Management Program designed to reduce the risk of waterborne and water associated infections within the skilled nursing facility. Included in the report is the Water Temperature Monitoring wherein the water temperature parameters are based on applicable federal, California, local, plumbing, resident safety and manufacturer requirements. Monitoring includes representative locations throughout the facility with particular attention to the resident rooms and bathrooms, showers, therapy areas, low- use fixtures, areas with known temperature – control concerns, and hot water storage and distribution points when available. On 8/20/26 at 1325 hours, an interview and concurrent record review was conducted with the Housekeeping, Maintenance, and Laundry Manager. The Housekeeping, Maintenance and Laundry Manager stated she checked the four boilers monthly for the water management program and stated, I check the thermostat and the proper temperature should be 140 degrees F, we do not have this in the protocol (referring to the facility's P&P). The Housekeeping, Maintenance, and Laundry Manager further stated she checked for leaking around the boiler surroundings, checked the vent of the boiler to the ceiling set – up, and sometimes there was a disconnected tube, which was connected right away. When asked if there was anything else that was checked, the Housekeeping, Maintenance and Laundry Manager stated, no, that's it. Review of the facility's Monthly Boiler Inspection Log provided by the Housekeeping, Maintenance and Laundry Manager which showed the date of inspection and initials was conducted. The Housekeeping, Maintenance and Laundry Manager verified there was no temperature written or if there are any significant observations and corrective actions performed, to the monthly inspection documented like the disconnected tube which was mentioned during the previous interview. The IP was present during the verification and verified the findings. On 8/20/26 at 1426 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 3. Review of facility's P&P titled Enhanced Barrier Precautions revised 6/17/24, showed in part, it is the policy of the facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. EBP are indicated for residents with any of the following: wounds, indwelling medical devices e.g. Urinary catheters, feeding tubes even if the resident is not known to be infected or colonized with a MDRO (Multi Drug Resistant Organism- hard to treat bacteria, germs). Make gowns and gloves available prior to performing tasks. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities. Medical record review for Resident 12 was initiated on 8/17/26. Resident 12 was admitted to facility on 12/18/24, and was readmitted on [DATE], with a diagnosis of benign prostatic hyperplasia (benign enlargement of prostate gland) with lower urinary tract symptoms and obstructive and reflux uropathy (blockage in flow of the urine). Review of Resident 12's Order Summary Report dated 8/19/26, showed physician's orders: - dated 2/27/26, for Enhanced Barrier Precaution related to Foley Catheter. - dated 7/16/26, for indwelling catheter size FR 18, 10 cc balloon size, change for blockage, leaking, and when pulled out. On 8/17/26 at 0920 hours, during a follow up observation in Resident 12's room, the CSR (Central Supply Room) designee who is also a CNA, was observed fixing Resident 12's right leg underneath the blanket to extend the leg because the staff heard Resident 12 calling for help. The CSR Designee was not wearing a gown and mask while attending to Resident 12. The CSR Designee was asked if he knew the meaning of the signage on the door entrance to Resident 12's room. The CSR Designee stated he should have worn the appropriate PPE while doing high contact care on residents on EBP. At that same time, LVN 11 came to the door of Resident 12's room with the medication cart. LVN 11 observed/verified the CSR Designee was not observed to be wearing the appropriate PPE. On 8/20/26 at 1440 hours, an interview was conducted with the DON and Regional Resource person. The DON acknowledged the above findings. 4. On 8/17/26 at 1016 hours, during the initial tour of the facility, an observation and concurrent interview was conducted with Resident 140. Resident 140 was observed lying in bed with the urinal with urine on top of the overbed table beside the water pitcher. Resident 140 stated that he did not have a place to put the urinal. On 8/17/26 at 1022 hours, an observation and concurrent interview for Resident 140 was conducted with CNA 1. CNA 1 verified the urinal with urine on top of the overbed table with water pitcher. CNA 1 stated there should be no urinals on top of the overbed table for infection prevention. Medical record review for Resident 140 was initiated on 8/17/26. Resident 140 was admitted to the facility on [DATE]. Review of Resident 140's H&P examination dated 4/22/26, showed Resident 140 had the capacity to make medical decisions. On 8/20/26 at 0903 hours, an interview was conducted with the DON. The DON was asked about the process where the urinals should be placed. The DON stated that it was not supposed to be on top of the table, and needed to be at the side of the overbed table to prevent infection and sanitary purposes. The DON verified the above findings. On 8/20/26 at 1318 hours, an interview was conducted with the DON and Regional Clinical Consultant. The DON and Regional Clinical Consultant were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 140 residents (Resident 134) was assessed for safe self-administration of medications. * The facility failed to ensure Resident 134 was safe to administer the zinc oxide ointment (medication used to treat and prevent skin irritation) medication found at bedside. This failure had the potential for Residents 134 to administer the medication inaccurately and negatively impact the health and safety of the resident.Findings: Review of the facility's P&P titled Self-Administration of Medications dated 4/2008 showed the residents who desired to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents in the facility. All nurses and aides are required to report to the charge nurse on duty any medication found at the bedside not authorized for bedside storage and to give unauthorized medications to the charge nurse for return to the family or responsible party. Families or responsible parties are reminded of this procedure and related policy when necessary. On 8/17/26 at 0838 hours, during the initial tour of the facility, an observation and concurrent interview was conducted for Resident 134. Resident 134 was observed lying on her bed, and a jar of zinc oxide was observed on the bedside table in Resident 134's room. Resident 134 stated she uses the zinc oxide to give to the nurse to apply on her buttocks area after diaper change. Medical record review for Resident 134 was initiated on 8/17/26. Resident 134 was admitted to the facility on [DATE]. Review of Resident's 134 H&P examination dated 4/27/26, showed Resident 134 has the capacity to understand and make decisions. Review of Resident 134's Order Summary Report failed to show a physician's order for Resident 134 to self-administer medications. Review of Resident 134's plan of care did not show a care plan problem to address Resident 134's self-administration of medications. Further review of Resident 134's medical record failed to show a physician's order to self-administer medications, nor was an assessment completed for Resident 134 to safely self-administer medications. On 8/17/26 at 1101 hours, an observation interview and concurrent medical record review was conducted for Resident 134 with LVN 3. LVN 3 verified the zinc oxide at bedside and stated no medication should be left at bedside at all times, because leaving medication at the bedside had the potential for other staff, visitors, or residents to access prescription medication at any time. LVN 3 verified Resident 134 did not have a physician's order, assessment, and care plan for the self-administration of the zinc oxide. On 08/20/26 at 1318 hours, an interview was conducted with the DON and Regional Clinical Consultant. The DON and Regional Clinical Consultant was informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the residents were treated with privacy and dignity for two of 28 final sampled residents (Residents 9 and 10) and one nonsampled resident (Resident 154). * The facility failed to provide privacy to Resident 9 during GT medication administration.* The facility failed to provide privacy to Resident 10 while performing wound care. * The facility failed to provide Resident 154 with proper toileting equipment, causing urine to spill onto the floor and leading to the resident's discomfort and distress. These failures had the potential for the residents to feel disrespected, exposed, and ashamed.Findings: Review of the facility's P&P titled Resident Rights revised 11/2021 showed it is the facility's policy to treat all residents with respect, dignity, and to recognize each residents' individuality. 1. On 8/20/26 at 0840 hours, an observation was conducted of the Room B and C's shared restroom. A wheeled shower chair was observed over the toilet. The shower chair was elevated above the toilet seat, and had a padded seat with an opening in the center, similar in shape with the toilet seat. The shower chair's bilateral arm rests and the back had a mesh fabric A foot stool was observed stored in front of the toilet, under the shower chair. On 8/20/26 at 0845 hours, an interview was conducted with OT 1. OT 1 stated she and the PT evaluated the resident since she was admitted yesterday. OT 1 stated she and the PT were currently doing the resident's initial evaluation. OT 1 stated the facility has bedside commodes available, however OT 1 and the PT wanted to evaluate the resident first to ensure she could safely transfer to and use the bedside commode. On 8/20/26 at 0859 hours, an observation and concurrent interview was conducted with Resident 154 in Room B. Resident 154 was sitting in a wheelchair. Resident 154 stated the staff provided her with a shower chair over the toilet to use for toileting, but when the resident pees, it gets all over the floor. The resident looked down at her lap, made a small gesture, looked up, and said that it bothered her when there was urine on the floor. On 8/20/26 at 1150 hours, an interview was conducted with CNA 2. CNA 2 stated she was assigned to Resident 154 today and yesterday, but only for approximately 15 minutes or so because the resident was admitted at the end of her shift yesterday. CNA 2 stated she had not transferred the resident to the shower chair over the toilet today because the resident wanted to wear an incontinent brief. CNA 2 stated once the resident received the bedside commode, the resident requested to wear underwear instead of the incontinent brief. On 8/20/26 at 1203 hours, a telephone interview was conducted with CNA 3. CNA 3 stated he was assigned to Resident 154 yesterday for his 1500 to 2300 hours shift. CNA 3 stated Resident 154 used a shower chair placed over the toilet twice during his shift. CNA 3 stated both times there was urine all over the floor and another CNA cleaned it up while he assisted the resident. 2. Medical record review for Resident 9 was initiated on 8/18/26. Resident 9 was admitted to the facility on [DATE]. Review of Resident 9's H&P examination dated 7/29/26, showed Resident 9 had no capacity to make decisions. Review of Resident 9's MDS assessment dated [DATE], showed Resident 9's BIMS score was 4, indicating severe cognitive impairment. Review of Resident 9's Order Summary Report dated 8/18/26, showed physician's order dated 7/28/26, for enteral feed order every shift for tube feeding placement check. On 8/18/26 at 0809 hours, during medication observation, LVN 1 did not close Resident 9's privacy curtain and door prior to checking the resident's GT placement. Resident 9's bed position was visible in the hallway. On 8/18/26 at 0918 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 did not close Resident 9's curtain for privacy prior to medication administration. LVN 1 verified the above findings. On 8/18/26 at 0934 hours, a follow-up interview was conducted with LVN 1. LVN 1 stated the licensed nurses must provide privacy prior to providing care and administration of medications to the residents by closing the curtain and door completely. On 8/20/26 at 1335 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 3. Medical record review for Resident 10 was initiated on 8/18/26. Resident 10 was admitted on [DATE]. Review of Resident 10's H&P examination dated 1/24/26, showed Resident 10 had a memory problem with dementia. Review of Resident 10's MDS assessment dated [DATE], showed Resident 10 had a BIMS Score of 3, indicating severe cognitive impairment. Review of Resident 10's Order Summary Report showed the following treatment orders: - dated 7/11/26, to cleanse left buttock MASD with superficial erosions and excoriations with normal saline, pat dry, apply zinc oxide (skin treatment) and cover with foam dressing daily and PRN if soiled or dislodged every day shift; and - dated 7/11/26, to cleanse right buttock MASD with superficial erosions and excoriations with normal saline, pat dry, apply zinc oxide and cover with foam dressing daily and PRN if soiled or dislodged every day shift. On 8/20/26 at 0906 hours, a wound care treatment observation for Resident 10 was conducted with LVNs 8 and 9. LVN 8 performed the wound care procedure while LVN 9 assisted the LVN by holding and positioning the resident. During the treatment, the privacy curtain between Beds 1 and 2 was not pulled. In addition, the glass wall on Bed 2's side was not covered, allowing visibility into and out of the room. On 8/20/26 at 1220 hours, an interview was conducted with LVN 8. LVN 8 verified the privacy curtain was not drawn between Beds 1 and 2 and the glass wall was visible during Resident 10's wound care treatment. LVN 8 stated they should have drawn the curtain to provide privacy. On 8/20/26 at 1426 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the residents were free from unnecessary psychotropic drugs for two of five final sampled residents (Residents 14 and 121) reviewed for unnecessary medications. * The facility failed to ensure informed consent was obtained prior to the administration of Resident 14's aripiprazole (antipsychotic medication).* The facility failed to ensure informed consent was obtained prior to administration of Resident 121's Risperdal (antipsychotic medication). In addition, the facility failed to ensure Resident 121's monthly behavior summary was accurate according to the total numbers of behavior episodes for the use of Risperdal medication in MAR. These failures had the potential for the residents to experience adverse effects from the psychotropic medications to not providing the correct data to the prescriber to adjust the dosage of the medications and negatively impact the residents' well-being.Findings: Review of the facility's P&P titled Psychotropic Medications revised on 10/2025 showed the following:- it is the policy of this facility to not use psychotropic medications as chemical restraints for the purpose of discipline or convenience and that chemical restraints are only initiated to treat a resident's medical symptoms and improve quality of life. Psychotropic medications are not administered without proper verification of informed consent;- residents will be reviewed for the use of psychotropic medications at a minimum of quarterly. If the resident is admitted with an order for psychotropic medications and informed consent has been verified, then the facility may include a brief assessment of the MDS completion is due but no later than 14 days after admission;- findings and assessments will be documented in the progress notes in accordance with the documentation policy and residents will have documented a plan of care on the long-term care plan that addresses the behavioral problem(s) with goals and interventions to the behavior(s); and- the IDT will check the physician orders for the medication includes the name of the medication, dose, route, times, and behavior(s) for which the medication is being administered. The order shall also include monitoring requirements for the behavior(s). Review of the facility's P&P titled Informed Consent revised on 10/2025 showed an informed consent will be verified by the facility with each order. In the event the physician has not obtained informed consent and/or the facility cannot verify such informed consent, then the facility may not administer psychotropic medications and/or physical restraints or commence any medical procedures requiring informed consent unless there is an emergency where there is danger to self or others documented in the clinical record. Informed consent and verification forms will be used. 1. Medical record review for Resident 14 was initiated on 8/19/26. Resident 14 was admitted to the facility on [DATE], readmitted on [DATE]. Review of Resident 14's H&P examination dated 4/14/26, showed Resident 14 had the capacity to understand and make decisions. Review of Resident 14's Order Summary Report showed physician's order dated 5/8/26, for aripiprazole oral tablet 5 mg, give one tablet by mouth one time a day for schizophrenia manifested by verbalizing hallucinations. Review of Resident 14's MDS assessment dated [DATE], showed Resident 14's BIMS score was 13, indicating intact cognition. Further review of Resident 14's medical record failed to show documented evidence an informed consent was obtained for the aripiprazole medication. On 8/19/26 at 0943 hours, an interview and concurrent medical record review for Resident 121 was conducted with RN 2. RN 2 verified there was no documented evidence an informed consent was obtained for the use of the aripiprazole medication ordered on 5/8/26. 2. Medical record review for Resident 121 was initiated on 8/19/26. Resident 121 was admitted to the facility on [DATE], readmitted on [DATE]. Review of Resident 121's Order Summary Report showed a physician's order dated 3/26/26, for Risperdal oral tablet 0.5 mg, give one tablet via GT two times a day for schizophrenia manifested by screaming or disruptive noises. Monitor episodes of screaming and disruptive noises every shift. Review of Resident 121's H&P examination dated 4/11/26, showed the resident had no capacity to understand and make decisions. Review of Resident 121's MDS assessment dated [DATE], showed Resident 121's BIMS score was 0 (zero), indicating severely impaired cognition. Review of Resident 121's MAR for June and July 2026 showed the following number of behavioral episodes for the Risperdal medication:- for June 2026, a total of 18 behavioral episodes; and- for July 2026, no episodes were documented. Review of Resident 121's Psychopharmaceutical Summary sheet for June and July 2026 showed the following number of behavioral episodes for the Risperdal medication:- for June 2026, a total of 16 behavioral episodes; and- for July 2026, no episodes were documented. Further review of Resident 121's medical record failed to show documented evidence an informed consent was obtained for the Risperdal medication. On 8/19/26 at 1003 hours, an interview and concurrent medical record review for Resident 121 was conducted with RN 2. RN 2 verified the above findings. RN 2 stated an informed consent must be obtained prior to the administration of any psychotropic medications. RN 2 stated if a resident was readmitted after 24 hours, a new informed consent must be obtained. In addition, RN 2 stated monthly summary of behavior episodes must be accurate and completed. RN 2 stated negative impact of inaccurate and incomplete monthly behavioral summary would affect the psychiatrist's recommendation and evaluation of the medication's effectiveness. On 8/20/26 at 1335 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, medical record review, and P&P review, the facility failed to develop a comprehensive person-centered care plan for one of 28 final sampled residents (Resident 15), one of three sampled residents (Resident 145) reviewed for closed records and one nonsampled resident (Resident 89). * The facility failed to develop a care plan addressing the use of a LAL mattress for Resident 15, who had a Stage 4 pressure injury on his right lateral malleolus. * The facility failed to develop a care plan addressing the use of the high perimeter or bolster mattress for Resident 89. *The facility failed to develop a care plan addressing the presence and management of Resident 145's central line. These failures posed the risk of not providing appropriate, consistent, and individualized care to the residents.Findings: Review of the facility's P&P titled Interdisciplinary Team Guidelines, Care Planning reviewed 10/2025 showed in part, it is the policy of this facility to include appropriate members of the IDT in the care planning process to effectuate, as appropriate, person-centered care. General guidelines are set forth and followed per the CMS RAI manual. 1. On 8/17/26 at 1124 hours, an observation was conducted of Resident 15's room. Resident 15 was on a LAL mattress set at 250 psi. Medical record review for Resident 15 was initiated on 8/19/26. Resident 15 was initially admitted to facility on 5/12/26, and readmitted on [DATE]. Review of Resident 15's Order Summary showed a physician's order dated 7/15/26, for LAL mattress for skin maintenance and integrity. Adjust to fit resident's comfort or weight. Monitor every shift for proper function. Review of Resident 15's care plan failed to show a care plan problem was developed to address the use of the LAL mattress. On 8/20/26 at 0955 hours, an interview and concurrent medical record review for Resident 15 was conducted with RN 2. RN 2 verified Resident 15 used a LAL mattress for skin maintenance. RN 2 verified there was no care plan developed for Resident 15's use of the LAL mattress. 2. On 8/17/26 at 0848 hours, an observation was conducted of Resident 89's room. Resident 89 was lying on her LAL mattress with the bilateral upper and lower bolsters. Resident 89 did not respond verbally to simple questions and conversations. Medical record review for Resident 89 was initiated on 8/17/26. Resident 89 was initially admitted to facility on 1/4/24, and was readmitted on [DATE]. On 8/19/26 at 1029 hours, an observation and concurrent interview was conducted with LVN 2 in Resident 89's room. LVN 2 stated the purpose of the bolster was to support the turning and to keep Resident 89 in the middle of the bed to prevent from sliding as a fall prevention. Review of Resident 89's care plan failed to show a care plan problem was developed to address the use of the high perimeter or bolster mattress. On 8/19/26 at 1047 hours, an interview and concurrent medical record review for Resident 89 was conducted with RN 5. RN 5 verified there was no care plan for Resident 89's use of the high perimeter or bolster mattress. On 8/19/26 at 1124 hours, an interview and concurrent medical record review for Resident 89 was conducted with the DON. The DON verified the use of the high perimeter or bolster mattress was not in the care plan and should have been included. 3. Medical record review for Resident 145 was initiated on 8/19/26. Resident 145 was admitted to the facility on [DATE]. Review of Resident 145's MDS assessment dated [DATE], showed Resident 145's BIMS score was 10, indicating moderate cognitive impairment. Review of Resident 145's Order Summary Report showed physician's order dated 5/30/26, for TPN infusion flow rate at 83 ml/hour for 24 hours continuously via central line. Review of Resident 145's care plan failed to show a care plan problem was developed to address the use and management of a central line. On 8/20/26 at 1028 hours, an interview and concurrent medical record review for Resident 145 was conducted with RN 2. RN 2 verified the findings and stated a care plan must be developed as a guide for the care to be implemented. On 8/20/26 at 1335 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure LVN 1 provided services meeting professional standards. * The facility failed to ensure LVN 1 prepared Resident 9's gabapentin (medication to treat nerve pain) 6 ml order via GT accurately. This failure posed the risk of the resident not receiving the correct dose as ordered by the physician.Findings: Review of the facility's P&P titled Medication Administration dated 10/2017 showed when administering potent medications on liquid or those requiring precise measurement, such as digoxin, devices provided by the manufacturer or obtained from the provider pharmacy like oral syringes are used to allow accurate measurement of doses. Medical record review for Resident 9 was initiated on 8/18/26. Resident 9 was admitted to the facility on [DATE]. Review of Resident 9's H&P examination dated 7/29/26, showed Resident 9 had no capacity to make decisions. Review of Resident 9's MDS assessment dated [DATE], showed Resident 9's BIMS score was 4, indicating severe cognitive impairment. Review of Resident 9's Order Summary Report showed physician's order dated 7/28/26, for gabapentin oral solution 300 mg/6 ml, give 6 ml via GT three times a day for neuropathy. On 8/18/26 at 0818 hours, during a medication observation, LVN 1 was observed pouring the gabapentin liquid in a medicine cup. LVN 1 checked it at eye level, however the medicine cup failed to show measurement marking for 6 ml. LVN 1 verified the medicine cup did not have a 6 ml mark to measure for accuracy and verified the findings. On 8/18/26 at 0934 hours, an interview was conducted with LVN 1. LVN 1 stated she should administer the correct dose by using a syringe to measure the liquid medication accurately. In addition, LVN 1 stated the negative outcome was a medication error. On 8/20/26 at 0945 hours, an interview and concurrent facility document review was conducted with the DSD. The DSD reviewed LVN 1's Medication Administration Competency dated 6/22/26, which showed LVN 1 completed the training for medication administration including administering medications for residents with GT. The DSD stated she would provide training and conduct another medication administration competency. On 8/20/26 at 1335 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. Cross reference to F755.

Based on interview, medical record, and facility P&P review, the facility failed to provide the necessary services to attain or maintain the highest practicable well-being for three of 28 final sampled residents (Residents 1, 13, and 150) and one of three sampled residents (Resident 146) reviewed for closed records. * The facility failed to ensure the insulin administration sites were rotated for Residents 1 and 13. * The facility failed to follow up on Resident 146's abnormal oxygen saturation and heart rate. * The facility failed to ensure Resident 150's change of bowel movement consistency was reported in a timely manner. These failures had the potential to negatively impact the residents. Findings: 1. Review of the facility's P&P titled General Documentation Guidelines 10/2025 showed it is the policy of this facility to document relevant findings in the clinical records specific to each individual resident's needs and condition. On [DATE] at 907 hours, an initial tour observation and concurrent interview was conducted with Resident 150 in Resident 150's room. Resident 150 had multiple creams and ointments at his windowsill. Resident 150 stated he needed the creams and ointments because he had diarrhea. On [DATE] at 1252 hours, a follow up observation and concurrent interview was conducted with Resident 150 in his room. Resident 150 did not want to eat and stated he had not eaten six meals because of his diarrhea. On [DATE] at 1256 hours, an interview was conducted with CNA 6. CNA 6 stated Resident 150 had loose, watery stools earlier in the morning which had started yesterday. CNA 6 further stated Resident 150 used to stand up before but yesterday he was weak and could not stand without assistance. CNA 6 stated the rehab therapist was there, and did not respond when asked if he reported Resident 150's loose stools to the nurse yesterday. CNA 6 stated he would report the resident's loose, watery stool and the resident not eating to the nurse today. Medical record review for Resident 150 was initiated on [DATE]. Resident 150 was admitted to the facility on [DATE]. Review of Resident 150's H&P examination dated [DATE], showed the resident was alert, oriented, and had right sided hemiparesis. Review of Resident 150's MDS assessment dated [DATE], showed the resident had a BIMS score of 12, indicating moderate cognitive impairment. Review of Resident 150's Bowel Elimination Report for [DATE] showed the following responses to bowel continence, amount of bowel movement and consistency of bowel movement: - dated [DATE] at 1339 hours: continent, formed/normal; - dated [DATE] at 2259 hours: continent, loose/diarrhea; - dated [DATE] at 1242 hours: no bowel movement, response not required; - dated [DATE] at 858 hours: continent, formed/normal; - dated [DATE] at 2248 hours: no bowel movement, response not required; - dated [DATE] at 608 hours: incontinent, loose /diarrhea; - dated [DATE] at 1202 hours: incontinent, loose/diarrhea; - dated [DATE] at 2142 hours: incontinent, loose/diarrhea; and - dated [DATE] at 2345 hours: no bowel movement; response not required. Review of Resident 150's Progress Notes from [DATE] to [DATE], did not show documentation of the loose bowel movements until the note entered on [DATE], which showed on [DATE] the charge nurse had reported three episodes of watery stools. On [DATE] at 1601 hours, an interview was conducted with the DON. The DON stated the staff were expected to report any changes in a resident's condition, including changes in bowel movements. The DON explained the CNAs were expected to document the resident's bowel elimination in the task section of the EHR including the amount and consistency of the bowel movement, and to report their observations to the nurse. The DON further stated the nurse was responsible for reviewing the resident's medications (such as determining whether to hold laxatives), assessing the resident, monitoring vital signs, reporting changes to the physician, and notifying the resident or the resident's responsible party of the observations and physician's orders. On [DATE] at 1451 hours, an interview was conducted with COTA 1. COTA 1 stated she worked with Resident 150 on [DATE] at the bedside and observed the resident was not his usual self. COTA 1 stated Resident 150 reported having diarrhea. COTA 1 stated she was also informed when a nurse informed her the resident had diarrhea, but could not recall which nurse told her. On [DATE] at 1426 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 2. Closed medical record review for Resident 146 was initiated on [DATE]. Resident 146 was readmitted to the facility on [DATE], and expired on [DATE]. Review of Resident 146's H&P examination dated [DATE], showed the resident was at an elevated risk for complications related to anticoagulation, recurrent hypoxic episodes, and decompensated heart failure. The facility will continue close monitoring or the resident's respiratory status including oxygen saturation, and cardiovascular status will be followed closely to include blood pressure and heart rate monitoring. Review of Resident 146's Weights and Vitals Summary for [DATE] showed the following: * For oxygen saturation: - dated [DATE] at 0906 hours, an oxygen saturation of 85%; - dated [DATE] at 0917 hours, an oxygen saturation of 84%; - dated [DATE] at 0917 hours, an oxygen saturation of 89%; The above results had warning alerts for exceeding the low parameter of 90% * For heart rate: - dated [DATE] at 1004 hours, a heart rate of 104 BPM; - dated [DATE] at 0921 hours, a heart rate of 102 BPM; and - dated [DATE] at 0917 hours, a heart rate of 109 BPM. The above heart rate results had warning alerts for exceeding the high parameter of 100 BPM. Review of Resident 146's medical record failed to show the physician was notified of the above abnormal vital signs. Review of Resident 146's Nurses Progress Note dated [DATE] at 2200 hours, showed at 2028 hours, the resident was noted to be unresponsive and pulseless. CPR was initiated and EMS was called. Paramedics arrived at 2038 hours, and took over the resident's care and continued rescue efforts until 2104 hours, when the resident was pronounced deceased . On [DATE] at 1428 hours, an interview and concurrent medical record review for Resident 146 was conducted with the DON. The DON stated the heart rates above 100 BPM and oxygen saturation below 92% were considered abnormal. The DON stated abnormal vital should always be rechecked to ensure they were accurate, and if still abnormal, the physician should be notified. The DON reviewed Resident 146's vital signs and verified the above oxygen saturations and heart rates are abnormal. The DON stated the CNA should have reported the abnormal vistal signs to the licensed nurse, the licensed nurse should recheck the abnormal vital signs and if the results are confirmed, the physician should have been notified. The DON reviewed Resident 146's medical record and verified there were no records to show the licensed nurse followed up on the abnormal vital signs to determine if they were accurate, and there was no record to show the above documented vital signs were reported to the physician or followed up on. On [DATE] at 1507 hours, an interview and concurrent medical record review for Resident 146 was conducted with CNA 4. CNA 4 stated she had been working as a CNA at the facility for six years. CNA 4 stated when she takes the vital signs and gets abnormal results, she always rechecks, and if they were still abnormal, she documents them in the EHR and notifies the nurse. CNA 4 stated the EHR also alerts to abnormal vital signs. CNA 4 stated when she gets low oxygen saturation results, she will use an alcohol wipe to make sure the probe sensor is clean, and make sure the resident's fingers aren't cold, because that will affect the results. For their heart rate, if it's too high, she will make sure their hand isn't shaky, since that can also affect the heart rate results. CNA 4 looked at Resident 146's abnormal vital signs above, and verified she took them, and documented them after she rechecked the vital signs. CNA 4 stated she notified the LVN for the resident, but could not recall who she told. CNA 4 stated her usual process for oxygen saturation below 90 and an elevated heart rate is to let the nurse know and then ask the nurse to recheck the vital signs. Review of the Daily Licensed Nurse Assignments for the day shift (0700-1900 hours) showed the following: - dated [DATE], LVN 7 was assigned to Resident 146; - dated [DATE], LVN 4 was assigned to Resident 146; and - dated [DATE], LVN 2 was assigned to Resident 146. On [DATE] at 1507 hours, an interview and concurrent medical record review for Resident 146 was conducted with LVN 2. LVN 2 stated she was not aware of Resident 146 having low oxygen saturation or an elevated heart rate. If a CNA reported abnormal vital signs, the nurse should recheck them and notify the physician. LVN 2 pulled up another resident's EHR and showed in the top right of the screen, where a table with recent vital signs was noted. LVN 2 stated abnormal vital signs have an alert symbol and if those are seen, the vitals should be rechecked. On [DATE] at 1534 hours, an interview and concurrent medical record review for Resident 146 was conducted with LVN 4. LVN 4 stated she was not aware of Resident 146 having low oxygen saturation or an elevated heart rate when she last had him. 3.a. Medical record review for Resident 1 was initiated on [DATE]. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's Order Summary Report showed a physician's order dated [DATE], for insulin Lispro 100 units/ml to be administered by subcutaneous injection, as per sliding scale before meals and at bedtime for diabetes. Review of Resident 1's Location of Administration Report for the month of [DATE], showed Resident 1's insulin injections sites were not rotated on the following dates and times: - On [DATE] at 1157 hours, the insulin was administered subcutaneously to Resident 1's left arm; - On [DATE] at 1830 hours, the insulin was administered subcutaneously to Resident 1's left arm; - On [DATE] at 1242 hours, the insulin was administered subcutaneously to Resident 1's left arm; - On [DATE] at 1835 hours, the insulin was administered subcutaneously to Resident 1's left arm; - On [DATE] at 1357 hours, the insulin was administered subcutaneously to Resident 1's left arm; - On [DATE] at 1752 hours, the insulin was administered subcutaneously to Resident 1's left arm; - On [DATE] at 1249 hours, the insulin was administered subcutaneously to Resident 1's left arm; - On [DATE] at 1207 hours, the insulin was administered subcutaneously to Resident 1's left arm; - On [DATE] at 2140 hours, the insulin was administered subcutaneously to Resident 1's left arm; - On [DATE] at 1145 hours, the insulin was administered subcutaneously to Resident 1's left arm; and - On [DATE] at 1818 hours, the insulin was administered subcutaneously to Resident 1's left arm. On [DATE] at 1030 hours, an interview was conducted with Resident 1. Resident 1 was asked if he had a preference as to where he received his insulin injections. Resident 1 stated the nurses could administer his insulin wherever they needed to. On [DATE] at 1039 hours, an interview and concurrent medical record review for Resident 1 was conducted with LVN 10. LVN 10 verified Resident 1's insulin injection sites were not rotated on the above listed dates and times. LVN 10 stated the injection sites should have been rotated to prevent lipohypertrophy, skin discomfort, and to promote insulin absorption. b. Medical record review for Resident 13 was initiated on [DATE]. Resident 13 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Review of Resident 13's H&P examination dated [DATE], showed the resident had the capacity to make medical decisions. Review of Resident 13's Order Summary Report showed a physician's order dated [DATE], for insulin Lispro 100 units/ml to be administered by subcutaneous injection, as per sliding scale before meals and at bedtime for diabetes. Review of Resident 13's Location of Administration Report for [DATE] showed the insulin Lispro was administered at the same injection site on the following dates: - On [DATE] at 2100 hours, the insulin was administered to the left lower quadrant of abdomen; - On [DATE] at 2100 hours, the insulin was administered to the left lower quadrant of abdomen; - On [DATE] at 2100 hours, the insulin was administered to the right arm; - On [DATE] at 2100 hours, the insulin was administered to the right arm; - On [DATE] at 2100 hours, the insulin was administered to the right arm; - On [DATE] at 2100 hours, the insulin was administered to the right arm; and - On [DATE] at 2100 hours, the insulin was administered to the right arm. On [DATE] at 1037 hours, an interview and concurrent medical record review for Resident 13 was conducted with RN 5. RN 5 stated prior to administering the insulin injection, the licensed nurse should check the MAR to see where the last administration site was. RN 5 further stated the insulin injection sites should be rotated to prevent complications of the skin from repeated injections to the same site. RN 5 reviewed Resident 13's MAR for [DATE] and verified the above findings. On [DATE] at 1318 hours, an interview was conducted with the DON and Regional Clinical Consultant. The DON and Regional Clinical Consultant was informed and acknowledged the above findings.

Based on observation, interview, medical record, and facility P&P review, the facility failed to ensure the necessary care was provided to prevent the deterioration of moisture associated skin damage (MASD) for one of five final residents reviewed for skin impairment (Resident 10). * The facility failed to ensure Resident 10's wound care treatment for the MASD to left and right buttocks were performed daily and as needed as ordered by the physician. This failure had the potential to negatively impact the resident's health outcome. Findings: Review of the facility's P&P titled General Documentation Guidelines dated 10/2025 showed it is the policy of the facility to document relevant findings in the clinical record specific to each individual resident's needs and condition. Medical Record review for Resident 10 was initiated on 8/18/26. Resident 10 was admitted on [DATE]. Review of Resident 10's H&P examination dated 1/24/26, showed Resident 10 had memory problem with Dementia. Review of Resident 10's MDS assessment dated [DATE], Section C for cognitive status, showed Resident 10 had a BIMS score of three, indicating severe cognitive impairment. Review of Resident 10's Order Summary Report showed the following orders:- dated 4/5/26, to cleanse left buttock MASD with soap and water, pat dry, apply zinc oxide (a white mineral compound primarily used as a protective skin treatment and a broad-spectrum, physical sunscreen. It is a skin barrier used for treating conditions like diaper rash, minor burns, cuts, and irritation) daily and PRN. The physician's order was discontinued on 7/11/26- dated 4/5/26, to cleanse right buttock MASD with soap and water, pat dry, apply zinc oxide daily and PRN. The physician's order was discontinued on 7/11/26- dated 7/11/26, to cleanse left buttock MASD with superficial erosions and excoriations with NS (normal saline), pat dry, apply zinc oxide and cover with foam dressing daily and PRN if soiled or dislodged, every day shift- dated 7/11/26, to cleanse right buttock MASD with superficial erosions and excoriations with NS, pat dry, apply zinc oxide and cover with foam dressing daily and PRN if soiled or dislodged, every day shift Review of the Resident 10's Skin Check Progress Notes dated 7/11/26, showed new physician's orders received and carried out and with Resident 10's care as follows:- repositioned in bed to offload sites,- collaborated with CNA and nursing staff to ensure resident is being repositioned every two hours and as needed,- clean and dry, call light within reach, bed in lowest position, - plan of care ongoing,- skin issue education: change /shift positions frequently, turn every two hours, moisture barrier, care of skin issue(s), treatment of skin issue. Review of the Resident 10's Skin Check Progress Notes dated 8/14/26 showed documentations for Resident 10 as follows:- skin issue note- resident is kept clean and dry to prevent further skin breakdown. - skin issue education- to change clothing / briefs, change /shift positions frequently, treatment of skin issue, moisture barrier, turn every two hours, care of skin issue(s).- to cleanse right buttock MASD with superficial erosions and excoriations with NS, pat dry, apply zinc oxide and cover with foam dressing daily and PRN if soiled or dislodged, every day shift, ordered on 7/11/26. Review of Resident 10's TAR for June and July 2026 showed Resident 150' treatment orders to left and right buttocks:- ordered on 4/5/26 and discontinued on 7/11/26, to cleanse left buttock MASD with soap and water, pat dry, apply zinc oxide daily and PRN, - ordered on 4/5/26 and discontinued on 7/11/26, to cleanse right buttock MASD with soap and water, pat dry, apply zinc oxide daily and PRN, - ordered on 7/11/26, to cleanse left buttock MASD with superficial erosions and excoriations with NS, pat dry, apply zinc oxide and cover with foam dressing daily and PRN if soiled or dislodged, every day shift. Review of Resident 10's TAR for June, July, and August 2026 showed documentation the left and buttocks treatment as being administered once daily as ordered. The TAR for June, July, and August 2026 did not reflect the treatment was provided on an as needed basis as ordered, despite Resident 10's bowel and bladder incontinence. Review of Resident 10's Nurses' Progress Notes dated June, July and August 2026 did not show documentation to address the wound care treatments to the left and right buttocks were done in addition to the once daily wound care treatments as ordered. Review of Resident 10's left and right buttocks MASD care plan initiated on 4/5/26, showed the following interventions:- keep skin clean, dry, and moisturize as ordered.- administer treatment/wound care as ordered. Update or clarify treatment orders PRN. On 8/20/26 at 915 hours, an interview and concurrent medical record review for Resident 10 was conducted with LVN 8. LVN 8 reported she performed wound care treatment to Resident 10's left and right buttocks as needed in addition to the daily wound care treatment as indicated. When asked where she documented the additional wound care treatment to the left and right buttocks since there was only one entry on each day documented on the TAR for June, July, and August 2026. LVN 8 stated it was entered in the nurses' progress notes. Review of the nurses' progress notes for June and July 2026 showed no documentation addressing any additional wound care treatment to the daily wound care documented in the TAR for June, July and August 2026. LVN 8 stated, I thought I did, I should have. Additionally, LVN 8 verified Resident 10's left and right buttocks had an exacerbation of existing MASD with superficial erosion/excoriation reported on 7/11/26, prompting changes in wound care treatment orders. When asked if the TARs for June and July 2026 were reviewed during the wound reassessment completed on 7/11/26, LVN 8 did not provide a response. On 8/20/26 at 0900 hours, a wound care treatment observation was conducted with LVN 8. LVN 8 performed the wound care treatment, assisted by LVN 9 in positioning Resident 10. Upon assessment, the left and right buttock MASD area showed excoriated open areas approximately larger than the last measurement documented on 7/11/26 as follows: - left buttock with length of 2 cm, width of 2 cm, and depth of 0.1 cm and- right buttock with length of 0.5 cm, width of 0.5 cm, and depth of 0 cm LVN 8 verified the findings observed during the treatment and stated, I will take care of it. On 8/20/26 at 0919 hours, an interview and concurrent medical record review for Resident 10 was conducted with RN 2. RN 2 verified there were no entries in the nurses' progress notes for June and July 2026 addressing as needed wound care treatment performed on Resident 10's left and right buttocks. RN 2 also confirmed there were no documentation for as needed wound care treatment entered in the TAR for June, July, or August 2026. RN2 stated, they should have done the treatment and signed the TAR or documented in the nurses' progress notes. On 8/20/26 at 1426 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed ensure adequate nutritional and hydration assessment, monitoring and care planning for two of 28 final sampled residents (Residents 11 and 150). * The facility failed to ensure effective monitoring of acceptable parameters of nutritional status when Resident 11 experienced severe weight loss of 20 lbs. The weight loss was not assessed and monitored and the physician was notified. * The facility failed to ensure a nutritional or hydration assessment was completed following observations of poor oral intake for Resident 150. These failures had the potential for adverse nutritional outcomes and negatively affected the nutritional needs of Residents 150 and 11. Findings: Review of the facility's P&P titled Nutritional Management dated 12/19/22, showed the following: - The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition; - Care plan implementation includes the resident's goals and preferences regarding nutrition will be reflected in the resident's plan of care, interventions will be individualized to address the specific needs of the resident to include disease specific interventions; - Monitoring of the resident's condition and care plan interventions will occur on an ongoing basis; and - The care plan will be updated as needed, such as when a resident's condition changes, goals are met or the resident changes his or her goals, interventions are determined to be ineffective, or as new causes of nutrition-related problems are identified. 1. Medical record review for Resident 150 was initiated on 8/17/26. Resident 150 was admitted to the facility on [DATE]. Review of Resident 150's H&P examination dated 7/1/26, showed the resident was alert, oriented, and with right-sided hemiparesis. Review of Resident 150's MDS dated [DATE], showed a BIMS score of 12, indicating moderate cognitive impairment. Review of Resident 150's Bowel Elimination Report showed Resident 150 had loose stools beginning 6/15/26. Review of Resident 150's Dietary Progress Notes from 7/1 to 8/20/26, showed no documentation addressing Resident 150's diarrhea and poor intake. Review of Resident 150's Nutritional assessment dated [DATE], documented the resident had excellent oral intake, which was adequate to meet estimated nutritional needs at that time. Review of Resident 150's progress notes showed a COC documentation dated 8/17/26, addressing Resident 150's multiple episodes of loose stools and plan of care. However, no subsequent nutritional reassessment was found following the COC documentation on 8/17/26. On 8/17/26 at 1252 hours, Resident 150's was observed declining lunch and stated, I haven't eaten six meals already. I have been having diarrhea since the other day. On 8/19/26 at 1445 hours, a follow-up room interview and concurrent observation was conducted with Resident 150. Resident 150 stated he continued to have diarrhea, and his urinal was observed with approximately 150 ml of dark colored urine. Resident 150 stated no one had addressed his poor appetite except for the CNAs and licensed nurses. Resident 150 stated no changes in food or drink offerings. When asked about preferences, he replied, I don't know what they have. On 8/19/26 at 1500 hours, an interview was conducted with the DSS. The DSS stated she was not aware of Resident 150's poor appetite or COC. The DSS went to assess the resident. 08/19/2026 at 1551 hours, the DSS returned and stated Resident 150 had no appetite to eat and provided his food and drink preferences. The DSS further stated she observed only Coke (type of soft drink) and water at the resident's bedside and stated, he should have been seen already before. On 8/20/26 at 1426 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 2. Medical record review for Resident 11 was initiated on 8/17/26. Resident 11 was admitted to the facility on [DATE]. Review of Resident 11's H&P examination dated 4/3/26, showed Resident 11 had the capacity to make medical decisions. Review of Resident 11's Weight Summary showed the following dates and weights: - dated 4/7/26, 135 lbs; - dated 4/9/26, 135 lbs; - dated 5/25/26, 135 lbs; - dated 6/4/26, 115 lbs, a weight loss of 20 lbs or 19.26 % from 4/7/26; and - dated 8/4/26, 115 lbs. However, further review of Resident 11's medical record failed to show documentation of a COC or notification to the physician and/or resident/responsible party following the weight loss of 20 lbs. on 6/4/26. Review of Resident 11's Nutrition progress note dated 6/12/26, showed a recommendation for lactobacillus (probiotic supplement), multivitamin with minerals (supplement), vitamin C (supplement) for 30 days and zinc (supplement) for 30 days. However, review of Resident 11's medical record failed to show follow-up with the physician. Review of Resident e-Interact Change of Condition Evaluation dated 7/9/26, documented the resident's weight loss of 20lbs and a recommendation from the primary physician for RD consult. Review of Resident 11's Nutritional assessment dated [DATE], showed a recommendation for CMP. However, further review of Resident 11's medical record failed to show the recommendation for CMP was followed up with the physician. Review of Resident 11's Order Summary Report dated 8/19/26, showed the following physician's orders: - dated 7/8/26, for regular puree diet, with thick liquid; and - dated 8/12/26, to administer Jevity 1.5 (enteral feeding formula) at 55 ml/hr for 20 hours to provide 1100 ml/1650 kcal per day, on at 1400 hours and off at 1000 or until the feeding dose was complete. On 8/19/26 at 1150 hours, an observation and concurrent interview was conducted with Resident 11. Resident 11 was observed in bed without GT enteral feeding connected. Resident 11 stated the enteral feeding was turned off and never turned back on. On 8/20/26 at 0814 hours, an interview was conducted with the RD. When the RD was asked about the process for the nutritional assessment for the residents, the RD stated they had 14 days after admission to check on the resident's diagnosis, medical and weight history to complete an initial nutritional assessment for residents. For significant weight loss, the IDT would meet to discuss the resident's weight loss, any recommendations and plan of care. The RD stated the recommendations discussed during the meeting was emailed to the DON and it was expected for the recommendations to be followed up with the physician within 72 hours. On 8/20/26 at 0831 hours, an interview and concurrent medical record review for Resident 11 was conducted with the DON. The DON stated a 10-lb or greater weight loss was significant and a COC should have been documented, and the physician and responsible party should have been notified. The DON verified the above findings. On 8/20/26 at 1318 hours, an interview was conducted with the DON and Regional Clinical Consultant. The DON and Regional Clinical Consultant were informed and acknowledged the above findings.

Based on observation, interview, and medical record review, the facility failed to provide the necessary care and services related to the GT feeding for two of three final sampled residents (Residents 11 and 88) reviewed for tube feedings. * The facility failed to ensure Residents 11 and 88 were administered the complete dose of the GT enteral feeding as per the physician's order. This failure had the potential to not meet Residents 11 and 88 nutritional needs and put the residents at risk for weight loss and/or dehydration. Findings: 1. Medical record review for Resident 88 was initiated on 8/17/26. Resident 88 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 88's MDS assessment dated [DATE], showed Resident 88 had severely impaired cognitive skills for daily decision making. Further review of Resident 88's MDS assessment dated [DATE], showed Resident 88 had a feeding tube and medical diagnosis of dysphagia (difficulty swallowing). Review of Resident 88's Order Summary Report dated 8/19/26, showed the following orders dated 8/12/26, to administer Jevity 1.5 (enteral feeding formula) at 55 ml/hr for 20 hours to provide 1100 ml/1650 kcal per day, on at 1400 hours and off at 1000 or until the feeding dose was complete. On 8/17/26 at 1019 hours, Resident 88 was observed in bed with Jevity 1.5 enteral feeding hanging and the GT feeding pump machine was turn off. On 8/17/26 at 1028 hours, an observation and concurrent interview for Resident 88 was conducted with LVN 3. Resident 88 was observed in bed with the GT feeding pump was turned off. LVN 3 verified Resident 88 was not connected with GT enteral feeding. When LVN 3 was asked to check Resident 88's GT feeding pump, the feeding pump showed feeding incomplete. The pump feeding history showed 225 ml left. LVN 3 verified Resident 88 did not receive the prescribed dose of 1100 ml of enteral feeding. On 8/18/26 at 0925 hours, Resident 88 was observed up in a wheelchair and was not connected to the GT enteral feeding. On 8/18/26 at 1030 hours, an interview for Resident 88 was conducted with LVN 5. When LVN 5 was asked to check Resident 88's GT feeding pump, the feeding pump showed feeding incomplete. LVN 5 was asked to check the feeding history. The pump feeding history showed 220 ml left. LVN 5 reviewed the resident's medical records and verified Resident 88 did not receive the prescribed dose of 1100 ml of the enteral feeding. 2. Medical record review for Resident 11 was initiated on 8/17/26. Resident 11 was admitted to the facility on [DATE]. Review of Resident 11's H&P examination dated 4/3/26, showed Resident 11 had the capacity to make medical decisions. Review of Resident 11's Order Summary Report dated 8/19/26, showed the following orders dated 7/15/26, to administer Jevity 1.5 (enteral feeding formula) at 70 ml/hr for 20 hours to provide 1400 ml/2100 kcal per day, on at 1400 hours and off at 1000 or until the feeding dose was complete. On 8/19/26 at 1150 hours, an observation and concurrent interview was conducted with Resident 11. Resident 11 was observed in bed and was not connected with GT enteral feeding. Resident 11 stated the enteral feeding was turned off and was never turn back on. On 8/19/26 at 1153 hours, an observation and concurrent interview was conducted for Resident 11 with RN 2. Resident 11 was observed in bed and was not connected with GT enteral feeding. RN 2 verified Resident 11 was not connected with the GT enteral feeding. When RN 2 was asked to check Resident 11's GT feeding pump, the feeding pump showed feeding incomplete. The pump feeding history showed 208 ml left. RN 2 verified Resident 11 did not receive the prescribed dose of 1400 ml of the enteral feeding. On 8/20/26 at 0903 hours an interview was conducted with the DON. The DON stated all the enteral feeding should be administered as per the physician's order. The DON further stated if the enteral feedings were not completely administered, there would be the potential risk of weight loss and/or dehydration. On 8/20/26 at 1318 hours, an interview was conducted with the DON and Regional Clinical Consultant. The DON and Regional Clinical Consultant was informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the IV accesses and properly provide IV care for one of 28 final sampled residents (Resident 111) and one of three sampled residents (Resident 145) reviewed for closed records. * The facility failed to ensure Resident 111's right upper arm midline catheter was changed as per the physician's order. * The facility failed to ensure Resident 145's Port-a-Cath central line was monitored and flushed every shift and as needed. These failures posed the risk of developing complications to the residents related to the use of the central and peripheral line catheter.Findings: Review of the facility's P&P titled Central Venous Catheter flushing dated 3/2023, showed the following: - to be performed by RNs and IV certified LVNs according to state law and facility policy; - a physician's order is required to flush a Central Venous Catheter. The order must include the flushing agent, strength or concentration, volume, and frequency; - use a 10 ml syringe or a syringe specifically designed to generate lower injection pressure; - all catheters are flushed between incompatible medications with normal saline or other flush solution as recommended by the manufacturer; - catheters must be flushed with the prescribed flushing agent following conversion of a continuous infusion therapy to an intermittent infusion therapy; - catheters must be flushed with prescribed flushing agent between intermittent ambulatory pump cassette changes; and - document in the medical records include but not limited to date and time, prescribed flushing agents, site assessment, resident response to procedure and/or medication, and resident teaching. 1. Medical record review for Resident 145 was initiated on 8/19/26. Resident 145 was admitted to the facility on [DATE]. Review of Resident 145's MDS assessment dated [DATE], showed Resident 145's BIMS score was 10, indicating moderate cognitive impairment. Review of Resident 145's Order Summary Report showed physician's order dated 5/30/26, for TPN infusion flow rate at 83 ml/hour x 24 hours continuously via Port-a-Cath central line. On 8/20/26 at 1028 hours, an interview and concurrent medical record review for Resident 145 was conducted with RN 2. RN 2 reviewed the above physician's order and verified it did not show the flushing and monitoring of the Port-a-Cath central line since 5/30/26. In addition, RN 2 stated central line must have an order for flushing with normal saline every shift and as needed. Furthermore, RN 2 stated the RNs must have an order for monitoring the central line for patency and signs and symptoms of infection every shift and as needed. On 8/20/26 at 1335 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 2. Review of the facility's P&P titled Midline Catheter Dressing Change dated 3/2023 showed the catheter dressing changes are to be performed by RNs and IV certified LVNs according to state law and facility policy. Dressing changes using transparent dressings are performed at least weekly. During the initial tour of the facility on 8/17/26 at 1010 hours, Resident 111 was observed lying in bed with right upper arm midline one lumen catheter on the right upper arm with transparent dressing dated 8/2/26. Resident 111 stated the midline catheter was used for his IV antibiotics. Medical record review for Resident 111 was initiated on 8/17/26. Resident 111 was admitted to the facility on [DATE]. Review of Resident 111's H&P examination dated 11/17/25, showed Resident 111 had capacity to make medical decisions. Review of Resident 111's Order Summary Report showed the following physician order dated 7/4/26, for midline transparent dressing change every seven days. On 8/17/26 at 1030 hours, an observation and concurrent interview was conducted with RN 1. RN 1 verified Resident 111 had a right upper arm midline dressing dated 8/2/26. RN 1 stated the midline dressing need to be changed weekly. On 8/20/26 at 0903 hours, an interview was conducted with the DON. The DON verified the above findings. The DON stated every week the midline dressing need to be change to prevent infection. On 8/20/26 at 1318 hours, an interview was conducted with the DON and Regional Clinical Consultant. The DON and Regional Clinical Consultant was informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide respiratory services in a safe and sanitary manner in accordance with the facility's P&P, for two nonsampled residents (Residents 37 and 138). * Residents 37 and 138's oxygen concentrator filters were not maintained in a sanitary manner. This failure had the potential for negative health outcomes for a highly vulnerable resident population related to poor infection control practices.Findings: Review of the facility's P&P titled Infection Prevention and Control Program revised 12/19/22, showed the facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. 1. Medical record review for Resident 37 was initiated on 8/17/26. Resident 37 was admitted to the facility on [DATE]. Review of Resident 37's Order Summary Report showed an order dated 4/25/26, for oxygen to be administered at a rate of two to five liters per minute via nasal canula, as needed for shortness of breath, to maintain an oxygen saturation greater or equal to 95%. Review of Resident 37's Care Plan Report showed an active care plan focus titled Asthma (undated). The care plan goal showed Resident 37 would remain free from complications of asthma. On 8/19/26 at 1559 hours, an observation and concurrent interview was conducted with Resident 37. Resident 37 was observed in her room . An oxygen concentrator was observed adjacent to Resident 37's bed. Resident 37 stated she utilized oxygen as needed when she had difficultly breathing. The oxygen concentrator contained a filter. The oxygen concentrator filter was observed with a large amount of dust and debris. On 8/19/26 at 1614 hours, an observation and concurrent interview was conducted with the Central Supply. The Central Supply verified Resident 37's oxygen concentrator filter was observed with a large amount of dust and debris. The Central Supply stated he conducted rounds throughout the facility every Monday. The Central Supply stated his rounds included observations of the residents' oxygen concentrator filters. The Central Supply stated he failed to conduct his Monday rounds this week for Resident 37's room and failed to inspect the oxygen concentrator filter. The Central Supply stated the oxygen concentrator filter needed to be cleaned. On 8/19/26 at 1620 hours, an observation and concurrent interview was conducted with the DON. The DON verified Resident 37's oxygen concentrator filter was observed with a large amount of dust and debris. The DON stated the filter needed to be cleaned or replaced for before Resident 37 utilized the oxygen concentrator again, for infection control. 2. Medical record review for Resident 138 was initiated on 8/17/26. Resident 138 was admitted to the facility on [DATE]. Review of Resident 138's Order Summary Report showed an order dated 3/12/26, for oxygen to be administered at a rate of two liters per minute via nasal canula, to maintain an oxygen saturation greater or equal to 90%. Review of Resident 138's Care Plan Report showed an active care plan focus titled COPD (undated). The care plan goal showed Resident 138 would remain free from signs and symptoms of respiratory infection. On 8/19/26 at 1627 hours, an observation and concurrent interview was conducted with the DON. Resident 138 was observed lying in bed receiving oxygen via an oxygen concentrator and nasal cannula. The oxygen concentrator was observed adjacent to Resident 138's bed. The oxygen concentrator was set to administer continuous oxygen at a rate of 2 liters per minute. The oxygen concentrator filter was observed with an unknown black substance. The DON verified the findings. The DON stated the filter needed to be cleaned or replaced, for infection control.

Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary pain management care and services for one of 28 final sampled residents (Resident 11). * The facility failed to administer the correct pain medication as per the physician's order for Resident 11's level of pain. This failure posed the risk for Resident 11 not to receive the appropriate and necessary interventions to manage the residents' pain.Findings: Review of the facility's P&P titled Pain Assessment revised 11/2021 shows it is the policy of the facility to assess residents for pain and provide adequate pain management as indicated. The facility considers pain assessment part of the vital signs process. Nursing and other personnel on each shift will assess residents during interactions with the residents. If the staff member noticing the resident in pain or distress is not a license nurse, he/she will report such findings to a licensed nurse in a timely manner. The licensed nurse shall upon receiving information that a resident is in pain or distress and/or by observation of pain or distress directly will assess the resident to determine the appropriate intervention. Medical record review for Resident 11 was initiated on 8/17/26. Resident 11 was admitted to the facility on [DATE]. Review of Resident 11's H&P examination dated 4/3/26, showed Resident 11 had the capacity to make medical decisions. Review of Resident 11's MAR for July 2026, showed the following physician's orders:- dated 6/26/26, to administer acetaminophen (pain reliever) 325 mg, to give two tablets by mouth every six hours as needed for mild-moderate pain 1-6 (using the 0-10 pain scale, 0=no pain and 10=worst pain); and-dated 7/20/26, to administer oxycodone-acetaminophen (pain medication) 7.5/325 mg, to give one tablet by mouth every six hours as needed for severe pain level of 7-10 (using the 0-10 pain scale, 0=no pain and 10=worst pain). Further review of Resident 11's MAR for July 2026 showed the resident was administered the following pain medications:- dated 7/17/26 at 2000 hours, acetaminophen 325 mg (two tablets) for a pain level of 8; and- dated 7/22/26 at 0837 hours, oxycodone-acetaminophen 7.5-325 mg for a pain level of 5. On 8/19/26 at 1600 hours, an interview and concurrent medical record review for Resident 11 was conducted with RN 2. RN 2 stated the pain medication would be administered as per the physician's order and within the parameters ordered. RN 2 further stated for the resident who reported pain, the licensed nurse would assess the resident's pain level prior to the administration of the pain medications. RN 2 verified Resident 11 was not given the correct pain medications according to the resident's reported pain level. On 8/20/26 at 1318 hours, an interview was conducted with the DON and Regional Clinical Consultant. The DON and Regional Clinical Consultant was informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the Consultant Pharmacist conducted a monthly MRR for one nonsampled resident (Resident 95) and failed to follow-up on the Consultant Pharmacist's recommendations timely for two of five final sampled residents (Residents 11 and 120) reviewed for unnecessary medications. * The Consultant Pharmacist's report for May 2026 failed to show Resident 95's MRR was reviewed by the pharmacist. * The Consultant Pharmacist's recommendations for July 2026 for Residents 11 and 120 were not followed up on timely. The recommendations were followed-up by facility staff on 8/18/26. These failures had the potential for the resident's receiving negative outcomes from unnecessary medications.Findings: Review of the facility's P&P titled IIIAIa: Medication Regimen Review (Monthly Report) dated 6/2021 showed the consultant will review each residents' medication regimen monthly. The MRR report will be provided to the facility within 72 hours. Recommendations will be acted upon by the facility staff and/or the prescriber. 1. Medical record review for Resident 95 was initiated on 8/18/26. Resident 95 was admitted to the facility on [DATE]. Review of the facility's MRR binder failed to show the MRR for May 2026 was reviewed by the Consultant Pharmacist. On 8/19/26 at 1018 hours, an interview and concurrent medical record review for Resident 95 was conducted with the DON. The DON reviewed the MRR for May 2026 and verified the report failed to show Resident 95 medication regimen was reviewed by the Consultant Pharmacist. The DON reviewed Resident 95's medial record and stated the resident was in the facility for all of May 2026 and should have had a MRR completed. 2. a. Review of NIH's NCBI Bookshelf, showed a resource titled Acetaminophen Toxicity dated 3/26/26, showed acetaminophen (a medication for pain) toxicity is the leading cause of acute liver failure, and has a maximum daily dose of 3 gm. Medical record review for Resident 11 was initiated on 8/17/26. Resident 11 was admitted to the facility on [DATE]. Review of the facility's MRR binder failed to show the consultant pharmacist MRR report for July 2026. Review of Resident 11's MAR for August 2026 showed the following physician's orders:- dated 6/26/26, for acetaminophen 750 mg, via GT every six hours PRN for pain level of one to six out of ten;- dated 7/20/26, for oxycodone-acetaminophen (medication for pain) 7.5-325 mg, administer one tablet by mouth every six hours PRN for severe pain, for a duration of 30 days. The order was discontinued on 8/1/26;- dated 8/1/26, for oxycodone-acetaminophen 7.5-325 mg, administer one tablet by mouth every six hours PRN for severe pain, for a duration of 30 days. The order was discontinued on 8/18/26; and- dated 8/18/26, for oxycodone-acetaminophen 7.5-325 mg, administer one tablet by mouth every six hours PRN for severe pain, for a duration of 30 days. Do not exceed 3 gm of acetaminophen in 24 hours, from all acetaminophen sources. On 8/18/26 at 0725 hours, an interview was conducted with the DON. The DON stated the Consultant Pharmacist conducted the MRR for Resident 11 during the week of 7/22/26, however the facility did not have the report yet. On 8/19/26 at 0949 hours, an interview was conducted with the Consultant Pharmacist. The Consultant Pharmacist stated he emailed July 2026's MRR report to the DON and Administrator on 7/27/26. b. Medical record review for Resident 120 was initiated on 8/17/26. Resident 120 was admitted to the facility on [DATE]. Review of Resident 120's MAR for August 2026 showed a physician's order dated 7/17/26, for Senna (a laxative) 17.2 gm daily for bowel maintenance. Review of Resident 120's Order Summary Report showed a physician's order dated 8/18/26, for Senna 17.2 gm daily for bowel management, hold for loose stools. Review of the facility's MRR binder failed to show a consultant pharmacist MRR report for July 2026. On 8/19/26 at 1018 hours, an interview was conducted with the DON. The DON stated she recently spoke to the Consultant Pharmacist, and he informed her he sent the July 2026's MRR reports for Residents 11 and 120 on 7/27/26. The DON stated she found the emailed report, and the QA Nurse was checking the nurses' stations to see if she could locate the MRR reports to show the facility followed up on the recommendations. On 8/19/26 at 1146 hours, the QA Nurse provided the Consultant Pharmacist's MRR report for July 2026 for Residents 11 and 120. Review of the report showed the Consultant Pharmacist made a recommendation for Resident 11's oxycodone-acetaminophen order and Resident 120's Senna medication order. For Resident 11, the recommendation showed the suggested daily dose of acetaminophen is 3 gm, and to update the resident's order to include not to exceed 3 gm of acetaminophen from all sources, in a 24 hour period. For Resident 120, the recommendation showed to consider adding hold for loose stools. On 8/19/26 at 1258 hours, a follow up interview and concurrent medical record review for Residents 11 and 120 was conducted with the DON. The DON stated the nursing staff were expected to follow up on the Consultant Pharmacist's recommendations within 72 hours of receiving the report. The DON stated the QA Nurse found the reports at a nurses' station and the follow-up was incomplete. The DON verified Residents 11 and 120's Consultant Pharmacist's recommendations were not followed up on timely.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of five sampled residents (Resident 11) reviewed for unnecessary medications was free from unnecessary medications. * The facility failed to follow the physician's order for metoprolol (medications to treat high blood pressure) medication by not administering the medication when Residents 11's systolic blood pressure was above 100 mmHg. This failure had the potential for Resident 11 not to receive necessary medications and to develop significant side effects.Findings: Review of the facility's P&P titled Medication Administration dated 10/2017 showed the medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medication do so only after they have familiarize themselves with the medication. Medications are administered in accordance with written orders of the attending physicians. Medical record review for Resident 11 was initiated on 8/17/26. Resident 11 was admitted to the facility on [DATE]. Review of Resident 11's H&P examination dated 4/3/26, showed Resident 11 had the capacity to make medical decisions. Review of Resident 11's Order Summary Report dated 8/19/26, showed a physician's order dated 4/2/26, to administer metoprolol 12.5 mg one tablet by mouth two times a day, hold if systolic blood pressure was below 100 mmHg or heart rate was below 60 beats per minute for hypertension (high blood pressure). Review of Resident 11's MAR for July 2026 failed to show Resident 11's metoprolol was administered on the following dates and times:- on 7/11/26 at 1700 hours, when the systolic blood pressure was 103 mmHg;- on 7/13/26 at 1700 hours, when the systolic blood pressure was 109 mmHg;- on 7/14/26 at 0900 hours, when the systolic blood pressure was 104 mmHg;- on 7/17/26 at 1700 hours, when the systolic blood pressure was 108 mmHg;- on 7/18/26 at 1700 hours, when the systolic blood pressure was 108 mmHg; and- on 7/26/26 at 1700 hours, when the systolic blood pressure was 108 mmHg; On 8/19/26 at 1600 hours, an interview and concurrent medical record review for Resident 11 was conducted with RN 2. RN 2 stated the licensed nurses check the resident's blood pressure prior to administering the antihypertensive medications. RN 2 stated if the blood pressure reading was within the ordered parameters, the medication should be administered; if the blood pressure reading was outside of the ordered parameters, the medication should be held. RN 2 reviewed Resident 11's medical record and verified the metoprolol medication was not administered even when Resident 11's systolic blood pressure was above 100 mmHg for the above dates and times. On 8/20/26 at 0903 hours, an interview was conducted with DON. The DON was informed of the above findings and stated the licensed nurses must follow the physician's order. The DON further stated the licensed nurses should have administered the blood pressure medication when the resident's systolic blood pressure was above 100 mmHg. On 8/20/26 at 1318 hours, an interview was conducted with the DON and Regional Clinical Consultant. The DON and Regional Clinical Consultant were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 7.69%. One of four licensed nurses (LVN 1) observed during the medication administration weas found to have made errors. * LVN 1 failed to administer the correct physician's order dosage for Resident 9's zinc sulfate (supplement). In addition, LVN 1 prepared and crushed Resident 9's Mucinex oral tablet extended release. These failures had the potential to negatively affect the resident's health condition.Findings: Review of the facility's P&P titled Medication Administration dated 10/2017 showed the following:- long-acting or enteric-coated dosage forms should generally not be crushed; an alternative should be sought; and- medications are administered in accordance with written orders of the attending physician. Medical record review for Resident 9 was initiated on 8/18/26. Resident 9 was admitted to the facility on [DATE]. Review of Resident 9's H&P examination dated 7/29/26, showed Resident 9 had no capacity to make decisions. Review of Resident 9's MDS assessment dated [DATE], showed Resident 9's BIMS score was 4, indicating severe cognitive impairment. Review of Resident 9's Order Summary Report showed the following physician's orders:- dated 7/31/26, Mucinex (expectorant medication) oral tablet extended release 12-hour 600 mg, give one tablet via GT every 12 hours for congestion; and- dated 8/11/26, zinc sulfate 220 mg, give one capsule by mouth one time a day. On 8/18/26 at 0818 hours, a medication administration observation for Resident 9 and concurrent interview was conducted with LVN 1. LVN 1 stated Resident 9's medications had to be administered via the GT. LVN 1 prepared the following medications for Resident 9:- one tablet of Mucinex extended release 600 mg (LVN 1 crushed the Mucinex with 15 ml of water); and- four tablets of zinc sulfate 50 mg (LVN 1 crushed the zinc sulfate with 15 ml of water), totaling 200 mg.; instead of 220 mg as per the physician's order. Then, LVN 1 crushed the zinc sulfate and Mucinex medications, mixed with 15 ml of water then administered to Resident 9 via GT. On 8/18/26 at 0934 hours, an interview was conducted with LVN 1. LVN 1 stated the licensed nurses must follow the physician's orders. LVN 1 further stated extended-release medications must not be crushed and the staff should have requested a liquid form of the medication to administer via GT. Furthermore, LVN 1 stated the negative outcome was a medication error. On 8/19/26 at 1333 hours, a telephone interview was conducted with the Consultant Pharmacist. The Consultant Pharmacist stated any extended release medications could not be crushed since they were a timed release and could lose their special delivery mechanism if crushed. On 8/20/26 at 1335 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the medical record was accurate for five of 28 sampled residents (Residents 1, 10, 13, 105, and 150 and one nonsampled resident (Resident 154) reviewed for accuracy in medical record. * 11 of Resident 1's medications and two of Resident 1's supplements showed to administer the resident's medications and supplements via GT. However, Resident 1 did not have a GT. * The facility failed to ensure Resident 10's Long Term Care Evaluations documentation under hearing status were accurate. * The facility failed to ensure Resident 13's blood pressure access site was accurately documented in the medical record. * The facility failed to ensure accuracy in documentation regarding the Advanced Directives for Resident 105. * The facility failed to ensure Resident 150's bowel movement description was accurately documented. * Resident 154's Controlled medication was not documented on the MAR for two doses of the hydrocodone-acetaminophen (controlled medication to relieve pain) pulled from the ADDS. These failures had the potential to negatively impact the residents' health management and outcomes due to inaccurate documentation, to not have the information to provide the necessary care and services, and had the potential to result in the residents' care needs not being met due to inaccurate medical information. Findings: 1. Review of the facility's P&P titled General Documentation Guidelines dated October 2025 showed it is the policy of this facility to document relevant findings in the clinical record specific to each individual resident's needs and condition. On 8/17/26 at 0942 hours, during the tour in Resident 10's room, Resident 10 was observed lying in bed with the eyeglasses on and motioned he could not hear, tapped his left ear then closed his eyes. Resident 10's roommate stated, he cannot hear. Medical Record review for Resident 10 was initiated on 8/18/26. Resident 10 was admitted to the facility on [DATE]. Review of Resident 10's H&P examination dated 1/24/26, showed Resident 10 had memory problems with Dementia. Review of Resident 10's MDS dated [DATE], under section B, showed under hearing Resident 10's ability to hear was moderately impaired with no hearing aid. Review of Resident 10's MDS assessment dated [DATE], under section C, showed Resident 10 has a BIMS score of three, indicating severe cognitive impairment. Review of Resident 10's Communication Care Plan dated 6/15/24, showed Resident 10 had a communication problem related to hearing deficit, deaf to both ears and was non-speaking. Review of Resident 10's Long Term Care Evaluation showed under section EENT hearing – ability to hear were as follows: - dated 7/28/26: adequate hearing - dated 8/3/36: moderately impaired - dated 8/10/26: adequate hearing On 8/18/26 0930 hours, an interview and concurrent medical record review for Resident 10 was conducted with RN 4. RN 4 stated Resident 10 was deaf. RN 4 verified Resident 10's Long Term Care Evaluation under section EENT hearing, ability to hear showed the following: - dated 7/28/26: adequate hearing - dated 8/3/36: moderately impaired - dated 8/10/26: adequate hearing When RN 4 was asked if the above documentations were accurate, RN 4 stated no, it should be highly impaired. RN 4 added the resident should be assessed before documenting the evaluation. On 8/18/26 at 0933 hours, an interview was conducted with CNA 10. CNA 10 verified Resident 10 had impaired hearing and stated, he's sort of deaf to both ears. CNA 10 further stated Resident 10 did not wear a hearing aid. On 8/18/26 at 1616 hours, an interview and concurrent medical record review for Resident 10 was conducted with the DON. The DON verified the above findings were inaccurate. The DON stated the entries documented in Resident 10's Long Term Care Evaluation under section EENT hearing, ability to hear, were completed inaccurately and it should have been impaired. 2. On 8/17/26 at 907 hours, an initial tour of the facility was conducted in Resident 150's room. Resident 150 stated, I have diarrhea. On 8/17/26 at 1252 hours, a follow up visit to Resident 150's room was conducted. Resident 150 stated, I haven't eaten six meals already. I have been having diarrhea since the other day. Review of Resident 150's Bowel Elimination Report showed the following responses to bowel continence, amount of bowel movement, and consistency of bowel movement: - 8/15/26 at 1339 hours: continent, formed/normal - 8/15/26 at 2259 hours: continent, loose/diarrhea -8/16/26 at 858 hours: continent, formed/normal -8/ 16/26 at 1242 hours: no bowel movement, response not required -8/16/26 at 2248 hours: no bowel movement, response not required -8/17/26 at 608 hours: incontinent, loose /diarrhea -8/17/26 at 1202 hours: incontinent, loose/diarrhea -8/17/26 at 2142 hours: incontinent, loose/diarrhea -8/17/26 at 2345 hours: no bowel movement; response not required On 8/17/26 at 1256 hours, an interview was conducted with CNA 7. CNA 7 stated Resident 150 had loose stools during the care earlier. CNA 7 further stated Resident 150's stools were loose and watery. CNA 7 was asked when Resident 150's diarrhea started, CNA 7 responded, the watery stools started yesterday, he used to stand up before, yesterday he was weak - not being able to stand, but rehab was there. CNA 7 did not respond when asked if he reported the watery stools of Resident 150 yesterday to the licensed nurse. On 8/18/26 1t 1601 hours, an interview and concurrent medical review for Resident 150 was conducted with the DON. The DON stated the CNAs document under the Task tab on the resident's medical record, if diarrhea was observed and reported to the nurse. The DON was informed of Resident 150's report of diarrhea since 8/15/26 and CNA 7's report of diarrhea since 8/16/26. The DON verified the documented entries on 8/16 and 8/17/26, were inaccurate based on Resident 150's and CNA 7's account. The DON was asked if the CNAs were supposed to document the number of diarrhea episodes, the DON responded supposedly, they should so we will know if the diarrhea is resolving and the treatment is effective. The DON added will have the staff re-inservice. On 8/20/26 at 0956 hours, a follow-up interview and a concurrent medical record review for Resident 150 was conducted with CNA 7. CNA 7 stated he could not remember who he reported the diarrhea on 8/16/26, and stated Resident 150 had loose stools twice and was really weak. CNA 7 was shown his documentation on Resident 150's bowel movement consistency which showed one bowel movement entry on 8/16/26 at 0858 hours: continent with formed/normal which was inconsistent with what he just stated of two loose stools on that day. CNA 7 stated oh no, I made a mistake, I'm sorry, I should have documented loose stools twice. On 8/20/26 at 1426 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 3. Medical record review for Resident 1 was initiated on 8/17/26. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's Order Summary Report dated 8/16/26, showed a list of Resident 1's active physician's orders for his medications and supplements. 11 of Resident 1's medications and two of supplements showed to administer medications via GT. Further review of Resident 1's medical record showed Resident 1 had his GT removed on 8/4/26, and since having his GT removed, Resident 1 received his medications and supplements orally. On 8/18/26 at 0930 hours, an interview and concurrent medical record review for Resident 1 was conducted with LVN 10. LVN 10 was assigned to care for Resident 1. LVN 10 stated Resident 1 had his GT removed on 8/4/26. LVN 10 stated after Resident 1 had his GT removed, she administered his medications and supplements orally. LVN 10 then reviewed Resident 1's active physician's orders for his medications and supplements and verified 11 of Resident 1's medications and two of supplements showed to administer via GT. LVN 10 stated the physician's orders would be clarified as Resident 1 no longer received his medications and supplements via GT. 4. Review of the facility's P&P titled IIA2: Medication Administration – General Guidelines revised October 2017 showed medications withheld or refused are documented on the MAR to show it why it was not administered. Medical record review for Resident 154 was initiated on 8/20/26. Resident 154 was admitted to the facility on [DATE]. Review of Resident 154's Order Summary Report showed the following physician's orders: - A discontinued order dated 8/19/26, for hydrocodone-acetaminophen 10-325 mg, administer one tablet by mouth every six hours PRN for severe pain. - A discontinued order dated 8/19/26, for hydrocodone-ibuprofen 10-200 mg, administer one tablet by mouth every four hours PRN for severe pain. - An active order dated 8/19/26, for hydrocodone-acetaminophen 10-325 mg, administer one tablet by mouth every four hours PRN for severe pain. (The order was discontinued on 8/19/26). Review of Resident 154's progress notes showed: - A nurses Progress Note dated 8/19/26 at 2245 hours, showed hydrocodone-acetaminophen 10-325 mg was retrieved form the ADDS and administered to the resident at 2245 hours. There was no active physician's order to administer the medication. - A nurses Progress Note dated 8/20/26 at 0336 hours, showed hydrocodone-acetaminophen 10-325 mg was retrieved form the ADDS and administered to the resident at 0335 hours, There was no active physician's order to administer the medication. Review of Resident 154's MAR for August 2026 failed to show the above medications were documented as administered in the MAR. On 8/20/26 at 1024 hours, an interview and concurrent medical record review was conducted with LVN 4. LVN 4 reviewed Resident 154's progress notes and MAR and verified the above findings. 5. Review of the facility's P&P titled Dialysis Resident, Care of revised 11/2021 showed it is the policy of this facility to provide nursing care to the dialysis resident in accordance with physicians orders, to maintain the patency of the AV shunt or Central Venous Catheter (CVC), and to minimize the risks of complications from the AV shunt or CVC. Maintain the AV shunt functionality by restricting the following in the shunt arm: no blood pressure. Medical record review for Resident 13 was initiated on 8/17/26. Resident 13 was admitted to the facility on [DATE], and was readmitted on [DATE]. Review of Resident 13's H&P examination dated 3/17/26, showed the resident had the capacity to make medical decisions. Review of Resident 13's MDS quarterly assessment dated [DATE], showed Resident 13 had an active diagnosis of end stage renal disease (ESRD) and dependence on dialysis. Review of Resident 13's Order Summary Report for August 2026 showed a physician's order dated 3/16/26, for no blood pressure, intravenous or blood draw on the left arm dialysis site. Review of Resident 13's documentation of blood pressure for July and August 2026 showed the following: - on 7/27/26 at 1949 hours, a blood pressure reading of 141/55 mmHg on the left arm; - on 7/28/26 at 1016 hours, a blood pressure reading of 138/70 mmHg on the left arm; - on 7/28/26 at 1713 hours, a blood pressure reading of 133/76 mmHg on the left arm; - on 7/29/26 at 0854 hours, a blood pressure reading of 135/76 mmHg on the left arm; - on 7/30/26 at 1914 hours, a blood pressure reading of 145/77 mmHg on the left arm; - on 8/4/26 at 0920 hours, a blood pressure reading of 144/76 mmHg on the left arm; - on 8/4/26 at 1806 hours, a blood pressure reading of 134/78 mmHg on the left arm; - on 8/5/26 at 0820 hours, a blood pressure reading of 137/76 mmHg on the left arm; - on 8/5/26 at 1821 hours, a blood pressure reading of 129/82 mmHg on the left arm; - on 8/10/26 at 0801 hours, a blood pressure reading of 114/64 mmHg on the left arm; - on 8/10/26 at 1749 hours, a blood pressure reading of 105/61 mmHg on the left arm; - on 8/15/26 at 1649 hours, a blood pressure reading of 105/50 mmHg on the left arm; - on 8/16/26 at 1736 hours, a blood pressure reading of 107/76 mmHg on the left arm; and - on 8/17/26 at 1853 hours, a blood pressure reading of 146/78 mmHg on the left arm. On 8/17/26 at 0858 hours, during the initial tour of the facility, Resident 13 was observed awake, lying in bed, with AV shunt noted on the left arm. Resident 13 stated she went to the dialysis every Monday, Wednesday, and Friday. Resident 13 stated she never allowed the licensed nurses to take her BP on the left upper arm. On 8/19/26 at 1037 hours, an interview and concurrent medical record review for Resident 13 was conducted with RN 5. RN 5 verified that Resident 13 had a left upper arm AV shunt and the documentation on the above blood pressure was documented as left upper arm. On 8/20/26 at 0903 hours, an interview and concurrent medical record review for Resident 13 was conducted with the DON. The DON verified the BPs were not taken on Resident 13's left arm and the documentation for the BP readings for July and August 2026 were inaccurate. The DON further stated taking the BP on the access site will increase the resident's risk for infection and blood clot to the left AV shunt. On 8/20/26 at 1318 hours, an interview was conducted with the DON and Regional Clinical Consultant. The DON and Regional Clinical Consultant were informed and acknowledged the above findings. 6. Medical record review for Resident 105 was initiated on 8/17/26. Resident 105 was admitted to facility on 6/20/23, and was readmitted on [DATE]. Review of Resident 105's POLST(Physician Order for Life Sustaining Treatment) dated 2/27/25, showed Resident 105 had no Advanced Directive. Review of Resident 105's SSD notes dated 5/28/26, showed an advanced directive was offered and reviewed with Agent A or emergency contact. On 8/18/26 at 1446 hours, an interview and concurrent medical record review for Resident 105 was conducted with the SSD. The SSD stated offering and review of the advanced directive were documented on the SSD notes. However, SSD verified there was no actual offering and review of the advanced directive done with Agent A or the emergency contact. On 8/20/26 at 1440 hours, the DON was made aware and acknowledged the above findings.

Based on observation, interview, medical record review, and facility document review, the facility failed to ensure the appropriate infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of infections were implemented as evidenced by: * The facility failed to assign dedicated healthcare personnel (licensed nurse and CNA) to work only on the COVID-19 positive care unit (Red Zone). The facility assigned one licensed nurse (on all shifts) and one CNA (on most shifts) to provide resident care to both the COVID-19 positive and negative residents. Due to not assigning dedicated healthcare personnel to work only on the COVID-19 positive unit, the staff went between the COVID-19 positive and negative units continuously throughout their shifts. These failures caused a COVID-19 outbreak at the facility resulting in six additional residents contracting COVID-19 and potentially contributed to Residents O and P's death from COVID-19 related complications. * The facility failed to consistently monitor for signs and symptoms of COVID-19 and assess the respiratory rates for two sampled residents (Residents 2 and 3) and 11 nonsampled residents (Residents C, D, E, F, G, H, I, J, K, L, and M) who were suspected with, exposed to, or confirmed with COVID-19. These failures posed the risk of the facility not accurately identifying infections and controlling the transmission of COVID-19 to the residents throughout the facility. On [DATE] at 1352 hours, the IJ situation was identified due to the following deficient practices: The facility failed to ensure the appropriate infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of infections were implemented as evidenced by: * The facility failed to assign dedicated healthcare personnel (licensed nurse and CNA) to work only on the COVID-19 positive care unit (Red Zone). The facility assigned one licensed nurse (on all shifts) and one CNA (on most shifts) to provide resident care to both the COVID-19 positive and negative residents. Due to not assigning dedicated healthcare personnel to work only on the COVID-19 positive unit, the staff went between the COVID-19 positive and negative units continuously throughout their shifts. These failures caused a COVID-19 outbreak at the facility, resulting in six additional residents contracting COVID-19 and potentially contributed to Residents O and P's deaths from COVID-19 related complications. On [DATE] at 1040 hours, the IJ was abated after the facility had implemented the following plan of corrective actions: * The facility assigned dedicated healthcare personnel to work on the COVID-19 positive unit. * In-services were provided on having dedicated healthcare personnel on the COVID-19 positive unit/Red Zone. * In-services were provided on not going to the other zones/areas of the facility when assigned to the Red Zone. Findings: 1. Review of the CDC's guidelines titled Responding to Coronavirus (COVID-19) in Nursing Homes updated [DATE], showed to assign dedicated healthcare personnel to work only on the COVID-19 positive care unit. At a minimum, this should include the primary nursing assistants and nurses assigned to care for these residents. Review of the California Department of Public Health's (CDPH) All Facilities Letter (AFL) ,[DATE] dated [DATE], showed the COVID-19 positive residents should be housed in a separate red area (building, unit, or wing) of the facility and have dedicated healthcare personnel who do not provide care for residents in other cohorts (residents who are not COVID-19 positive). Review of the Orange County Health Care Agency's Guidance on COVID-19 in SNFs (Skilled Nursing Facilities) dated [DATE], showed the Red Unit should have dedicated staff. The staff should not go from the Red Unit to another unit on the same day. Review of the CDPH's AFL ,[DATE].3 dated [DATE], showed this AFL requires all SNFs to report daily COVID-19 facility data (including any staffing shortages) to the CDPH via an online survey. This reporting is to ensure that California has the information necessary to respond to the COVID-19 outbreak and to provide resources and support to the SNFs. a. On [DATE] at 1110 hours, an interview was conducted with the Administrator and DON. The DON stated there were two residents in the Red Zone and 12 residents in the Yellow Zone for observation. The DON stated 10 of the residents in the Yellow Zone had completed their 14 days of observation and were going to be moved to the Green Zone. The DON stated the residents in the Yellow Zone were COVID-19 negative and did not have any COVID-19 related symptoms. On [DATE] at 1210 hours, LVN 10 was observed answering the resident call lights in the Yellow Zone. On [DATE] at 1504 hours, a tour of the Red Zone and concurrent interview with LVN 10 was conducted. Two residents (Residents 2 and C) were observed in the Red Zone. LVN 10, who was earlier observed answering resident call lights in the Yellow Zone, was observed working in the Red Zone. LVN 10 stated she was ending her shift working in the Red Zone. LVN 10 was asked who administered the morning medications to Residents 2 and C. LVN 10 stated she started her shift at approximately 0700 hours and worked in the Red Zone first to administer Residents 2 and C their morning medications. LVN 10 stated after she finished working in the Red Zone, she went to work in the Yellow Zone. LVN 10 stated she stayed in the Yellow Zone to administer the residents their morning and afternoon medications and returned to the Red Zone towards the end of her shift. LVN 10 was asked who tended to the residents in the Red Zone if they needed to be assessed or required a PRN (as needed) medication while she worked in the Yellow Zone. LVN 10 stated she would go to the Red Zone to administer the residents their PRN medications if they needed it and would return to the Yellow Zone to finish her work. Review of Resident 2 and C's Medication Administration Records showed on [DATE], LVN 10 administered the residents their morning medications. Review of Resident 3 and F's (residents in the Yellow Zone) Medication Administration Records showed on [DATE], LVN 10 administered Residents 3 and F their morning and afternoon medications (after first working in the Red Zone). LVN 10 verified the findings. On [DATE] at 1527 hours, an interview and concurrent facility document review was conducted with the DON. Review of the 7 AM - 3 PM Shift Assignment dated [DATE], showed one licensed nurse was assigned to both the Red and Yellow Zones. The DON was asked about staffing for the Red and Yellow Zones. The DON verified there was only one licensed nurse assigned to work in both Red and Yellow Zones. The DON verified the Red Zone was supposed to have its own dedicated staff and the staff should not go from the Red Zone to any other areas of the facility to prevent spreading COVID-19. The DON stated it was sometimes difficult to have adequate staffing. When asked about the facility's staffing contingency plan, the DON stated a licensed nurse was able to provide total care (perform both licensed nurse and CNA duties) if the census was low, offer overtime to the staff, or utilize contracted registry staffing services. On [DATE] at 0835 hours, an interview was conducted with RN 1. When asked about the residents in the Yellow Zone, RN 1 stated the residents in the Yellow Zone were all tested for COVID-19 on [DATE]. RN 1 stated Resident D's test result returned on [DATE], and showed Resident D was positive for COVID-19. RN 1 was asked about the Red Zone staffing. RN 1 stated the Red Zone did not have a dedicated licensed nurse. RN 1 stated the nurse from the previous shift was staying over until about 0900 hours. RN 1 stated the Red Zone would not have a nurse there until the afternoon, towards the end of LVN 10's shift, who was assigned to the Yellow Zone. RN 1 stated if the residents in the Red Zone needed anything, LVN 10 or herself would have to go to the Red Zone and return to the Yellow Zone to finish their work. On [DATE] at 0849 hours, an interview and concurrent medical record and facility document review was conducted with the Infection Preventionist. The Infection Preventionist stated the facility did not have any residents with COVID-19 approximately from the beginning of [DATE] until [DATE]. The Infection Preventionist stated Residents L and M tested positive for COVID-19 and were placed in the Red Zone on [DATE]. The Infection Preventionist stated the residents were kept in the Red Zone for at least 14 days. Review of the facility's COVID-19 Positive Case Line Listing showed the following: - Resident O developed shortness of breath on [DATE], and was transferred to the acute care hospital where he tested positive for COVID-19. The notes showed Resident O expired. The Infection Preventionist stated Resident O was transferred to the acute care hospital because he developed shortness of breath and had low oxygen saturation level while on the supplemental oxygen. The Infection Preventionist stated Resident O tested positive for COVID-19 and expired on the same day he was transferred to the acute care hospital. - Resident P tested positive for COVID-19 and was moved to the Red Zone on [DATE]. Resident P developed congestion and low oxygen saturation level on [DATE]. - Resident N tested positive for COVID-19 and was moved to the Red Zone on [DATE]. - Resident C tested positive for COVID-19 and was moved to the Red Zone on [DATE]. Resident C developed a cough on [DATE]. - Resident 2 tested positive for COVID-19 and was moved to the Red Zone on [DATE]. - Resident D tested positive for COVID-19 and was moved to the Red Zone on [DATE]. The Infection Preventionist verified the findings. Review of the facility's census dated [DATE], showed Residents L and M were in the Red Zone. The census also showed Residents C, D, N, O, P, and 2 were in the Yellow Zone as of [DATE]. The Infection Preventionist verified the findings. Review of the facility's Shift Assignments dated [DATE] to [DATE], showed the facility assigned only one licensed nurse (on all shifts) and one CNA (on most shifts) to provide resident care to both the COVID-19 positive residents in the Red Zone and to the negative COVID-19 residents who were in the Yellow Zone. The Infection Preventionist verified the findings. The Infection Preventionist stated she was previously unaware of the Red Zone's staffing situation. The Infection Preventionist verified the Red Zone was supposed to have dedicated staff to keep the staff from going from the Red Zone to the Yellow Zone to not spread, or to reduce the spread of COVID-19. The Infection Preventionist stated her biggest question about how the facility's latest COVID-19 outbreak occurred was now answered. The Infection Preventionist verified Residents C, D, N, O, P, and 2 were previously tested for COVID-19 and were negative. The Infection Preventionist was asked about the facility's visitation policy and if the residents were allowed to routinely leave the facility. The Infection Preventionist stated the facility did not allow in-person visitations and the residents were only allowed to leave if they had a medical appointment. The Infection Preventionist stated only Residents C and D routinely left the facility for their [MEDICAL TREATMENT] appointments. The Infection Preventionist stated she did not believe the other residents (N, O, P, and 2) had left the facility. On [DATE] at 1113 hours, an interview was conducted with CNA 9. CNA 9 verified she was sometimes assigned to work in both Red and Yellow Zones. CNA 9 stated she started working in the Red Zone first because there were less residents there. CNA 9 stated she started by taking their vital signs, providing ADL (activities of daily living) care like cleaning and changing the residents, serving the residents their food and assisting them to eat if they needed it, and emptying their urinary drainage bags if they had a urinary catheter. CNA 9 stated after she was done in the Red Zone she would go to the Yellow Zone. CNA 9 stated when she was assigned to both Red and Yellow Zones, it would require her to go back and forth between the zones throughout her shift because the residents needed care more than once per shift. On [DATE] at 1123 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified the residents were only allowed to leave the facility for medical appointments or for emergencies. RN 1 verified Residents N, O, P, and 2 had not left the facility since they were last admitted . On [DATE] at 1145 hours, an interview was conducted with CNA 1. CNA 1 verified she had previously been assigned to both Red and Yellow Zones. CNA 1 stated when she was assigned to both Red and Yellow Zones, she had to go back and forth between the Red and Yellow Zones during her shift to provide resident care. On [DATE] at 1352 hours, an interview was conducted with the Administrator. The Administrator stated he was aware the Red Zone required dedicated staff to only work on that unit, but the facility was having trouble getting staff. The Administrator stated he utilized the registry staffing services. On [DATE] at 1405 hours, the VP (Vice President) of Clinical Services, the District Director of Clinical Services, and the Administrator requested to speak to the survey team. The VP of Clinical Services asked where it stated the facility had to have dedicated staffing for the Red Zone. The VP of Clinical Services stated the facility had a staffing shortage and was staffing based on their staffing crisis contingency plan. However, review of the CDPH COVID-19 Facility Survey - SNF Survey Results Lookup Tool from [DATE] to [DATE], submitted by the DON showed the facility reported they had no urgent staffing needs and had no anticipated critical staffing shortages, and the facility did not contact the local public health or the state's Medical Health Operational Area Coordinator (MHOAC) to report and/or request assistance with staffing needs. On [DATE] at 1426 hours, an interview was conducted with the Administrator. The Administrator verified the facility did not report and/or request assistance with staffing needs to the local public health, CDPH, or MHOAC. On [DATE] at 1431 hours, an interview was conducted with the Scheduler. The Scheduler stated he was in regular contact with the registry staffing company. The Scheduler stated the registry staffing company could sometimes provide the requested staff and sometimes could not. The Scheduler stated he had morning and afternoon staffing meetings with the Administrator and DON to present to them what staff were available from the registry staffing company. When asked, the Scheduler stated the Administrator and DON did not request to get enough staffing from the registry to ensure the Red Zone had dedicated staffing. On [DATE] at 1511 hours, an interview was conducted with LVN 11. LVN 11 stated when she was assigned to the station, she was always assigned to work in both Red and Yellow Zones. LVN 11 stated there was no dedicated licensed nurse that stayed in the Red Zone and the nurses had to float back and forth between the Red and Yellow Zones during their shift. LVN 11 stated oftentimes there was only one CNA assigned to provide patient care to both the COVID-19 positive residents in the Red Zone and the COVID-19 negative residents in the Yellow Zone. b. On [DATE] at 0934 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 stated it had been the facility's practice to assign only one licensed nurse to work in both Red and Yellow Zones. The nurse had to go between the Red and Yellow Zones to administer the residents their medications. For example: * Resident L was tested positive for COVID-19 and placed in the Red Zone on [DATE]. Review of Resident L's EMAR Administration Details showed the licensed nurse administered Resident L's medications on the following dates and times: - [DATE] at 0828 hours, - [DATE] at 0804 hours, - [DATE] at 0804 hours, - [DATE] at 0820 hours, - [DATE] at 0848 hours, and - [DATE] at 0859 hours. The same nurse then went to the Yellow Zone to administer medications to the COVID-19 negative residents as follows: * Resident O, who was in the Yellow Zone, was administered medications on the following dates and times: - [DATE] at 0849 hours, - [DATE] at 0925 hours, - [DATE] at 0846 hours, and - [DATE] at 0940 hours. * Resident P, who was also in the Yellow Zone, was administered medication on the following dates and times: - [DATE] at 1120 hours, - [DATE] at 1141 hours, - [DATE] at 1030 hours, - [DATE] at 1159 hours, - [DATE] at 1111 hours, and - [DATE] at 1039 hours. c. Resident M was tested positive for COVID-19 and placed in the Red Zone on [DATE]. Review of Resident M's EMAR Administration Details showed the licensed nurse administered Resident M's medications on the following dates and times: - [DATE] at 1734 hours, - [DATE] at 1705 hours, - [DATE] at 1700 hours, - [DATE] at 1717 hours, - [DATE] at 1636 hours, and - [DATE] at 1723 hours. The same nurse then went to the Yellow Zone to administer medications to the COVID-19 negative residents as follows: * Resident O, who was in the Yellow Zone, was administered medications on the following dates and times: - [DATE], at 2029 hours, - [DATE] at 2053 hours, and - [DATE] at 2120 hours. * Resident P, who was also in the Yellow Zone, was administered medications on the following dates and times: -[DATE], at 1740 hours, -[DATE], at 1734 and 2010 hours, and -[DATE], at 1707 and 2042 hours. RN 1 verified the above findings. Review of the medical records for Residents O and P was initiated on [DATE], and showed the following: * Resident O was admitted to the facility on [DATE]. Review of Resident O's Progress Notes showed the following nursing entries dated: -[DATE] at 1454 hours, Resident O verbalized having trouble breathing, had sudden severe shortness of breath, and Resident O's respiratory rate was 40 (normal respirations are 12 to 20 breaths per minute). -[DATE] at 1917 hours (a late entry for [DATE]), Resident O passed away at 1748 hours at the acute care hospital (shortly after being transferred from the facility) due to shortness of breath. Review of Resident O's medical records from the acute care hospital dated [DATE], showed Resident O's chief complaint was respiratory distress. Resident O was tested positive for COVID-19. The physician's assessment and plan showed Resident O had septic shock (a life-threatening condition caused by a severe localized or system-wide infection), pneumonia due to COVID-19, and acute [MEDICAL CONDITION]. Resident O's medical records from the acute care hospital further showed that at 1948 hours, Resident O was apneic (cessation of breathing), pupils were fixed and dilated, had no spontaneous respiratory effort, and heart sounds and pulses were not palpable. Resident O was pronounced dead at the acute care hospital. * Resident P was admitted to the facility on [DATE]. Review of Resident P's Progress Notes showed the following nursing entries dated: - [DATE] at 1606 hours, Resident P was lethargic, had low oxygen saturation, and was unable to tolerate physical and occupational therapy. - [DATE] at 1120 hours, Resident P was tested positive for COVID-19 and transferred to the Red Zone. - [DATE] at 0705 hours, Resident P had a low-grade fever. - [DATE] at 1406 hours, Resident P was having difficulty swallowing, was not eating or drinking very much, continued to be lethargic, and had a cough. - [DATE] at 2009 hours, Resident P had shallow breathing and was bradycardic (abnormally low pulse). - [DATE] at 2101 hours, Resident P was not breathing and had no pulse. Resident P was pronounced dead at 2020 hours. RN 1 verified the above findings. 2. Review of the facility's COVID-19 Mitigation Plan revised [DATE], under Cohorting and Designation of space, showed the residents will be cohorted into three separate units. The Isolation Unit (Yellow) will accommodate the following residents: a. Admissions/Readmissions b. PUI (Person Under Investigation) - Exposed, test pending - Signs/Symptoms, test pending c. Other Possible Cohorts to be assessed on an individual case by case basis - Residents with frequent external appointments (i.e. [MEDICAL TREATMENT]) - Recovery as required by LHD (14 days after COVID is resolved) The Red Unit will accommodate COVID positive residents and the Green Unit will have COVID-Free residents only. Further review of the facility's COVID-19 Mitigation Plan, under the section for Resident Assessment showed the facility will document the vital signs, oxygen saturation levels, and temperatures of all residents each shift. New admissions, residents suspected with COVID-19, exposed to COVID-19 (PUI), or confirmed with COVID-19 will have an additional assessment of vital signs, including checking the temperatures, oxygen saturation levels, and respiratory rates two times per shift. Review of the facility's census dated [DATE], showed there were three residents (Residents 2, C, and D) residing in the Red Unit and 10 residents (Residents 3, E, F, G, H, I, J, K, L, and M) residing in the Yellow Unit. a. Medical record review for Resident 2 was initiated on [DATE]. Resident 2 was admitted to the facility on [DATE]. Review of the Medication Administration Record [REDACTED]. Review of Resident 2's Weights and Vitals Summary for [DATE] failed to show documentation the staff were consistently monitoring for the temperature, oxygen saturation level, and respiratory rate twice per shift as identified in the facility's COVID-19 Mitigation Plan. For example, Resident 2's temperature and respiratory rate were only documented once on ,[DATE], ,[DATE], ,[DATE], and [DATE]. b. Medical record review for Resident C was initiated on [DATE]. Resident C was admitted to the facility on [DATE]. Review of the Medication Administration Record [REDACTED]. There was no documented evidence showing Resident C was screened on ,[DATE] and [DATE], at 0000 and 0400 hours. Review of Resident C's Weights and Vitals Summary for [DATE] failed to show documentation the staff were monitoring Resident C's respiratory rate twice per shift as identified in the facility's COVID-19 Mitigation Plan. For example, Resident C's respiratory rates were only documented once on ,[DATE], ,[DATE], ,[DATE], ,[DATE], and [DATE]. c. Medical record review for Resident D was initiated on [DATE]. Resident D was admitted to the facility on [DATE]. Review of the Medication Administration Record [REDACTED]. There was no documented evidence showing Resident D was screened on ,[DATE] and [DATE], at 0000 and 0400 hours. Review of Resident D's Weights and Vitals Summary for [DATE] failed to show documentation the staff were monitoring for Resident D's respiratory rate twice per shift as identified in the facility's COVID-19 Mitigation Plan. Resident D's respiratory rates were only documented once on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and [DATE]. d. Medical record review for Resident E was initiated on [DATE]. Resident E was admitted to the facility on [DATE]. Review of the Medication Administration Record [REDACTED]. For example, there was no documentation showing Resident E was screened on ,[DATE], ,[DATE], and [DATE] at 0400 hours. Review of Resident E's Weights and Vitals Summary for [DATE] failed to show documentation the staff were monitoring for Resident E's respiratory rate twice per shift as identified in the facility's COVID-19 Mitigation Plan. For example, Resident E's respiratory rates were only documented once on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and [DATE]. e. Medical record review for Resident F was initiated on [DATE]. Resident F was admitted to the facility on [DATE]. Review of the Medication Administration Record [REDACTED]. Review of Resident F's Weights and Vitals Summary for [DATE] failed to show documentation the staff were monitoring for Resident F's respiratory rate twice per shift as identified in the facility's COVID-19 Mitigation Plan. f. Medical record review for Resident 3 was initiated on [DATE]. Resident 3 was admitted to the facility on [DATE]. Review of the Medication Administration Record [REDACTED]. There was no documented evidence showing Resident 3 was screened on [DATE] at 0400 hours. Review of Resident 3's Weights and Vitals Summary for [DATE] failed to show documentation the staff were monitoring for Resident 3's respiratory rate, twice per shift, as identified in the facility's COVID-19 Mitigation Plan. Resident 3's respiratory rates were only documented twice on [DATE], and once on [DATE]. g. Medical record review for Resident G was initiated on [DATE]. Resident G was readmitted to the facility on [DATE]. Review of the Medication Administration Record [REDACTED]. For example, there was no documented evidence showing Resident G was screened on ,[DATE] and [DATE] at 0000 and 0400 hours. Review of Resident G's Weights and Vitals Summary for [DATE] failed to show documentation the staff were monitoring for Resident G's respiratory rate twice per shift as identified in the facility's COVID-19 Mitigation Plan. Resident G's respiratory rates were only documented once on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and [DATE]. h. Medical record review for Resident H was initiated on [DATE]. Resident H was readmitted to the facility on [DATE]. Review of the Medication Administration Record [REDACTED]. There was no documented evidence showing Resident H was screened on ,[DATE], ,[DATE], ,[DATE], and [DATE] at 0000 and 0400 hours. Review of Resident H's Weights and Vitals Summary for [DATE] failed to show documentation the staff were monitoring for Resident H's respiratory rate twice per shift as identified in the facility's COVID-19 Mitigation Plan. Resident H's respiratory rates were only documented once on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE] ,[DATE], and [DATE]. i. Medical record review for Resident I was initiated on [DATE]. Resident I was readmitted to the facility on [DATE]. Review of the Medication Administration Record [REDACTED]. For example, there was no documented evidence showing Resident I was screened on ,[DATE] and [DATE] at 0100 and 0500 hours. Review of Resident I's Weights and Vitals Summary for [DATE] failed to show documentation the staff were monitoring for Resident I's respiratory rate twice per shift as identified in the facility's COVID-19 Mitigation Plan. Resident I's respiratory rates were only documented once on ,[DATE], ,[DATE], ,[DATE], ,[DATE], and [DATE]. j. Medical record review for Resident J was initiated on [DATE]. Resident J was admitted to the facility on [DATE]. Review of the Medication Administration Record [REDACTED]. For example, there was no documented evidence showing Resident J was screened on ,[DATE], ,[DATE], ,[DATE], and [DATE] at 2300 hours. Review of Resident J's Weights and Vitals Summary for [DATE] failed to show documentation the staff were monitoring for Resident J's respiratory rate twice per shift as identified in the facility's COVID-19 Mitigation Plan. Resident J's respiratory rates were only documented once on ,[DATE], ,[DATE], ,[DATE], ,[DATE], and [DATE]. k. Medical record review for Resident K was initiated on [DATE]. Resident K was admitted to the facility on [DATE]. Review of the Medication Administration Record [REDACTED]. For example, there was no documented evidence showing Resident K was screened on ,[DATE] and [DATE] at 0100 and 0500 hours. Review of Resident K's Weights and Vitals Summary for [DATE] failed to show documentation the staff were monitoring for Resident K's respiratory rate twice per shift as identified in the facility's COVID-19 Mitigation Plan. Resident K's respiratory rates were only documented once on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and [DATE]. l. Medical record review for Resident L was initiated on [DATE]. Resident L was admitted to the facility on [DATE]. Review of the Medication Administration Record [REDACTED]. For example, there was no documented evidence showing Resident L was screened on ,[DATE], ,[DATE], and [DATE] at 0000 and 0400 hours. Review of Resident L's Weights and Vitals Summary for [DATE] failed to show documentation the staff were monitoring for Resident L's respiratory rate twice per shift as identified in the facility's COVID-19 Mitigation Plan. Resident L's respiratory rates were only documented once on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and [DATE]. m. Medical record review for Resident M was initiated on [DATE]. Resident M was admitted to the facility on [DATE]. Review of the Medication Administration Record [REDACTED]. For example, there was no documented evidence showing Resident M was screened on ,[DATE] and [DATE] at 0000 and 0400 hours. Review of Resident M's Weights and Vitals Summary for [DATE] failed to show documentation the staff were monitoring for Resident M's respiratory rate twice per shift as identified in the facility's COVID-19 Mitigation Plan. Resident M's respiratory rates were only documented once on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and [DATE]. On [DATE] at 0912 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified the above findings. RN 1 stated all residents were to be monitored for signs and symptoms of COVID-19 every four hours. Staff monitored all residents for cough, shortness of breath, difficulty breathing, fever, chills, rigors, muscle pain, headache, sore throat, and new loss of taste or smell. In addition, the staff also monitored the residents' temperatures and oxygen saturation levels every four hours. RN 1 stated the vital signs documented in the MAR indicated [REDACTED]. RN 1 verified the staff only documented the COVID-19 screening in the MAR. When asked if the staff monitored the residents' respiratory rate, RN 1 replied the respiratory rate was monitored at least once per shift. RN 1 verified the staff did not monitor the residents' respiratory rate every four hours as part of the facility's COVID-19 screening. On [DATE] at 0943 hours, an in (TRUNCATED)

Based on observation, interview, and medical record review, the facility failed to provide the necessary care and services to ensure one of 24 final sampled residents (Resident 84) was free from accident hazards. * The front wheel of Resident 84's wheelchair slid into an uncovered drain on the smoking patio while she was self-propelling towards the covered area of the smoking patio. As a result, Resident 84 fell on to the ground and sustained a fracture to the left proximal femur (the thigh bone above the knee joint) and underwent a surgical procedure to repair the fracture. Findings: On 4/7/19 at 0844 hours, an interview was conducted with Resident 84. Resident 84 stated she sustained a fall and fracture while in the facility. Resident 84 stated she went out to the smoking patio to smoke when the front wheel of her wheelchair got caught in a drainage hole that was not covered. Resident 84 stated her wheelchair tipped over and she fell out of the wheelchair. She sustained a fracture to her left hip and had surgery to fix it. Medical record review for Resident 84 was initiated on 4/7/19. Resident 84 was admitted to the facility on [DATE], and was readmitted on [DATE]. Review of the Significant Change MDS dated [DATE], showed Resident 84 was cognitively intact. Review of the Fall Risk assessment dated [DATE], showed Resident 84 was a high risk for falls. Review of the Safe Smoking Evaluation dated 11/15/18, showed Resident 8 was determined a safe smoker and did not require supervision while smoking. Review of the Documentation Survey Report v2 (CNA's ADL flowsheet) for the month of January 2019 showed inconsistencies in the assistance provided and number of person(s) required to assist Resident 84 with locomotion off the unit (how the resident moved to and returned from off-unit locations). However, on 2/1 and 2/2/19, for the 0700 to 1500 hours shift, documentation showed Resident 84 was totally dependent on one person's physical assistance for locomotion off the unit. Review of the Maintenance Issues log for Station 2 from January 2019 to present failed to show any maintenance issues reported regarding the smoking patio. Review of the SBAR Communication Form and Progress Note dated 2/2/19, showed LVN 1 notified Resident 84's physician at 1220 hours regarding Resident 84's fall and complaint of left hip pain. Resident 84 was found lying on her left side on the smoking patio with her wheelchair beside her. Review of the Progress Notes showed an entry dated 2/2/19 at 1230 hours, by LVN 2, at approximately 1150 hours, showed Resident 84 went out to the smoking patio while it was raining. Resident 84 stated she was .going toward the wall furthest from entrance to smoking patio to be away from rain. Resident 84's wheelchair slid into the drain and fell to the side. Resident 84 was found lying on her left side next to her wheelchair. Resident 84 complained of left hip pain 8 out of 10 (on a pain scale of 0 to 10 with 0 = no pain and 10 = severe pain). Review of the Radiology Report showed an x-ray of the left hip was done on 2/2/19. The result showed a non-displaced fracture (alignment of the fractured bone) of the left proximal femur. Review of the Pain Evaluation on 2/2/19 at 1245 hours, showed Resident 84 experienced sharp, aching pain 7 out of 10 (severe pain) to the left hip almost constantly due to the fracture of the left hip status post fall. Review of the Medication Administration Record dated 2/2/19, showed Resident 84 was administered the following PRN (as needed) pain medications due to left hip pain: - At 1200 hours, [MEDICATION(S)] (a narcotic pain medication) 10-325 mg one tablet by mouth for pain 8 out of 10. - At 1230 hours, [MEDICATION(S)] (a narcotic pain medication) 50 mg one tablet by mouth for pain 8 out of 10. - At 1600 hours, [MEDICATION(S)] 10-325 mg one tablet by mouth for pain 6 out of 10. Further review of the Progress Notes showed the following: - An entry dated 2/2/19 at 1700 hours, by LVN 1 showed Resident 84 was transferred to the general acute care hospital. Resident 84 complained of pain 6 out of 10 to the left hip at 1600 hours and was given PRN [MEDICATION(S)] .with little relief noted. - An entry dated 2/4/19 at 1849 hours, by RN 3 showed Resident 84 was readmitted back to the facility from the general acute care hospital status post left hip ORIF (open reduction internal fixation - a type of surgery to fix broken bones where bones are held together with hardware like metal pins, plates, rods, or screws). Review of the Medication Administration Record for February 2019 showed on 2/5/19, Resident 84 was administered PRN [MEDICATION(S)] 10-325 mg one tablet for breakthrough pain of 7-8 out of 10 at 0144, 0700, 1103, 1609, and 2300 hours. On 4/8/19 at 1230 hours, an observation and concurrent interview were conducted with Residents 84 and 40. Both residents were observed sitting in their wheelchairs on the smoking patio. There was no staff member present. Resident 40 stated he witnessed Resident 84's fall on 2/2/19, and screamed for help. Resident 40 stated at the time of the fall, it was starting to drizzle. He and another resident (Resident 106) were on the smoking patio by the left side under the overhang. Resident 40 saw Resident 84 wheeling herself towards the right side of the smoking patio under the overhang (covered area), heading towards the umbrella located at the middle back portion of the smoking patio. Resident 84 stated by the time she got under the umbrella, the front wheel of her wheelchair got caught in the drainage hole, tipped over, and she fell out of her wheelchair. Residents 40 and 84 stated there were no warning signs nor any precautions regarding the uncovered drain hole. On 4/8/19 at 1547 hours and 4/9/19 at 0806 hours, an interview was conducted with the Maintenance Supervisor. The Maintenance Supervisor stated the drain on the smoking patio was covered by a metal drain cover (grate). The metal cover was heavy and one had to intentionally pick it up in order to remove it. The metal cover was heavy enough not to move by itself. The Maintenance Supervisor measured the uncovered drain as 7.5 inches in diameter and 29 inches deep. The width of the overhang surrounding the patio was 36 inches. The size of the smoking patio was 19 feet x 24 feet. The Maintenance Supervisor stated when it rained, the residents had to go under the overhang in order to get to the umbrella, which was the residents' only protection from the rain on the smoking patio. The drain was located beneath the umbrella. The Maintenance Supervisor stated he was not aware the drain on the smoking patio was not covered on 2/2/19, and nobody informed him about this. On 4/9/19 at 0806 hours, an interview was conducted with the Case Manager. The Case Manager stated she was the Manager On Duty (MOD) on 2/2/19. When she learned of Resident 84's fall, the Case Manager stated she interviewed the Maintenance Assistant and was told he removed the drain cover earlier that morning because there was debris and stuff inside the drain, to prevent flooding since they were expecting rain that day. The Case Manager stated there were no precaution signs placed near the uncovered drain to alert the residents. On 4/9/19 at 0824 hours, an interview was conducted with CNA 1. CNA 1 stated Resident 84's routine was to get out of bed to her wheelchair at around 1130 hours every day. Resident 84 then self-propelled to the smoking patio to smoke.all the time, that's her routine. CNA 1 stated Resident 84 went out to smoke by herself as she normally did on 2/2/19; the only difference was, it was raining that day. However, Resident 84 had been smoking outside when it was raining, that was not the first time Resident 84 went out to smoke when it was raining. On 4/9/19 at 0859 hours, an interview was conducted with the Maintenance Assistant. The Maintenance Assistant stated the facility had issues with flooding when it rained. However, on 2/2/19, the Maintenance Assistant stated he went to the smoking patio in the morning around 0755 hours, but did not check the drain. The last time he checked the drain was on Friday (2/1/19) and it was covered. The Maintenance Assistant stated he went out to the smoking patio again after he learned Resident 84 had a fall and found the drain uncovered; the metal cover was sitting on top of the trash can by the door. The Maintenance Assistant acknowledged there were no precautions nor warning signs provided to alert the residents of the uncovered drain and the drain was located under the umbrella used to protect the residents from the rain. The Maintenance Assistant stated he was supposed to check all the drains in the facility because they were expecting rain, but he only checked the drains outside. The Maintenance Assistant measured the front wheel of Resident 84's wheelchair at 7 inches in diameter. On 4/9/19 at 0923 hours, an interview was conducted with CNA 2. CNA 2 stated when Resident 84 fell on [DATE], it was raining .but not too hard. CNA 2 stated there were no instructions provided to the CNAs nor the residents not to smoke on the smoking patio when it rained. On 4/9/19 at 0935 hours, an interview was conducted with Resident 106. Resident 106 stated he and Resident 40 were on the smoking patio when Resident 84 fell on [DATE]. Resident 106 stated there were no instructions from facility staff not to go out to the smoking patio when it rained. On 4/9/19 at 0957 hours, a telephone interview was conducted with LVN 1. LVN 1 stated she was at her medication cart when she saw Resident 84 propelling in her wheelchair on 2/2/19. LVN 1 stated she did not say anything to Resident 84. LVN 1 stated she knew where Resident 84 was going. Resident 84 was going out to smoke, which she did every day. When it was raining in the past, the residents went out to the smoking patio to smoke. The smoking patio was the only designated smoking area in the facility. LVN 1 stated the maintenance staff did not inform the nursing staff the drain was not covered, so no precautions or warnings were given to the residents. On 4/9/19 at 1150 hours, an interview was conducted with LVN 7. LVN 7 stated a few minutes prior to Resident 84's fall, she saw Resident 84 wheeling herself out to the smoking patio. It was not raining at that time, it was starting to drizzle. LVN 7 stated there were no instructions not to let residents out because it was raining. When asked if they checked the smoking patio to ensure the residents safety, LVN 7 stated she never went outside to the smoking patio to check. On 4/9/19 at 1401 hours, an interview and concurrent facility document review was conducted with LVN 8. LVN 8 stated each nurses' station had a maintenance binder where they logged any maintenance issues. LVN 8 reviewed the log and verified there were no maintenance issues concerning the smoking patio in the log from January 2019 to present. On 4/9/19 at 1604 hours, an interview was conducted with RN 5. RN 5 stated there were no routine safety checks conducted on the smoking patio even when it rained. The residents went in and out of the patio unsupervised. RN 5 stated the smoking patio could get flooded when it rained. On 4/10/19 at 0807 hours, an interview was conducted with the OT. The OT stated he evaluated Resident 84 on 2/5/19, and provided therapy until 2/12/19. The OT stated Resident 84 was functionally the same; however, Resident 84 was very lethargic and was in a lot of pain. When asked if the fall and fracture had affected Resident 84's therapy, the OT stated it did affect Resident 84's overall drive and motivation. On 4/11/19 at 0920 hours, an interview was conducted with LVN 9. LVN 9 stated they did not conduct routine checks of the smoking patio and she would assume the Maintenance Department was responsible for checking. On 4/11/19 at 0954 hours, an interview was conducted with LVN 3. LVN 3 stated residents smoked on the smoking patio even when it rained. LVN 3 stated the smoking patio could get flooded when it rained. LVN 3 stated they did not conduct safety checks of the smoking patio on a routine basis, even when it rained. LVN 3 stated she had not seen Resident 84 attend group activities. Resident 84 socialized with other residents when smoking. On 4/11/19 at 1358 hours, a follow-up interview was conducted with Resident 84. Resident 84 stated the day she fell , there were no instructions from the staff not to smoke on the smoking patio. There were no warning signs nor precautions to avoid the uncovered drain. When asked how the fall and the fracture affected her, Resident 84 stated, before the fall, she experienced generalized muscle pain, now, she experienced dull and throbbing pain to her left thigh.I did not have this pain before. Resident 84 stated her fall could have been avoided if the facility staff were working on something they could have placed a .yellow tape to alert the residents. Resident 84 stated they were under the impression that everything was fixed after the flood. Resident 84 stated her activity and only form of socialization in this place was smoking.

Based on interview, medical record review, and facility document review, the facility failed to provide the necessary care and services to ensure adequate supervision was in place to prevent a fall, which resulted in injuries to one of three sampled residents (Resident 2). * Resident 2 fell to the floor while CNA 8 was providing incontinence care, sustaining a skin tear to the upper lip, right frontal scalp hematoma (abnormal collection of blood outside of a blood vessel), and fracture of the left distal femoral shaft (thigh bone above the knee joint). Findings: According to the Journal of the American Geriatrics Society (June 2005), an air-filled mattress compresses on the side to which a person moves, thus raising the center of the mattress and lowering the side. This may make it easier for a resident to slide off the mattress. Precautions may include following manufacturer equipment alerts and increasing supervision. Medical record review for Resident 2 was initiated on 8/11/17. Resident 2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the History and Physical Note dated 9/28/16, showed Resident 2 did not have the capacity to understand and make decisions. Review of the Fall Risk assessment dated [DATE], showed Resident 2 was assessed to be at high risk for falls. Review of Resident 2's plan of care showed a care plan problem with the initiation date of 9/28/15, to address the risk for falls. A revision to the interventions dated 5/1/17, showed two persons' assistance with transfers, bed mobility, and all ADL care, including incontinence care. Review of Resident 2's MDS dated [DATE], showed the resident had severe cognitive impairment and required total assistance of one to two persons for bed mobility, dressing, toilet use, and personal hygiene. Review of the Order Recap Report for August 2017 showed a physician's orders [REDACTED]. Review of the Service Document from the mattress company showed the LAL mattress was ordered and delivered for Resident 2 on 8/4/17. According to the LAL mattress manufacturer's specifications regarding safety information on resident migration, specialty bed products are designed to reduce/redistribute pressure and the shearing/friction forces on the resident's skin. The risk of inadvertent bed exit may be increased due to the nature of these products. Review of the plan of care did not show a care plan problem was developed or revised to address the safety precautions for the use of the LAL mattress. Review of the Incident/Accident Report prepared by RN 1 dated 8/5/17 at 2338 hours, showed CNA 8 was providing incontinence care to Resident 2 who was turned towards her right side. Resident 2 moved her arms, rolled off the mattress, and fell to the floor. Resident 2 sustained a skin tear on her upper lip and was later found to have a bruise on the right side of her face. The form stated the incident was also witnessed by RN 1. Review of the SBAR Communication Form and Progress Note dated 8/5/17, showed RN 1 notified Resident 2's physician at 2140 hours regarding Resident 2's fall. For the entry for functional status changes (compared to baseline), N/A was checked off. The other areas not checked off included falls and description of symptoms or signs. In the area for assessment by an RN, RN 1 documented the right face and upper lip small skin tears were noted. No other assessments were found. Review of the Skin - Head to Toe Skin Checks dated 8/5/17, showed Resident 2 was noted with bruises to the top of the scalp and the back of the head; and skin tears to the upper lip and face. There were no measurements included in the assessment. Review of the Progress Notes showed the following: - An entry dated 8/6/17 at 0457 hours, by RN 1 showed, on assessment bruise on forehead & back of the head noted, ice pack with lateral position applied. continue monitoring. - An entry dated 8/6/17 at 0558 hours, by LVN 7 showed a slight bump to the right side of Resident 2's head with purple discoloration was noted. New orders were obtained from the physician for a skull x-ray; - An entry dated 8/6/17 at 1615 hours, by RN 3 showed Resident 2 was noted to be moaning and grimacing during incontinence care. CNA 7 noticed Resident 2's left leg was flaccid, which was not normal for Resident 2. The x-rays were ordered and the result showed a fracture of the left distal femur. Resident 2 was transferred to the acute care hospital for further evaluation. Review of the ED record from the acute care hospital showed an x-ray of the left femur was done on 8/6/17. The result showed the following conclusions: comminuted (a break of the bone into more than two fragments), impacted (broken ends of the bone were jammed together), and displaced (the bone ends were displaced from their original position) fracture of the left distal femoral shaft (thigh bone above the knee joint). Review of the ED record showed a CT scan of the brain was done on 8/6/17. The conclusion included right frontal scalp hematoma. Review of the ED history and physical examination [REDACTED]. Review of the ADL flowsheets from 7/1 to 8/11/17, showed inconsistencies in the number of staff required to provide care for bed mobility, toileting, personal hygiene, dressing, and transfers. On 8/11/17 at 0916 hours, an interview was conducted with CNA 7. CNA 7 stated Resident 2 had required two persons' assistance for all ADL care before the fall. On 8/11/17 at 1020 hours, an interview was conducted with LVN 3. LVN 3 stated before the fall, Resident 2 required total assistance of two persons for her ADL care since she was contracted to the both upper and lower extremities. On 8/11/17 at 1030 hours, an interview was conducted with LVN 1. LVN 1 stated she had been the unit manager on the unit where Resident 2 resided. LVN 1 stated prior to the fall, Resident 2 had required two persons' assistance with care. On 8/11/17 at 1339 hours, an interview was conducted with Resident 2's RP. Resident 2's RP stated he came to visit Resident 2 every day during lunch and dinner time. Resident 2's RP stated he observed when the staff provided incontinence care, occasionally, two staff members would provide care, at times there would only be one staff person, depending on who the staff were. On 8/11/17 at 1516 hours, an interview was conducted with RN 1. RN 1 stated he witnessed Resident 2's fall on 8/5/17, at approximately 2130 hours. RN 1 also stated he saw Resident 2 roll over from the bed, hitting her left knee on the floor first, then her head hit the feeding pump pole standing next to her bed. RN 2 stated he assessed Resident 2 right away, however, did not try to assess range of motion of bilateral upper and lower extremities due to Resident 2 was contracted. On 8/11/17 at 1534 hours and 8/15/17 at 1606 hours, an interview was conducted with CNA 8. CNA 8 stated he worked the shift from 1500 to 2300 hours and was assigned to Resident 2. CNA 8 stated Resident 2 had always required one person's assistance with ADL care, including incontinence care. CNA 8 stated the only thing different that day was Resident 2's mattress was changed to a LAL from a regular mattress. CNA 8 stated before he provided incontinence care, he raised the bed up to his waist level (measured three and a half feet high) to protect himself from injury. CNA 8 turned Resident 2 to her right side, placed his left hand on Resident 2's left buttock, and wiped the buttocks with his right hand. CNA 2 stated Resident 2 made a sudden jerk, slid off the bed, and fell to the floor. CNA 8 stated he did not receive any in-service regarding the use of the LAL mattress. CNA 8 also stated he thought Resident 2 was not a fall risk because she had not had any prior falls. On 8/15/17 at 1642 hours, a telephone interview and concurrent medical record review was conducted with LVN 1. LVN 1 stated she received the order for the LAL mattress on 8/4/17. When asked if the care plan was updated when Resident 2's mattress was changed to a LAL, LVN 1 stated no. LVN 1 also stated there were no new interventions implemented for the risk for falls in reference to the use of the LAL mattress. When asked if she received an in-service regarding the use of LAL mattress, LVN 1 stated no. LVN 1 also acknowledged Resident 2 required two persons' assistance and the care plan was revised on 5/1/17; however, she failed to update the ADL care plan. On 8/17/17 at 1326 hours, a telephone interview and concurrent medical record review was conducted with RN 2. RN 2 verified the inconsistencies in the number of staff support required to provide care for Resident 2 from 7/1/17 to 8/11/17. Resident 2 had required one and two persons' assistance with bed mobility, toileting, personal hygiene, dressing, and transfers.

Based on observation, interview, clinical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development and promote healing of pressure ulcers for one of 24 sampled residents (Resident 11) and two nonsampled residents (Residents T and V) * Resident 11 informed staff of pain to the right heel for a week before the staff identified the resident had developed a DTI (deep tissue injury) to the right heel. This resulted in the resident requiring further treatment to attempt to heal the pressure ulcer, further discomfort due to having to wear a special boot, and posing the risk of a possible infection. * Resident V was incontinent and had no pressure ulcers upon admission to the facility on [DATE]. There was no care plan intervention to address incontinence care for the resident. Seven days later later, on 11/29/16, the resident developed a Stage III pressure ulcer to the coccyx (tailbone) area. Resident V's incontinence brief and wound dressing on his coccyx were observed to be heavily soaked with urine. The resident was not provided with necessary care timely to prevent worsening of the pressure ulcer due to the facility not having enough nursing staff to provide proper care for the residents throughout the facility. The facility had five CNAs on 12/12/16, during the 11-7 shift to care for 153 residents. Cross references to F312 and F353. * Resident T was admitted to the facility with a Stage IV pressure ulcer to the sacrococcyx area. The resident's pressure ulcer was observed to be covered with loose stool. There was no documentation the staff had turned, repositioned, checked every two hours, and provided the resident's pericare after each incontinence episode as care planned, due to the facility not having enough nursing staff to provide proper care for the residents throughout the facility. Cross references to F312 and F353. Findings: Review of the facility's P&P titled Skin Management dated 8/2012 showed upon admission, all residents are assessed for skin integrity by completing a head to toe physical assessment and completing the Braden Scale (for predicting pressure sore risk). Appropriate preventive surfaces of beds, wheelchairs, etc. will be implemented on all residents identified at risk (score of 18 or less on the Braden Scale). Following admission, the Braden Scale will be completed weekly for three additional weeks (for a total of four weeks, including admission). A weekly skin check will be conducted and documented on the Head to Toe Skin Check. 1. Review of the facility's Skin - Weekly Pressure Ulcer Record described a DTI as a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Clinical record review for Resident 11 was initiated on 11/30/16. Resident 11 was admitted to the facility on [DATE]. The MDS dated [DATE], showed Resident 11 to be cognitively intact. On 11/30/16 at 1630 hours, an interview was conducted with Resident 11. Resident 11 stated she needed assistance with bed mobility, transfers, and toileting. Resident 11 stated she had a sore on her right heel which needed treatment and had to wear a boot which was uncomfortable. Resident 11 stated she had been telling the staff her right heel was hurting for at least a week before the blister was found, but nobody had paid attention. Review of Resident 11's physician's orders [REDACTED]. Review of the Braden Scale for Predicting Pressure Sore Risk dated 10/13/16, showed Resident 11 was at moderate risk with slightly limited mobility (makes frequent though slight changes in body or extremity position independently). Friction and shear was a problem showing Resident 11 required moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. [DIAGNOSES REDACTED], contractures or agitation leads to almost constant friction. Review of the Head to Toe Skin Checks dated 10/13/16, showed Resident 11 was admitted with a Stage 1 pressure area (intact skin with non-blanchable redness) to the coccyx area, bruising to the right upper extremity, and redness to the left under-breast. There was no documentation of any skin breakdown on the heels. Review of Resident 11's care plan problem dated 10/14/16, titled Resident having Potential/Actual Skin Issues related to pressure ulcer related to mobility showed the interventions were to conduct weekly skin checks per facility protocol, document the findings, turn, and reposition frequently to decrease pressure. Review of the clinical record showed no documented evidence of any weekly skin checks and/or assessments as per the care plan. Review of the Nursing Weekly Summary showed no documented evidence the nurse had completed a weekly nursing summary to address the resident's weekly skin assessments. Not until 11/11/16 (almost four weeks since the resident's admission), a Nursing Weekly Summary was completed on 11/11/16, and showed Resident 11 did not have a pressure ulcer; the area for skin conditions was blank. However, review of the Weekly Pressure Ulcer Record dated 11/11/16, showed a new right heel DTI, measuring 3 cm (length) x 2 cm (width) of dark purple skin with an onset date of 11/9/16. Review of the Weekly Pressure Ulcer Record dated 11/29/16, showed a right heel DTI measured 4.5 cm x 4 cm and covered with black and purple colored skin. Review of Resident 11's care plan problem dated 11/30/16, titled ADL self-care performance deficit related to cervical fracture and chronic pain in the left shoulder showed Resident 11 was at risk for ADL decline and required extensive assistance of two staff persons for repositioning and turning in bed. On 12/5/16 at 1500 hours, an interview was conducted with RN 2. RN 2 verified Resident 11 was admitted without a pressure ulcer to the heels. RN 2 verified a skin assessment/weekly summary should be done weekly, but Resident 11 failed to have one completed until 11/11/16, four weeks after the admission Head to Toe Skin Check dated 10/13/16. RN 2 was unable to find any documentation of preventative care regarding Resident 11's heels. RN 2 verified Resident 11's right heel DTI could have been avoided. On 12/6/16 at 1000 hours, an interview and concurrent clinical record review was conducted with the DON. Upon review of the Incident/Accident Investigation Follow-Up dated 11/9/16, the DON verified the section showing past interventions attempted showed N/A (not applicable). The DON was unable to find any documentation of a skin assessment completed between 10/13 and 11/10/16, and was unable to find any documentation regarding preventative measures being done to prevent the right heel pressure ulcer. On 12/8/16 at 1345 hours, a telephone interview was conducted with the DON. The DON verified the facility's Skin Management P&P was not followed. A Braden Scale should have been completed weekly for three additional weeks following admission and a weekly skin check should have been conducted and documented for Resident 11, neither of which were completed. 2. On 12/13/16 at 0735 hours, CNA 15 was observed going in Resident V's room. CNA 15 stated she had changed Resident V's incontinence brief between 0100 to 0200 hours (more than five hours ago). Resident V's incontinence brief was observed soaked with urine. In addition, Resident V had a dressing on his coccyx which was also soaked with urine. CNA 15 was informed the dressing on Resident V's coccyx was soaked. CNA 15 stated the treatment nurse would change it later. CNA 15 was observed putting on a new incontinence brief over the soaked dressing to Resident V's coccyx. Clinical record review for Resident V was initiated on 12/13/16. Resident V was readmitted to the facility on [DATE]. The MDS dated [DATE], showed Resident V was incontinent of bowel and bladder. The Readmission Skin - Head to Toe Skin Check dated 11/22/16, showed Resident V's skin was intact. Review of Resident V's care plan showed a care plan problem to address increased risk for altered skin integrity. The interventions included providing pressure relieving cushion and low air low mattress. Further review of Resident V's care plan showed there was no intervention included to address Resident V's incontinence in preventing the development of pressure ulcers. The Skin - Head to Toe Skin Check dated 11/28/16, showed Resident V's skin was intact. The Skin - Head to Toe Skin Check dated 11/29/16, showed Resident V had a new stage III pressure ulcer to the coccyx, measuring 1.5 cm (length) x 1.2 cm (width) x 0.2 cm (depth). The Skin - Weekly Pressure Ulcer dated 12/2/16, showed Resident V's pressure ulcer on the coccyx measured 1.5 cm x 1.2 cm x 0.2 cm with 20% slough (dead tissue) with a small amount of serosanguineous (pinkish blood tinged) drainage. The Skin - Weekly Pressure Ulcer dated 12/9/16, showed Resident V's pressure ulcer on the coccyx measured 1 cm x 1.2 x 0.2 cm with 10% slough. On 12/13/16 at 1105 hours, LVN 1 was observed providing wound treatment to Resident V. LVN 1 was asked if Resident V developed the pressure ulcer while at the facility. LVN 1 replied yes. LVN 1 removed the dry dressing on Resident V's coccyx and measured the pressure ulcer. The measurements were 1.4 cm x 1.5 cm with superficial depth. During a telephone interview with RN 1 on 12/14/16 at 1130 hours, RN 1 acknowledged Resident V developed a new pressure ulcer on 11/29/16. RN 1 was asked what the facility's protocol was in identifying skin impairment. RN 1 stated the CNA who provided ADL care should report any skin impairment, i.e. redness, open area to the charge nurse. RN 1 stated the licensed nurse also completed a weekly summary of the resident's status, including a head to toe assessment. RN 1 was informed the Skin - Head to Toe Skin Check for Resident V dated 11/28/16, showed the resident's skin was intact and the next day (11/29/16), the documentation showed Resident V had a Stage III pressure ulcer. RN 1 verified the skin assessment dated [DATE], showed Resident V's skin was intact. RN 1 was asked if Resident V had redness to the coccyx. RN 1 replied the documentation showed no redness. RN 1 was unable to explain how Resident V had developed a Stage III pressure ulcer in one day. RN 1 was asked what interventions the facility should have implemented to prevent the development of a pressure ulcer. RN 1 replied the staff should have provided incontinence care every two hours and as needed. RN 1 was asked if the care plan problem to address increased risk for the development of pressure ulcers included an intervention to provide incontinence care every two hours and as needed. RN 1 acknowledged there was no intervention in the care plan to provide incontinence care every two hours and as needed. RN 1 was informed of the above observation of Resident V on 12/13/16 at 0735 hours. RN 1 acknowledged they were short-staffed during that shift and tried their best, but they did not get enough help. The facility had five CNAs on 12/12/16 during the 11-7 shift to care for 153 residents. 3. On 12/13/16 at 0515 hours, an interview was conducted with CNA 15. CNA 15 stated she was assigned to care for 30 Residents today because a few CNAs had called off. She started her shift with focusing on residents who needed their diapers changed. CNA 15 also stated she had six residents in one hallway who were incontinent and that was not including the other hallway she was assigned to. CNA 15 stated she also tried to answer the call lights in between changing her residents. On 12/13/16 at 0540 hours, CNA 15 was observed at resident T's bedside. Resident T was observed lying on her left side. CNA 15 initiated pericare by removing Resident T's incontinence brief. During the process of removing Resident T's incontinence brief, the dressing to Resident T's pressure ulcer fell off into the soiled brief, exposing the pressure ulcer. Loose stool was noted up on Resident T's lower back and around Resident T's pressure ulcer. CNA 15 wiped the stool from Resident T's lower back, removed the soiled brief and sheet, placed a new sheet under Resident T, and covered Resident T with a clean sheet. CNA 15 stated she needed to inform LVN 14 about placing a new dressing to Resident T's pressure ulcer before she placed a new brief on Resident T. CNA 15 then proceeded to inform LVN 14 of Resident T's dressing and continued with other Resident assignments. On 12/13/16 at 0620 hours, LVN 14 placed a new dressing to Resident T's pressure ulcer and completed Resident T's pericare. Resident T continued to lay on her left side. On 12/1316 at 0720 hours, an interview was conducted with CNA 15. CNA 15 stated she typically changed a Resident's diaper every two hours. CNA 15 stated Resident T was last changed between 0100 and 0200 hours this morning. CNA 15 stated she changed and turned her residents with pressure ulcers every two hours, but I'm not going to lie; a night like tonight, it is impossible to get to everyone on time. Clinical record review for Resident T was initiated on 12/13/16. Resident T was admitted to the facility on [DATE]. Review of the MDS dated [DATE], showed Resident T had severe cognitive impairment was incontinent of bowel and bladder with a urinary catheter in place. Resident T was admitted to the facility on [DATE], with a Stage IV pressure ulcer to the sacrococcyx area (tailbone). Review of Resident T's care plan showed a care plan problem to address bowel incontinence. The interventions included checking the resident every two hours and providing pericare after each incontinent episode. Further review of Resident T's care plan showed a care plan problem to address the pressure ulcer. The interventions included to provide wound care and preventative skin care, and turn and reposition frequently. On 12/13/16 at 0830 hours, 0930 hours, Resident T was observed lying on her left side. On 12/13/16 at 0945 hours, LVN 1 was at Resident T's bedside performing daily wound care to Resident T's pressure ulcer. Resident T's incontinence brief was soiled with loose stool. LVN 1 was asked how often Resident T's incontinence brief should be checked. LVN 1 stated very two hours. On 12/13/16 at 1000 hours, CNA 17 was at Resident T's bedside performing pericare. Resident T was placed on her right side. CNA 17 was asked how often she checked Resident T's incontinence brief and turn her. CNA 17 stated every two hours. During a telephone interview with RN 1 on 12/14/16 at 1150 hours, RN 1 was asked what the facility protocol was for a resident who was incontinent of bowel and had a pressure ulcer to the sacrococcyx area. RN 1 stated to keep the resident dry, turned and repositioned every two hours, perform good hand hygiene, check and change soiled diapers every two hours and as needed, perform urinary catheter care, and the treatment nurse should change the dressing daily.

Based on observation, interview, clinical record review, and facility P&P review, the facility failed to ensure the residents remained free from accident hazards and appropriate assistive devices were in place to prevent accidents for four of 24 sampled residents (Residents 3, 9, 10, and 12). * Resident 10 suffered a fall with injury while being transferred using a Hoyer lift (a mechanical lift to transfer residents to and from the bed or chair). Resident 10 fell from the Hoyer lift sling, resulting in fractured ribs and hospitalization . In addition, Resident 10 was scratched by Resident S's dog and suffered from a skin tear on the right forearm. * Resident 12 got up from the bed and ambulated unassisted. He had dementia and an unsteady gait, had four falls within two weeks, and was then transferred to a room away from the nurses' station where he was not visible from the hallway. This had the potential for Resident 12 to sustain unwitnessed falls with possible injury. * Resident 3 sustained a fall with a right hip pain and fracture. The resident had six more fall incidents which were not investigated thoroughly in an attempt to prevent further falls. * The facility failed to place a pad alarm in Resident 9's wheelchair as ordered by the physician. This had the potential of Resident 9 getting up unassisted, falling, and sustaining injuries. * Two television sets in two different resident rooms were not secured and a portable air conditioner with wheels on the bottom was observed on top of table with a blue paper tape securing the air conditioner. These posed potential hazards in the event of an earthquake for residents, staff, and visitors. Findings: 1. Clinical record review for Resident 10 was initiated on 11/30/16. Resident 10 was initially admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. a. Review of Resident 10's MDS dated [DATE], showed he needed two persons' assistance for transfers. Resident 10 was assessed to need a Hoyer lift for transfers. Further review of Resident 10's clinical record showed a hospital CT scan dated 7/1/16, which showed Resident 10 had rib fractures. On 12/5/16 at 0940 hours, during an interview with Resident 10, Resident 10 stated he fell on to the floor and suffered rib fractures while being transferred via a Hoyer lift. Review of Resident 10's fall investigation showed Resident 10 fell on [DATE], while being transferred using a net sling (the part of the machine in which the resident is allowed to rest) attached to a Hoyer lift. On 12/6/16 at 1140 hours, an interview regarding Resident 10's fall on 7/1/16, was conducted with the DON. The DON stated Resident 10 had requested a specific sling be used during his transfers with the Hoyer lift. When asked if documentation existed to show Resident 10's sling preference, the DON stated all communication regarding this was done verbally and not documented. On 12/6/16 at 1350 hours, an interview with the OT was conducted. The OT stated she was called to assist CNA 7 with transferring Resident 10 from his bed onto a shower chair using a Hoyer lift on 7/1/16. The OT stated Resident 10 was already on the sling and it was already attached to the Hoyer lift. When asked what type of sling Resident 10 had underneath him during the transfer, the OT stated the sling was made of sturdy mesh material. When asked what the condition of the sling was on 7/1/16, the OT was unable to state; the OT just remembered the sling snapped and Resident 10 fell on to the ground. On 12/7/16 at 1130 hours, an interview with CNA 7 was conducted. When asked about Resident 10's fall on 7/1/16, CNA 7 stated she and the OT were in the room assisting Resident 10 to transfer him via a Hoyer lift onto a shower chair. When asked about the sling used to transfer Resident 10, CNA 7 stated she used a sling she had been informed Resident 10 preferred. CNA 7 stated it was a blue cloth-like material which extended from Resident 10's mid back area to Resident 10's back of the shoulder area. CNA 7 stated the cloth area of the sling then continued underneath Resident 7's legs, which CNA 7 stated she criss-crossed in between his legs and then attached onto the Hoyer lift. CNA 7 stated Resident 10 was to one side of his bed, approximately four feet above the ground when three of the slings straps snapped and Resident 7 fell on to the ground. CNA 7 stated two of the sling's straps snapped at the seam area where the straight edge and looped area of the straps met, and the third strap snapped about midway down. CNA 7 stated she saw drops of blood coming out of the left side of Resident 10's head. CNA 7 stated Resident 10 was transported to the acute care hospital afterwards. On 12/8/16 at 1135 hours, an interview with Resident 10 was conducted. When asked what type of sling was used on 7/1/16, during his transfer and subsequent fall from the Hoyer lift, Resident 10 stated a blue mesh sling was placed underneath him. Resident 10 stated while he was suspended in the air, he felt the back cord against his back break and his back hit the floor. When asked if he had expressed a preference of the type of sling to be used on him for transfers with the Hoyer lift, Resident 10 stated he did not request any specific sling; staff chose which sling to use for his transfers. On 12/8/16 at 1426 hours, an interview with the DON was conducted. When asked if she looked at the sling used on Resident 10 on 7/1/16, after Resident 10 fell , the DON stated she did not look at the sling but was focused on caring for Resident 10 after he fell . The DON stated the mechanical lift used on Resident 10 on 7/1/16, was called a Joerns Hoyer Presence 500; however, the sling used with this lift on 7/1/16, was a toileting sling designed to be used with the Invacare mechanical lift, not the sling for the Joerns Hoyer Presence 500. Review of the Joerns Hoyer Presence User Instruction Manual showed to not use a sling unless it is recommended for use with this lift. b. Review of the facility's P&P titled Animals in the Long Term Care Facility revised 9/2015 showed animal-assisted activities and resident animal programs - animals that are fully vaccinated for zoonotic diseases (infectious diseases that can be transmitted from animals to humans) and that are healthy, clean, well-groomed, and negative for enteric parasites (parasites that can infect the gastro-intestinal tract of humans and other animals) or otherwise have completed recent anthelmintic treatment (used to destroy parasitic worms) under the regular care of a veterinarian will be used in the program. During an observation on 11/30/16 at 1600 hours, Resident 10 was observed to have two white dressings on the right hand and forearm. A two inch by two inch white dressing was placed on Resident 10's right hand and a two inch by six inch white dressing was on Resident 10's right forearm. During an interview with LVN 5 on 11/30/16 at 1610 hours, LVN 5 stated Resident 10 was trying to pet Resident S's dog and the dog scratched him. LVN 5 stated Resident 10 acquired a skin tear from the dog's scratch and was getting treatment with normal saline. During an interview with the DON on 12/5/16 at 1440 hours, the DON stated she did not have Resident S's dog's immunization record. The DON stated the Activity Manager was contacting Resident S's husband to bring in the immunization record. 2. Clinical record review for Resident 12 was initiated on 11/30/16. Resident 12 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 11/30/16 at 1650 hours, Resident 12 was observed walking without assistance in Room H with the bed alarm sounding. Resident 12 walked with an unsteady gait to the opposite side of the room, then back to his bed, and sat down, which then stopped the bed alarm from sounding. Room H was shaped like an L. Bed A was visible from the hallway, but in order to see Beds B and C, the staff had to walk into the room and turn to the left. Resident 12's bed was the furthest from the door (Bed C) and not visible from the hallway. Further impeding the view were the privacy curtains, which were drawn between the three beds. LVN 9 verified the above. On 12/1/16 at 0650 hours, Resident 12 was observed sleeping in his bed with both legs hanging over the side of the bed touching the floor; the privacy curtains were drawn between the beds. On 12/1/16 at 0700 hours, an interview was conducted with LVN 8. LVN 8 stated at night, Resident 12 went to the bathroom by himself, but the staff listened for the alarm and went to assist him. LVN 8 stated sometimes Resident 12 needed help to lift his legs onto the bed. Review of the MDS dated [DATE], showed Resident 12 had severe cognitive impairment and needed extensive assistance with transfers, walking, and toileting. Resident 12's balance was not steady, only able to stabilize with human assistance when moving from a seated to a standing position, walking, turning around, and surface-to-surface transfers. Review of the Incident/Accident Report dated 10/31/16 at 2200 hours, showed Resident 12 attempted to get out of bed unassisted and had an unwitnessed fall with no apparent injury. Review of Resident 12's physician's orders [REDACTED]. Review of the Incident/Accident Report dated 11/1/16 at 1530 hours, showed Resident 12 had an unwitnessed fall near his bed, resulting in a head laceration. Review of Resident 12's physician's orders [REDACTED]. Review of the SBAR Communication Form and Progress Note dated 11/8/16, showed Resident 12 had an unwitnessed fall near the bathroom of the resident's room. Resident 12 had no apparent injury. Review of the Incident/Accident Report dated 11/8/16 at 1800 hours, showed Resident 12 was found standing in his bathroom with a laceration to the left eyebrow. The facility did not determine how it had occurred. Review of the SBAR Communication Form and Progress Note dated 12/6/16 at 0317 hours, showed Resident 12 had an unwitnessed fall in his bathroom, resulting in a left elbow wound, measuring 2 cm (length) x 3 cm (width). On 12/6/16 at 0900 hours, an interview and concurrent clinical record review was conducted with the DON. The DON was unaware Resident 12 had a fall in the morning. The DON verified Resident 12 had four falls from 10/27 to 11/8/16. The DON verified Resident 12 was moved to his current room on 11/10/16, and the reason was not documented. The DON verified Resident 12 got up and walked without assistance. Resident 12 was observed in his room on the bed. Two straps, holding the mattress to the bed frame, were observed laying on the floor where Resident 12 stood up. The DON verified it was a fall hazard. The DON verified Resident 12 could not be seen from the doorway and the view was further impeded by the curtain being drawn between the beds. The DON verified Resident 12's room was not near the nurses' station as per the physician's orders [REDACTED].> 3. Review of the facility's P&P titled Incident Investigation dated March 2008 showed all employee reports of incidents must be thoroughly investigated at the time the incident is reported. The incident investigation process is designed to determine the root cause of the incident. Clinical record review for Resident 3 was initiated on 11/30/16. Review of the Admission Record showed Resident 3 was initially admitted to the facility on [DATE], and readmitted on [DATE]. Review of the MDS dated [DATE], showed Resident 3 had severe cognitive impairment and was not able to be interviewed. In addition, Resident 3 required supervision for eating and extensive assistance for dressing, bathing, and daily hygiene care. Review of the Fall risk assessments for Resident 3 dated 4/4, 5/2, 5/31, 6/21, 7/7, 8/9, 10/18, 10/21, and 10/25/16, showed Resident 3 was at a high risk for falls. Review of history and physical examination [REDACTED]. Review of the history and physical examination [REDACTED]. She had severe right hip pain. X ray showed intertrochanteric (upper part of the thigh bone) and proximal fracture at the right hip. Review of Resident 3's care plan showed a care plan problem dated 4/22/16, to address the resident's fall to the floor when attempting to get back to bed from the bathroom. The interventions included to continue safety whenever ambulating, make sure the bed alarm was in place, have staff respond promptly, monitor the resident while in bed, place pads on the floor, offer assistance to the restroom, provide area for safe ambulation, and use of bed and wheelchair alarm. Review of the Interdisciplinary Post Fall Review for Resident 3 dated 4/25/16, showed the section for witnessed or unwitnessed was blank. The section for Injury was blank. The location of the resident prior to the fall was blank, predisposing disease, the footwear or assistive device at time of fall, and the medications that may contribute was documented as none. There was no documentation to identify the circumstances surrounding the fall (i.e. whether the resident was in bed or in a wheelchair when she fell and/or what external factors could have contributed to the resident's fall, etc.). Review of the Incident/Accident Investigation Follow-Up dated 4/23/16, showed Resident 3 was found on the floor complaining of hip pain; she fell when she was trying to get back to bed from the bathroom. Documentation showed the resident was interviewed; however, there was no documented evidence to show the direct care staff and licensed nurse were interviewed. Review of the Interdisciplinary Post Fall Review dated 5/31/16, showed Resident 3 was noted to be sitting on the floor at the bedside complaining of moderate pain to the right hip. The facility interviewed only the OT; however, there was no direct care staff or licensed nurse interviewed. Review of the Incident/Accident Investigation Follow-Up dated 7/2/16, showed Resident 3 was found sitting on the floor in the room at the bedside. The Summary of Investigation (Reasonable Conclusion) showed the resident was trying to get out of bed unassisted. It failed to show if the staff or resident was interviewed and what was the reason the resident wanted to get out of bed. Review of the Interdisciplinary Post Fall Review for Resident 3 dated 7/7/16, showed a resident assisted fall in the hallway in front of the smoking patio by resident care services. The environmental factors and medications that might contribute to the fall were left blank. Review of the Interdisciplinary Post Fall Review dated 9/11/16, showed Resident 3 fell in the front lobby, unassisted transfer from the wheelchair to the sofa. The footwear or assistive devices at the time of the fall were left blank. Review of the Incident/Accident Investigation Follow-Up dated 10/18/16, showed Resident 3 was found sitting on the floor in the front lobby. The Past Interventions Attempted was left blank. The Recommendations/New Interventions showed frequent visual checks. The Summary of Investigation (Reasonable Conclusion) showed when the resident was asked what happened, the resident continuously spoke in her primary language. Review of the Incident/Accident Investigation Follow-Up dated 10/21/16, showed Resident 3 was found sitting on the floor; she stated she was coming out from the toilet and slid. The Past Interventions Attempted were left blank. Review of the Interdisciplinary Post Fall Review for Resident 3 dated 10/21/16, showed the areas to document the injury, vital signs, hypotension on the fall, location of the fall, location of the resident prior to the fall, activity at the time of the fall, predisposing diseases, conditions that might contribute to the fall, footwear or assistive devices at time of fall, environmental factors, and medications that might contribute to the fall were left blank. There was no documentation to identify the circumstances surrounding the fall (i.e. whether Resident 3 was in bed or in a wheelchair when she fell and/or what external factors could have contributed to the resident's fall, etc.). On 12/2/16 at 0915 hours, an interview was conducted with CNA 9. CNA 9 was asked if Resident 3 asked for assistance to the restroom or for toileting, bathing, and dressing. CNA 9 stated Resident 3 could press the call light and asked for assistance to go to the toilet but could not wait long. CNA 9 stated she was very busy helping other residents. Sometimes she helped other residents in the restroom, so she could not go to Resident 3 right away and Resident 3 would get up unassisted to go to the toilet. On 12/6/16 at 1330 hours, an interview and concurrent clinical record review was conducted with the DON and LVN 4. When asked regarding the fall incidents involving Resident 3, LVN 4 stated Resident 3 sustained a right hip fracture after the fall on 4/22/16. Each of the fall incidents was investigated. LVN 4 was asked if the fall incident on 4/22/16, where the location of the resident prior to the fall, predisposing disease, footwear or assistive device, medication, who supervised or monitored the resident and if any staff was interviewed. LVN 4 stated she did not know the location, the predisposing disease should be documented for Parkinson's, hypertension, and dementia, and the medication should be documented for hypertension, and psychoactive. LVN 4 stated she did not know how the resident transferred herself to the bathroom and if the bed alarm or wheelchair alarm sounded. When asked if she could show any documentation for any information regarding the fall, LVN 4 stated she did not have it. When asked what happened on 9/11/16, LVN 4 stated the volunteer who spoke in Resident 3's language left the resident alone in the lobby; the volunteer should not have left her alone. LVN 4 was asked if the volunteer was interviewed about the fall incident or if the volunteer knew or was made aware Resident 3 was at high risk for falls prior to the fall. LVN 4 stated there was no documentation of an interview with the volunteer. When asked what past interventions were in place for the incident on 10/18/16, LVN 4 stated she did not know the details and was unable to provide any information. When asked about the incomplete investigation dated 10/21/16, and the IDT assessment, LVN 4 confirmed the fall investigation was not conducted thoroughly. LVN 4 stated she depended on staff to keep her informed of any incidents that needed the investigation. LVN 4 acknowledged Resident 3 had six more fall incidents in the facility after the fall incident on 4/22/16. 4. Clinical record review was initiated for Resident 9 on 12/2/16. Resident 9 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the MDS dated [DATE], showed Resident 9 was cognitively intact. Review of the history and physical examination [REDACTED]. Further review of Resident 9's MDS dated [DATE], showed Resident 9 required extensive assistance and one person's physical assistance for transfers from one surface to another. Review of the Order Summary Report for the month of December 2016 showed an order to apply a pad alarm in the chair due to episodes of getting up unassisted and monitor episodes of getting up unassisted from the chair. Review of Resident 9 's care plan showed a care plan problem dated 4/12/16, to address the potential safety fall risk related to disease process and anxiety. The interventions showed to observe for placement and function of devices per the facility's protocols and place the pad alarms in the bed and wheelchair due to episodes of getting up unassisted. Resident 9 was observed on 12/2/16 at 0815 hours, sitting in a wheelchair, eating breakfast, and watching television. No pad alarm was observed on the wheelchair. On 12/2/16 at 1510 hours, Resident 9 was observed sitting in his wheelchair in the doorway of his room watching television. No pad alarm was observed on the wheelchair. On 12/2/16 at 1535 hours, an interview was conducted with CNA 9. When asked how the staff ensured Resident 9 was not getting out of his chair unassisted when the staff were not available to help him when needed, CNA 9 stated she did not know, but the resident let her know when he wanted to get up. CNA 9 was asked if Resident 9 should have a pad alarm in place while up in his wheelchair. CNA 9 stated she did not know, but the resident did not have one in his chair. On 12/2/16 at 1540 hours, an interview and concurrent clinical record review was conducted with LVN 2. When asked if Resident 9 should have a pad alarm while in his wheelchair, LVN 2 stated the resident should have one and then verified the physician's orders [REDACTED]. LVN 2 verified Resident 9 was sitting in his wheelchair without a pad alarm. 5. On 12/2/16 at 0930 hours, during an environmental tour of the facility, resident Room B was observed. A television in Room B was observed sitting on a night stand adjacent to a resident's bed. The Maintenance Supervisor verified the television was not secured. On 12/1/16 at 0940 hours, a television in resident Room C was observed sitting on a night stand next to the wall adjacent to a resident's bed. The Maintenance Supervisor verified the television was not secured. During initial tour with LVN 5 on 11/30/16 at 1145 hours, a detached portable air conditioner with wheels on the bottom was observed on top of a table in Room D next to the window. The portable air conditioner was secured with a blue paper tape. This finding was verified by LVN 5.

Based on observation, interview and clinical record review, the facility failed to ensure supervision and approaches identified on the plan of care were implemented for one of 23 sampled residents (Resident 16). This resulted in Resident 16 falling and sustaining a left hip fracture. Resident 16 was found lying on the floor yelling in his room, with the door closed. There were no landing mats on the floor next to the resident's bed and no sensor pad alarm was sounding. Resident 16 complained of severe pain and was transferred to the acute care hospital, where he was diagnosed with [REDACTED]. Findings: 1. According to the Centers for Disease Control and Prevention; Hip Fractures among Older Adults, hip fractures can cause severe health problems and lead to reduced quality of life and premature death. Providing residents with hip pads or mats may prevent a hip fracture if a fall occurs. Using devices such as alarms that go off when residents try to get out of bed or move without help can help prevent falls. On 4/13/11 at 1420 hours, the door to Resident 16's room was closed. The resident was heard from the hallway yelling from inside. The AD walked by the closed door and stated the resident was fine because staff was assisting him. A loud thud and bang against the wall was heard. The surveyors intervened to check the resident's safety. The door could not be opened completely due to the resident's head was on the floor, blocking the door from opening. Staff was summoned for help. The resident was able to move his head slightly out of the way and the door was then opened by staff. Resident 16 was found lying on the floor between his bed and the wall, yelling. The resident's clothing was partially removed and his adult brief loosened. The resident was alone in the room with no staff present. The sensor pad (a pad placed on the bed underneath the resident with an alarm which sounds when the resident rises up from bed) was not alarming and there were no landing floor mats (soft mats placed on the floor next to the bed to minimize injuries if the resident falls) on the floor next to the resident's bed. The AD called other staff for help and the resident was assisted into his bed. On 4/13/11 at 1425 hours, during an interview with the Maintenance Supervisor, he stated Resident 16 was really agitated and the door was shut because he was disrupting other residents. On 4/13/11, clinical record review for Resident 16 was initiated. The Change of Condition form dated 4/13/11, showed Resident 16 was found on the floor between his bed and the wall. The resident was found with his head on the floor towards the foot of the bed. The resident was assisted to bed with the use of three staff. Resident 16 complained of left hip, left pelvic and left sided abdominal discomfort. Resident 16 had increased confusion with screaming and yelling. The physician was notified and STAT x-rays of the resident's left hip pelvic area, and skull were ordered. Review of the physician's orders [REDACTED]. The physician's orders [REDACTED]. The care plan problem titled "Falls" dated 8/7/10, showed Resident 16 was at high risk for falls due to short term memory deficit, incontinence, poor vision, poor balance, arthritis, episodes of attempting to get out of bed unassisted, the use of narcotic medication and dementia. A goal listed on the care plan showed Resident 16's fall risk will be minimized. Approaches listed on the care plan to help meet this goal included visual checks and a sensor pad alarm to alert staff if the resident attempted to get out of bed unassisted. On 4/13/11 at 1600 hours, during an interview with LVN 1, when asked why the sensor pad alarm had not sounded, the LVN stated the alarm did not activate because the resident was moving around. When asked why there were no landing mats on the floor next to the resident's bed, as ordered, LVN 1 stated the CNA must have removed them. When asked why the resident was left alone in the room with the door closed, LVN 1 was unable to state. On 4/18/11, clinical record review continued, the Resident Transfer Form dated 4/16/11, showed Resident 16 complained of "severe" pain to his left leg. The physician's orders [REDACTED]. The acute care hospital's Emergency Physician Record dated 4/16/11, showed Resident 16 had moderate left hip pain following a fall at the facility. Resident 16 had a CT scan of his left hip which showed a greater trochanter (hip) fracture. The resident complained of pain to his left leg and required morphine sulfate intravenously. The acute care hospital's Physician's Consultation dated 4/17/11, showed Resident 16 continued to have severe pain to his left hip and was admitted to the acute care hospital. 2. Review of the facility's P&P titled Safe Smoking Policy dated 6/2007, showed the IDT will determine if a resident is a safe or unsafe smoker. An assessment is done for all smoking residents. A care plan will be developed which includes the degree of supervision which is necessary and if the resident needs to wear a smoking apron. If the IDT determines the resident to be a safe smoker, the degree of supervision is less than an unsafe smoke but "staff supervision is encouraged for all residents who smoke." On 4/13/11 at 1140 hours, Resident 17 and Resident I were observed on the patio smoking cigarettes. No staff was present. On 4/13/11 at 1245 hours, Resident 17 and Resident I were observed on the patio smoking cigarettes. Resident I was not wearing a smoking apron. No staff were present. On 4/14/11 at 0940 hours, Resident L was observed on the patio smoking cigarettes. No staff was present. On 4/14/11 at 1025 hours, Resident I was observed on the patio smoking cigarettes. Resident I was not wearing a smoking apron. No staff was present. On 4/15/11 at 1010 hours, Resident C and Resident I were observed on the patio smoking cigarettes. Resident I was not wearing a smoking apron. No staff was present. On 4/13/11, clinical record review was initiated for Resident I. The Safe Smoking Evaluation dated 1/18/11, did not show the degree of supervision the resident required while smoking. The boxes next to occasional, frequent or constant were blank. The care plan problem titled "At Risk for Injury Related to Smoking" dated 10/28/10, showed Resident I required a smoking apron while smoking. On 4/13/11, clinical record review for Resident 17 was initiated. The record showed no care plan was developed related to smoking. On 4/13/11, clinical record review for Resident L was initiated. The care plan problem titled "At Risk for Injury Related to Smoking" dated 4/11/11, showed Resident L required supervised smoking. On 4/13/11, clinical record review for Resident C was initiated. The care plan problem titled "At Risk for Injury Related to Smoking" dated 3/23/11, showed Resident C required supervised smoking. On 4/15/11 at 1015 hours, during an interview with the SSA, when asked why the IDT was not conducting the assessments, the SSA stated nursing will usually do the assessment. If they do not conduct the assessment, she will do it. When asked about the facility's P&P and resident's care plans showing supervision was required and the degree of supervision not specified in the residents' care plans, the SSA stated the care plans were preprinted and not specific to the residents. 3. On 4/15/11 at 1400 hours, Room F was observed with a tall wooden dresser at the foot of the resident's bed. The dresser was not secured to prevent it from falling over. 4. Review of the facility's P&P titled "Fall Management" dated 2/10, showed the facility will take a proactive approach for new residents and will consider new admissions at risk for falls. Upon admission, the admitting nurse will complete the Fall Risk Assessment, then weekly for 3 additional weeks. The nurse will also complete the initial care plan and address risk factors related to the resident on the plan of care. During initial tour rounds on 4/13/11 at 0740 hours, accompanied by LVN 4, Resident 6's bed was not in the lowest position, with the head of the bed elevated. The call light was observed on the floor, out of the resident's reach. The bedside table with water pitcher and personal items was located against the wall at the foot of his bed. His emesis basin was on the floor, next to his bed. Review of the clinical record for Resident 6 was initiated on 4/13/11. Resident 6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 4/13/11 at 0945 hours, during an interview with Resident 6, he stated he had a bad fall at home, and still has dizziness with a spinning sensation, weakness, and vomiting at times. Review of the clinical record showed no initial fall risk assessment was completed after Resident 6's admission. On 4/13/11 at 0950 hours, during an interview with LVN 5, she stated they should do the initial fall risk assessment right away when the resident comes in. Review of the resident's plan of care showed a care plan problem dated 4/12/11, to address the risk for falls due to a recent fall. The approaches included to place the call light within reach, offer or assist the resident to the toilet frequently as accepted, place frequently used items within reach. On 4/13/11 at 1000 hours, an interview was conducted with CNA 12. When asked how they care for the residents at risk for falls, the CNA stated the call light should be within the resident's reach, the bed is supposed to be in the lowest position at all times, assist the resident with toileting, and their personal items need to be as close as possible. On 4/14/11 at 1010 hours, an interview was conducted with RN 3. The RN confirmed call lights should be within reach and the beds in the lowest position for the residents at risk for falls. 5. Clinical record review was initiated for Resident 9 on 4/13/11. Review of Resident 9's comprehensive care plan showed a care plan problem dated 2/4/11, to address the resident's risk for falls. Approaches to the care plan problem included the use of a bed alarm. Review of a Change of Condition form dated 2/18/11 at 1815 hours, showed Resident 9 was found on the floor. The form showed a CNA went to the resident's room in response to a pressure sensor bed alarm sounding and found the resident on the floor. (A pressure sensor bed alarm, is an assistive device placed on the mattress under the bed linens. An alarm will sound when the device senses a pressure reduction as when one is getting up out of bed. The purpose of the alarm is to alert staff when one is getting out of bed unassisted.) The Change of Condition form further showed documentation the resident stated she went to the bathroom, then changed her clothes, then became tired so she layed down on the floor. On 4/18/11 at 0915 hours, interview with record review was conducted with RN 4. The above described Change of Condition form was reviewed with RN 4. When asked how the resident was able to get out of bed, go to the bathroom, then change her clothes, then lay down on the floor before someone responded to the resident's bed alarm, RN 4 was unable to answer. The RN then stated, based on the time documented on the form, 1815 hours, it would have been dinner time, so maybe that was the reason.