Every finding on record at Plum Tree Care Center

Based on observation, interview, and record review, the facility failed to ensure to follow their policy and procedure (P&P) for answering the call light for one of five sampled resident rooms when:1 .Resident 1 stated call light response time was more than 20 minutes at times;2. Resident 2 stated call light response time was more than 10 minutes at times;3. Observation of call light response time was five minutes for Resident room [ROOM NUMBER]. This failure had the potential to affect residents' care, health conditions and well-being of residents in sampled resident rooms.Findings:1.During an observation and interview with Resident 1 on 7/29/2026 at 12:10 p.m., in Resident 1's room, Resident 1 stated she had to wait long time to receive incontinent and other care needs, staff were taking more than 20 minutes to answer her call light most of the times. During an interview with Resident 1's significant family member (SFM) who was in Resident 1's room on 7/29/2026 at 12:20 p.m., Resident 1's SFM stated Resident 1 was nice enough to say 20 minutes to wait, Resident 1 waited more than 30 minutes for her call light to be answered by staff for several times. Resident 1's SFM also stated after waiting 30 minutes, she herself went out to the hallway to find a certified nursing assistant (CNA) to assist Resident 1 before any staff answered Resident 1's call light.Review of Resident 1's face sheet (FS, a document that gives resident's information in a quick glance) indicated Resident 1 was admitted to facility on 7/21/2026.Review of Resident 1's FS indicated Resident 1's diagnoses included intertrochanteric left femur fracture (broken left hip at the top of the thigh bone) with routine healing and need for assistance with personal care.Review of Resident's brief interview for mental status (BIMS) assessment dated [DATE] indicated Resident 1's BIMS score of 15/15 (score of 0-7: severely impaired cognition, 8-12: moderately impaired cognition, 13-15: intact cognition).Review of Resident 1's bowel/bladder assessment dated [DATE] indicated Resident 1 was incontinent (being unable to control urine and bowel movement) of bowel and bladder with approaches included to provide incontinent care after each incontinent episode.Review of Resident 1's care plan for ADL (active daily living, basic and routine tasks required for a resident) self-care performance deficit, dated 7/21/2026 indicated with intervention to provide appropriate self-performance and support needed during ADL care and encourage to use of call light for assistance.2.During an interview with Resident 2 on 7/29/2026 at 12:28 p.m., at Resident 2's bedside, Resident 2 stated she had to wait long time for staff to answer her call light. Resident 2 also stated depending on the time and the day, it takes more than 10 minutes for staff to answer her call light and to attend to her care needs. Resident 2 further stated staff were answering call lights right away today since state person was in the building.Review of Resident 2's FS indicated Resident 2 was admitted to facility on 7/11/2026.Review of Resident 2's FS indicated Resident 2's diagnoses included cerebral infarction affecting right dominant side (brain tissue death caused by blocked blood flow with right sided weakness) and need for assistance with personal care.Review of Resident 2's s minimum data set (MDS, resident assessment tool) assessment dated [DATE] indicated Resident 2's BIMS score of 15/15, intact cognition.Review of Resident 2's admission data collection and baseline care plan tool document dated 7/11/2026 for bowel/bladder assessment indicated Resident 2 was incontinent of bowel and bladder with approaches included to provide incontinent care and peri care (cleaning of genital and anal areas, personal hygiene) after each incontinent episode.Review of Resident 2's care plan for ADL self-care performance deficit, dated 7/11/2026 indicated with intervention to provide appropriate self-performance and support needed during ADL care and encourage to use of call light for assistance.3. During an observation for Resident room [ROOM NUMBER] on 7/29/2026 at 1:08 p.m., noted call light was on at 1:08 p.m. Observed license vocational nurse A (LVN A) went inside Resident room [ROOM NUMBER], answered the call light at 1:13 pm, five minutes after call light was on.During an interview with LVN A on 7/29/2026 at 1:15 p.m., LVN A confirmed call light was on for five minutes for Resident room [ROOM NUMBER] before she answered. LVN A stated staff should answer call light as soon as it was on. LVN A also stated staff should have answered this call light without waiting for five minutes.During an interview with facility's director of staff development (DSD) on 7/29/2026 at 1:58 p.m., in DSD's office, DSD stated staff should answer residents' call light as soon as possible. DSD also stated Resident waiting for staff to answer resident's call light for 5 minutes was too long a wait to attend to care needs for any resident in the facility.During an interview with facility's interim director of nursing (IDON) on 7/29/2026 at 2:03 p.m., IDON stated facility staff should answer residents' call light as soon as light turned on.Review of facility's P&P titled, Answering the Call Light, revision date September 2022, the P&P indicated, Answer the resident call system immediately.

Based on interview and record review, the facility failed to address the residents' discharge needs when Resident 1's durable medical equipment (DME, medically necessary devices prescribed for everyday use to manage illnesses, injuries, or disabilities at home) was not available upon discharge. This failure had the potential for compromising the resident's well-being and safety.Review of Resident 1's record indicated he was admitted on [DATE] and had diagnoses including cerebral infarction (the death of brain tissue caused by a blocked or severely restricted blood supply) and abnormalities of gait and mobility. Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 5/4/26, indicated his Brief Interview for Mental Status (BIMS) was 10, indicating he had moderate cognitive impairment in daily decision-making skills. Review of Resident 1's physician order, dated 5/1/26, indicated may discharge home with medications including narcotics (medications to relieve pain and induce sleep) and psychotropic medications (prescription drugs that alter brain chemistry, affecting mood, and behavior) and home health services for physical therapist (PT, a healthcare discipline that uses movement and physical techniques to treat illnesses)/occupational therapist (OT, a healthcare discipline that helps individuals with participate in everyday activities)/home health agent (HHA, a type of medical care provided in a resident's home to function independently)/registered nurse (RN)/social worker (SW) and DME as needed. Review of Resident 1's care plan of discharge plan indicated, Obtain needed equipment, medication and supplies. Review of Resident 1's Plan of Care Note, dated 5/1/26, written by the director of rehabilitation (DOR) indicated, Approached the resident with the SSD [social service director], .Resident is excited to discharge to home on Monday [5/4/26]. DME needs FWW [front wheel walker] and BSC [bedside commode]. During phone interview with a family member on 5/14/26 at 9:36 a.m., she stated the facility did not provide a walker when Resident 1 was discharged home. During an interview and record review with the DOR on 6/11/26 at 10:31 a.m., she confirmed the above Plan of Care Note dated 5/1/26. The DOR stated FWW and BSC were recommended to Resident 1 for safe discharge. During an interview with the SSD on 6/11/26 at 11:18 a.m., he confirmed that he was with the DOR when the DOR explained needed DME at home to Resident 1 on 5/1/26. The SSD stated he ordered FWW for Resident 1 on 5/4/26 and did not order BSC. The SSD stated Resident 1 said he has a walker at home, but the facility did not confirm whether he has walker at home or not. During an interview and record review with the director of nursing (DON) on 6/11/26 at 12:00 p.m., she confirmed the DOR recommended FWW and BSC as DME for Resident 1's discharge. The DON stated FWW and BSC should have been available when Resident 1 was discharged home. The DON stated the SSD should have initiated the DME preparation when Resident 1's discharge home on 5/4/26 was planned. During an interview and record review with the DON on 6/11/26 at 12:51 p.m., she confirmed Resident 1's BIMS was 10. The DON stated the facility should have ensured FWW was available for Resident 1 when he was discharged home even though he said he has a walker at home. During phone interview with the family member on 6/17/26 at 2:55 p.m., she stated Resident 1 did not have a walker at home, and she informed the facility Resident 1 did not have a walker at home. The family member further stated Resident 1 was forgetful, and the facility should not have relied on his statement. Review of the facility's policy and procedure (P&P), dated 6/2016, titled Discharge Planning Process indicated The facility has a discharge planning process which addresses each resident's discharge goals and needs .

Based on interview and record review the facility failed to follow it's policy titled, Release of Information, for one of 3 sampled residents (Resident 1), when the facility failed to comply with a medical records request for Resident 1's Medical Record within the 2 day time period stated in the policy. This failure resulted in Resident 1's family to receive the medical records outside the mandated time period. During an interview on 7/30/35, at 9:12 a.m., with Medical Records (MR), MR stated, she received a medical records request signed by Resident 1's family on 4/30/25 via email. MR stated she sent the medical records via email to the requestee on 5/9/25.During a review of emails to MR dated 4/30/25-5/9/25 indicated, a medical record request was emailed to the facility on 4/30/25 for Resident 1. Emails indicated on 5/9/25 medical records were emailed to the requestee by MR.During an interview on 7/30/25, at 10:05 a.m., with Administrator (Admin) Admin stated, the facility policy states we have to send medical record requests in two business days. Admin stated, she saw the email request dated 4/30/25 from the requestee for Resident 1's medical records. Admin stated, according to the emails MR sent the medical records on 5/9/25. During a review of the facility's policy and procedure (P&P) titled, Release of information dated 2001, the P&P indicated, A resident may obtain photocopies of his or her records by providing the facility with at least a forty-eight (48) hour (excluding weekends and holidays) advance notice of such a request.

Based on interview and record review the facility failed to document reason to withheld medications and failed to notify primary care physician (PCP) when withheld medications for one of three sampled resident (Resident 2) to meet professional standards. This failure had the potential to affect Resident 2's medical condition and well-being. Review of Resident 2's face sheet (FS: a documenta that gives resident's information at a quick glance) indicated Resident 2 was admitted to facility on 4/30/2025 and discharged home on 5/21/2025. Resident 2 was self-responsible for daily decision making.Review of Resident 2's diagnoses included tachycardia (a rapid heartbeat that may be regular or irregular), depression (a mood disorder that causes persistent feeling of sadness and loss of interest in day to day activities), anxiety (persistent worry and fear about everyday situations), and headache (a painful sensation in any part of the head ranging from sharp to dull).Review of Resident 2's minimum data set (MDS, clinical and functional assessment tool) dated 5/21/2025 indicated Resident 2's brief interview for mental status (BIMS) score of 15/15 (score of 0-7: severely impaired cognition, 8-12: moderately impaired cognition and 13-15: intact cognition), intact cognition.Review of Resident 2's order summary report indicated medication auvelity (used to treat depression) 45-105 MG (mg-milligram, a unit of mass or weight equal to one thousandth of a gram) two times a day for depression, dated 4/30/2025.Review of Resident 2's order summary report also indicated medication ivabradine (used to treat certain heart conditions) 5 MG one time a day for angina (a type of chest pain caused by reduced blood flow to the heart, dated 5/1/2025.Review of Resident 2's order summary report further indicated medication emgality (used to treat headache in adults) 120 mg inject subcutaneously (inject into fatty tissue just underneath the skin) every 30 day (s) for migraine (a health condition that is more just a bad headache with nausea, vomiting or sensitivity to light and sound), dated 5/13/2025.Review of Resident 2's electronic medical record (EMAR, a digital system used to document medication administration to residents) for May 2025 indicated medication auvelity was documented as 3 at 0900 on 5/3/2025, 1 dose. Medication ivabradine was documented as 3 at 0900 on 5/8/2025, 5/17/2025, 5/18/2025 and at 2100 on 5/8/2025, 5/16/2025, and 5/17/2025, total 6 doses. Medication emgality was documented as 3 at 0900 on 5/13/2025, one dose.Review of Resident 2's EMAR chart codes/follow up codes for 3, indicated Hold/Progress notes MD (medical doctor) Notification. Further review of nursing progress notes indicated there was no documented evidence for the reason to withheld above medications and no documented evidence of notification to Resident 2's PCP when withheld above medications.During a telephone interview with Resident 2 on 6/3/2025 at 3:51 p.m., Resident 2 stated did not receive multiple medications for several days when Resident 2 was in facility. Resident 2 was told by nursing staff some of medications not available to give as ordered for several days during Resident 2's stay in facility. During a concurrent record review of Resident 2's EMAR for May/2025 and interview with license vocational nurse A(LVN A) on 7/16/2025 at 11:23 a.m., LVN A confirmed above medications during those days and timings were held, not administered to Resident 2 as indicated in EMAR. LVN A also confirmed EMAR documented code for 3 means license nurse held the medication. LVN stated nurse should document the reason and notify PCP when hold any ordered medication to residents. LVN A also stated progress notes dated 5/8/2025 indicated medication ivabradine not available to give, possible reason for the several medications were held multiple times due to lack of supply of medications for Resident 2.During a concurrent record review of Resident 2's EMAR for May/2025, progress notes, and interview with facility's director of nursing (DON) on 7/16/2025 at 12:23 p.m., DON confirmed above medications were withheld, not administered to Resident 2. DON also confirmed there were no documented evidence for reason to withheld multiple medications and notification to PCP for Resident 2. DON stated license nursing staff should have documented the reason and notified PCP when withheld medications for Resident 2. DON also stated potential to affect for Resident 2's medical condition when medications were withheld and not been notified to Resident 2's PCP.Review of facility's policy and procedure (P&P) titled, Administering Medications, undated, the P&P indicated, any explanatory note on the reverse side of the MAR (medication administration record) must be entered when drugs are withheld, refused, or given other than at scheduled times. (Note: The director of nursing serves and attending physician must be notified when two (2) consecutive doses of a medication are refused or withheld.)

Based on interview and record review, the facility failed to ensure to notify blood work results to primary care physician (PCP) and resident's responsible party (RP: individual person designated to make decisions and receive information on behalf of a resident) for one of three sampled resident (Resident 1). This failure had the potential to compromise to address Resident 1's medical condition and well-being.Review of Resident 1's face sheet (FS: a document that provides resident's information at a quick glance) indicated Resident 1 was admitted to facility on 4/3/2024. Review of Resident 1's diagnoses included diabetes type 2 (DM 2: high sugar levels in blood) and congestive heart failure (CHF: chronic condition in which heart does not pump blood as well as it should).Review of Resident 1's FS also indicated significant family member was assigned as Resident 1's RP.Review of Resident 1's physician order summary report indicated Resident 1 had an order for blood test for complete blood count (CBC: number and type of cells in the blood, common blood test used to assess overall health and screen for various health conditions) and comprehensive metabolic panel (CMP: a blood test to screen for certain medical conditions and monitor effects of medications) dated 4/22/2025 and 4/29/2025.Review of CMP blood test results dated 4/22/2025 and 4/29/2025 indicated out of range high levels of glucose (sugar in blood), blood urea nitrogen (BUN: amount of waste product formed when liver [a body organ plays a vital role for overall health and survival] breaks down protein [acting as a building block for muscles, bones, skin, and blood] also indicates kidney [a vital body organ filtering waste and extra fluid from blood to produce urine] function), BUN/creatinine ( Cr: a chemical found naturally in the body) ratio (a blood test that measures the levels of two substances in the blood, urea and creatinine to assess kidney function) and carbon dioxide (key indicator of how lungs [body organs essential for breathing and sustaining life], kidneys and metabolic processes [the set of all chemical reactions that occur in a living organism to maintain life] are functioning ). Review of CBC blood test results dated 4/22/2025 and 4/29/2025 indicated high levels of RDW (red cell distribution width, measures the size of red blood cells), absolute monocytes (type of blood cells indicate various conditions including infections), absolute basophils (type of cells, high level indicates body's reaction or fighting an infection), and low level of hemoglobin (essential protein component to maintain overall health, found in red blood cells). Review of Resident 1's nursing notes indicated there was no documented evidence of notification to PCP and RP for above 4/22/2025 and 4/29/2025 out of range CBC and CMP blood test results for Resident 1.During an interview with facility's director of nursing (DON) on 7/16/2025 at 2:58 p.m., DON confirmed license nursing staff did not inform PCP and RP for 4/22/2025 and 4/29/2025 abnormal blood work results for Resident 1. DON stated license staff should inform PCP and RP when received blood test results. DON also stated license staff should have informed blood test results to PCP for further plan of care as needed to meet Resident 1's medical condition and informed RP as needed.Review of facility's policy and procedure (P&P) titled, Lab and Diagnostic Test Results-Clinical Protocol, undated, the P&P indicated, A physician can be notified by phone, fax, voicemail, e-mail, mail, pager, or a telephone message to another person acting as the physician's agent (for example, office staff). Facility staff should document information about when, how, and to whom the information was provided and response.

Based on observation, interview and record review, the facility failed to ensure professional standards of practice were followed for three out of six sampled residents (Resident 5, 11, and 39) when: 1. [NAME] color particles (solid particles settle out of urine), and cloudy color urine (urine appears hazy or white color particles) in urinary catheter (U/C-a thin, flexible tube inserted into urethra [urinary opening] to drain urine from bladder [body organ that stores urine] into a collection bag) in U/C drain tube were not assessed and reported to medical doctor (MD) for Resident 5; 2. Controlled drug record (CDR-record of every transaction involving a controlled drug [CD-medication that can be easily abused and under strict government control] purchasing, receiving, dispensing, or disposal) was not signed, dated, and documented amount of controlled drug received from pharmacy for Resident 11, and 39. Above failures had the potential for infection, health and well-being for Resident 5, and accountability of CD record for Resident 11 and 39. Findings: 1. During an observation on [DATE] at 9:15 a.m., noted Resident 5's U/C drain tube with white color particles, and cloudy urine. During review of Resident 5's face sheet (FS-a document that gives a resident's information at a quick glance) indicated Resident was admitted to facility on [DATE]. Resident 5's FS also indicated Resident 5's diagnoses including history of urinary tract infections (an illness of the system of organs that makes urine), presence of urogenital implants (implantation of artificial devices in the urinary system), and neuromuscular dysfunction of bladder (condition where bladder control problems due to dysfunction of muscles that control bladder leading to difficulty emptying or controlling urine). Review of Resident 5's physician order dated [DATE] indicated suprapubic urinary catheter (SUC-a medical device inserted through a small incision in the lower abdomen into the bladder to drain urine from bladder into a collection bag) size FR#,d+[DATE] (catheter tube outer diameter, I FR equal to ,d+[DATE] millimeter) for neuromuscular dysfunction of bladder. Review of Resident 5's another physician order dated [DATE] indicated catheter: monitor/record/report to MD for signs and symptoms of urinary tract infection . Review of clinical documentation indicated there was no documentation for assessment and notification to MD for white color particles and cloudy urine in urinary catheter drain tube for Resident 5. Review of care plan for Resident 5 SUC dated [DATE] indicated with intervention to observe output for color, odor, threads, & sedimentation. During an interview with certified nursing assistant L (CNA L) on [DATE] at 9:22 a.m., CNA L confirmed white color and cloudy urine in U/C drain tube for Resident 5. CNA L stated she did not notice before, will report to charge nurse now. During an interview with licensed vocational nurse H (LVN H) on [DATE] at 9:34 a.m., LVN H confirmed white sedimentation, and cloudy urine for Resident 5's U/C drain tube. LVN H stated abnormal to have sedimentation and cloudy urine, did not notice before. LVN H also stated urine should be clear and amber color not cloudy with sedimentation, will notify MD. During an interview with facility's director of nursing (DON) on [DATE] at 10:45 a.m., DON stated nursing staff should have monitored, assessed white sedimentation with cloudy urine and notified MD to prevent and control urinary infection for Resident 5. 2. Review of Resident 11's FS indicated Resident 11 was admitted to facility on [DATE] and expired on [DATE]. Resident 11's FS also indicated diagnoses including malignant neoplasm of ovary (ovary- small glands produce and release eggs for female reproductive system, ovarian cancer). Review of Resident 11's physician orders dated [DATE] indicated morphine sulfate (MS-schedule 11 controlled drug, used to treat pain) oral solution 20 mg/5 ml (mg-milligram, unit of mass equal to one thousandth of a gram/ ml-milliliter, unit of volume equal to one thousandth of a liter). Give 20 ml by mouth every 3 hours as needed for pain Review of Resident 11's CDR for MS medication dated [DATE] indicated no license nurse signature, not dated, and not documented number of doses when received MS medication from pharmacy. Review of Resident 39's FS indicated Resident 39 was admitted to facility on [DATE]. Resident 39's FS also indicated diagnoses including pain, and neoplasm of cervix (cervix-a small canal that connects uterus, cervical cancer). Review of Resident 39's physician orders dated [DATE] indicated oxycodone (schedule 11 controlled drug used to treat pain). Review of Resident 39's CDR dated [DATE] indicated no signature by license nurse, not dated, and not documented of number of doses when received oxycodone medication from pharmacy. During an interview with registered nurse I (RN I) on [DATE] at 5:02 p.m., RN I reviewed CDR documents for Resident 11 for medication MS, and Resident 39 for oxycodone. RN I confirmed both CDR documents for both residents not signed by license staff, not dated, and not documented amount of medication received for Resident 11 and 39. RN I stated license staff should have signed, dated and documented amount of medication received from pharmacy for both residents. During an interview with RN J on [DATE] at 5:20 p.m., RN J reviewed CDR forms for Resident 11 and 39. RN J confirmed license nurse did not sign, not dated and written number doses received for Resident 11 for MS and Resident 39 for oxycodone. RN J stated license nurse should have signed, dated, and documented number of doses received for both residents when received from pharmacy. During an interview with facility's director of nursing (DON) on [DATE] at 10:33 a.m., DON reviewed CDR document for Resident 11 for medication MS, and Resident 39 for oxycodone. DON confirmed missing license nurse signature, date, and number of doses of medication received pharmacy for above both residents. DON stated license nurse should have signed, dated and documented number of doses received pharmacy for accountability for controlled medications and as per facility's policy. Review of facility's policy and procedure (P&P) titled, Catheter Care, Urinary, revision date [DATE], the P&P indicated, Observe the resident for complications associated with urinary catheters. Report unusual findings to the physician or supervisor immediately. If urine has an unusual appearance (i.e., color, blood, etc.). Review of facility's P&P titled, Controlled Medication Storage, undated, the P&P indicated, A controlled medication accountability record is prepared when receiving inventory of a Schedule 11 medication .The following information is completed: a. Name of resident b. Prescription number c. Name, strength (if designated), and dosage form of medication d. Date received e. Quantity received f. Name of person receiving medication.

Based on observation, interview and record review, the facility failed to ensure to provide proper oxygen (a colorless, odorless gas) care and treatment services for three of 15 sampled residents (Residents 16, 20, and 53) when: 1. Resident 16 had room air concentrator (RAC- a medical device take in air from room and filter out nitrogen [a colorless, odorless and nontoxic gas, humans do not breath directly] to provide enriched oxygen [O2-a colorless, odorless, and tasteless gas essential to living organisms])and there was no oxygen signage posted on the door; 2. Residents 20 had an oxygen concentrator (a portable device that provides oxygen) at the bedside, but there was no oxygen signage posted on the door. 3. Residents 53 had an oxygen concentrator at the bedside, but there was no oxygen signage posted on the door. This deficient practice had the potential for accidents and hazards that could pose harm to residents in the facility. Findings: 1. During an observation on 3/24/2025 at 9:55 a.m., noted RAC not in use, placed next to Resident 16's bed. There was no sign posted for no smoking/oxygen in use for this room. Review of Resident 16's face sheet (FS-a document that gives a resident's information at a quick glance) indicated Resident 16 was admitted to facility on 5/28/2019. Resident 16's FS also indicated Resident 16's diagnoses including cerebral ischemic attack (caused by a brief disruption of blood flow to brain), and hypertension (pressure in blood vessels too high). Review of Resident 16's physician orders indicated oxygen: at 2liters/min via nasal cannula (NC, a thin, flexible tube to deliver supplemental O2) every shift for hypoxia (low levels of O2)/shortness of breath (SOB-feeling of can't get enough air into lungs). Goal was to maintain oxygen saturation above 90% dated 3/26/2025. During an interview with license vocational nurse H on 3/24/2025 at 10:50 a.m., LVN H confirmed there was no sign for oxygen in use posted for Resident 16's room. LVN H also confirmed Resident 16 uses O2 on and off for SOB. LVN H stated oxygen in use sign should have been posted for Resident 16's room. LVN H also stated nursing staff should have posted oxygen in use sign outside Resident 16's room. During an interview with facility's director of nursing (DON) on 3/27/2025 at 10:04 a.m., DON stated nursing staff should have posted O2 in use sign for Resident 16's room when Resident 16 uses O2 on and off. 46553 2 .During an observation on 3/24/25, at 10:08 a.m., Resident 20 was lying in bed, asleep, with oxygen concentrator at the bedside, nasal cannula delivering oxygen inside the plastic bag not in used. There was no Oxygen in use/No smoking signage posted on Resident 20's door. Review of Resident 20's order summary report dated 2/18/25 indicated Resident 20's has order for Oxygen at 2 liters (L, metric unit of volume) /minutes via nasal cannula for history of obstructive sleep apnea (OSA, a condition where sleep is interrupted by abnormal breathing) every evening and night shift. During a concurrent observation and interview on 3/24/25 at 10:18 a.m., with the Infection Preventionist (IP), the IP confirmed there was no Oxygen in use/No smoking sign posted by Resident 20's door. The IP stated there should have been a sign posted by the door for precautionary that resident in oxygen in use for safety. 3. During an observation on 3/24/25, at 10:24 a.m., Resident 53 was lying in bed, with oxygen concentrator at the bedside, nasal cannula delivering oxygen inside the plastic bag not in used. There was no Oxygen in use/No smoking signage posted on Resident 53's door. Review of Resident 20's order summary report dated 11/20/24 indicated Resident 53's has order for Oxygen at 2 L/Min via NC PRN (pro re nata, means when required) to keep 02 saturation > 90 percent as needed. On hold from 03/25/25 17:36 to 03/30/25 17:35. During a concurrent observation and interview on 3/24/25 at 10:26 a.m., with the IP, the IP confirmed there was no Oxygen in use/No smoking sign posted by Resident 53's door. During an interview on 3/28/25 at 10:23 a.m., with the IP , the IP further stated there should have been signage in the room for safety hazard to remind staff there was oxygen in use. During an interview with DON on 3/28/25 at 11:36 a.m., the DON stated there should have been oxygen signage to alert the staff in case of emergency when admitted and with order of oxygen. During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration , dated 2001, the P&P indicated, The purpose of this procedure is to provide guidelines for safe oxygen administration. Equipment and supplies: The following equipment . 4. No Smoking /Oxygen in Use signs .Steps in procedure1. Place an Oxygen in Use sign on the outside of the room entrance room. During a review of the facility's policy and procedure (P&P) titled, Signage and Posting, undated, the P&P indicated, The facility will maintain mandatory posting on facility grounds in compliance with State and Federal regulations as well as posting that are helpful for guidance for staff, resident and visitors.1. The maintenance department is responsible for maintaining signage in good repair on facility grounds. Periodic observations will be made to assure the signage is legible and within regulatory guidance.

Based on observation, interview and record review, the facility failed to ensure proper medication storage and labeling of medications and supplies when: 1. An opened multi use eye drop medication with no opened date for Resident 175; 2. Expired over the counter (OTC- medication that can be purchased without a prescription) laxative (medication that helps to promote bowel movement) stored in supply cabinet in medication room [ROOM NUMBER]; 3. Expired suction machine (a medical device that is used for removing obstructions from resident's airway [the path that air follows to get into and out of the lungs]) tubing stored in supply area in medication room [ROOM NUMBER]. Above deficient practices had the potential for resident to receive medications and care equipment supplies with reduced potency from expired medications, and expired equipment supplies and/or medication errors due to medications not being labeled. Findings: 1. During concurrent observation of medication cart 1 and interview with licensed vocational nurse K (LVN K) on 3/27/2025 at 3:38 p.m., noted opened, multi dose rocklatan (used to treat high pressure in the eye) eye medication without opened date written on bottle or bottle stored packet in medication cart for Resident 175. Further review of manufacturer's directions for this medication indicated this medication may be kept at 36-to-77-degree Fahrenheit (F-temperature scale, 36-77, room temperature) for up to 6 weeks. LVN K confirmed multi dose eye medication bottle was opened and currently licensed staff are using this medication for Resident 175. LVN K confirmed opened date not documented on medication bottle or bottle stored packet. LVN K stated license staff should have labeled opened date to stop using this medication 6 weeks after opened. LVN K also stated without opened date labeled unable to know when to stop using this medication. 2. During concurrent observation of medication room [ROOM NUMBER] and interview with facility's director of nursing (DON) on 3/27/2025 at 10:24 a.m., observed OTC miralax (brand name laxative medication) single use packets x3 with 2/2025 expiration date stored in OTC supply cabinet. DON confirmed this expiration date for all 3 packets. DON stated licensed staff should have verified and removed expired OTC medications weekly while checking supplies in medication room [ROOM NUMBER]. 3. During concurrent observation of medication room [ROOM NUMBER] and interview with DON on 3/27/2025 at 10:35 a.m., noted suction machine tubing in sealed package with expiration date of 12/1/2024 placed in a supply's storage area. DON confirmed this observation. DON stated licensed staff should have removed and discarded expired suction machine tubing from supplies storage area in medication room [ROOM NUMBER]. During an interview with DON on 3/27/2025 at 10:43 a.m., DON stated license staff should have labeled with opened date on bottle or bottle stored packet for multi dose eye drop medication when opened. DON also stated without opened date label, licensed staff would not know when to stop using this medication for Resident 175 as recommended by manufacturer to avoid using expired medication. Review of facility's policy and procedure (P&P) titled, Medication Administration General Guidelines, dated 09/18, the P&P indicated, b. The nurse shall place a 'date opened' sticker on the medication if one is not provided by the dispensing pharmacy and enter the date opened. Manufacturer recommendations for beyond use dating should take precedence, taking into consideration 'not to exceed' limitations. The beyond use dating, which only lists month/year, falls to the last day of that month.

Based on observation, interview, and record review, the facility failed to ensure staff implemented proper infection control practices when: 1. Uncovered feeding tube (a thin, flexible tube one end attached to feeding formula bottle and other end attached to gastrostomy tube [GT-a thin, flexible tube inserted into the stomach to provide nutrition and medications to resident who cannot eat or drink by mouth]) when feeding was not in use; 2. Resident 39's nephrostomy (a surgery to make an opening from the outside of the body to the renal pelvis [part of the kidney that collects urine]) collection bag was laying in the floor; 3. Nebulizer (a small machine that turns liquid medicine into a mist, allowing you to breathe it in directly into your lungs through a mouthpiece or mask) kit was not properly stored after use for Resident 32. These failures had the potential for development and transmission of communicable diseases and infections in the facility. Findings: 1. During an observation on 3/25/2025 at 9:45 a.m., noted Resident 29's GT feeding machine was turned off. Further observation noted end of feeding tube which was disconnected from Resident 29's GT, left on GT machine, and uncovered feeding tube. Other end of feeding tube was connected to ready to use 3/4 th full feeding formula bottle hanging on a pole next to Resident 29's bed. Handwritten documentation on feeding formula bottle noted started on 3/25/2025 at 4:30 am, rate 65 cc/hr. Review of Resident 29's face sheet (FS-a document that gives a resident's information at a quick glance) indicated Resident 29 was admitted to facility on 6/1/2022. Resident 29's FS also indicated Resident 29's diagnoses including cerebral infarction (happens when blood supply to brain disrupted), gastrostomy status (surgically inserted tube into stomach to provide nutrition and medications for resident who can not eat or drink my mouth due to medical reasons), and diabetes type 2 (a disease in which high levels of sugar in blood). Review of Resident 29's orders indicated enteral feed order every shift enteral: Tube feeding Glucerna 1.2 (brand name ready to use nutritional formula) at 65cc/hrx20 hours to provide 1560 kcal (a unit of energy measurement used to quantify the calorie content of food) /day. Start feeding via pump at 12 noon stop feeding at 8 am or until volume was met dated 11/6/2024. During an interview with license vocational nurse H (LVN H) on 3/25/2025 at 9:50 a.m., LVN H confirmed end of GT feeding tube left uncovered when Gt feeding was not in use for Resident 29. LVN also confirmed using same feeding formula bottle and feeding tube to restart feeding at 12 noon for Resident 29. LVN also stated feeding tube should have been covered when not in use, nursing staff should have not leave uncovered. During an interview with facility infection preventionist (IP) on 3/25/2025 at 9:55 a.m., IP confirmed GT feeding tube left uncovered. IP discarded feeding formula bottle along with feeding tube. IP stated nursing staff should have placed feeding tube in a plastic bag when not in use for infection control. During on telephone interview with director of sales (DS) from a medical supply company that supplies GT feeding supplies to facility on 3/28/2025 at 1:18 p.m., DS stated manufacturer for GT feeding tube recommending covering the GT feeding tube when not in use and when re-using same supplies later on for infection control. 46553 2.During an observation on 3/24/25 at 11:19 a.m., Resident 39 was lying in bed, where in a nephrostomy tube connected to a nephrostomy collection bag was laying in the floor. During a concurrent observation and interview on 3/24/25 at 11:23 a.m., with the Infection Preventionist (IP), the IP confirmed Resident 39's nephrostomy collection bag was laying in the floor. During an interview with Director of Staff Development (DSD) on 3/26/25 at 3:24 p.m., DSD confirmed the nephrostomy collection was bag was laying in the floor and stated it should have been hanging to drain correctly and prevent infection. During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program , revised 8/2022, the P&P indicated, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections. 49345 3. A review of Resident 32's medical record included a diagnosis of chronic obstructive pulmonary disease with (acute) exacerbation (COPD, a common lung disease causing restricted airflow and breathing problems). A review of Resident 32's Physician Order started on 2/24/25 indicated, Ipratropium-Albuterol Solution [used to treat symptoms of COPD] 0.5/2.5 (3)mg [milligram, unit of measurement]/3 ml [milliliter, unit of measurement] inhale orally every 4 hours as needed for SOB [shortness of breath] or wheezing [a high-pitched, whistling sound that occurs during breathing, often when airways in the lungs are narrowed or blocked, signaling potential breathing difficulties] via nebulizer During a concurrent observation and interview on 3/25/25 at 9:41 a.m. in Resident 32's bedside with the DON, the DON verified the nebulizer mask hanging by its string on the nebulizer machine. The nebulizer mask was still attached to the medication cup and was connected via its tubing to a nebulizer. The DON stated it should have been placed in a plastic bag. The DON proceeded to put the nebulizer mask in an unlabeled plastic bag. Resident 32 stated he turned off the nebulizer because the nurse had not come back yet. During an interview on 3/28/25 at 8:57 a.m. with the Infection Preventionist Nurse (IP), the IP stated that nebulizer masks must be rinsed after use and then put in a plastic bag. A review of facility's Policy and Procedure (P&P) entitled Medication Administration Nebulizers indicated, .18. When treatment is complete, turn off nebulizer and disconnect T-Piece, mouthpiece and medication cup .20. Rinse and disinfect the nebulizer equipment according to manufacturer's recommendations and facility policy .22. When equipment is completely dry, store in a plastic bag with the resident's name and date on it.

Based on observation, interview, and record review, the facility failed to ensure respect and dignity was maintained for one of four sampled residents (Residents 39) when staff failed to provide privacy bag for above residents' nephrostomy (a surgery to make an opening from the outside of the body to the renal pelvis [part of the kidney that collects urine]) collection bag. This failure had the potential to affect the emotional and psychosocial well-being of the residents. Findings: Review of Resident 39's clinical record indicated, she was admitted on [DATE] with diagnoses that include malignant neoplasm (an abnormal growth of tissue that can be benign or malignant) of cervix(the lower , narrow end of the uterus that connects the uterus to the vagina), unspecified; cystitis (inflammation of the bladder [hollow organ that stores urine before it leaves the body]), unspecified without hematuria (presence of blood in urine); urinary tract infection (occur when bacteria enter the urinary tract through the urethra and begin to spread in the bladder) site not specified. During an observation on 3/24/25 at 11:19 a.m., Resident 39 was lying in bed, with nephrostomy collection bag was laying in the floor. The nephrostomy collection bag was not covered, and the contents were visible. During a concurrent observation and interview on 3/24/25 at 11:23 a.m., with the Infection Preventionist (IP), the IP confirmed Resident 39's nephrostomy collection bag was not covered and visible. The IP stated the nephrostomy collection bag should have been covered. During an interview with Director of Staff Development (DSD) on 3/26/25 at 3:24 p.m., the DSD stated the nephrostomy collection bag should have been with privacy bag. During a review of the facility's policy and procedure (P&P) titled, Dignity , revised 2/2021, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.12. Demeaning practice and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist resident; for example: a. helping the resident to keep urinary catheter bags covered.

Based on observation, interview and record review, the facility failed to ensure one (Resident 58) out of 15 sampled residents was free from physical restraint not required to treat medical symptoms when Resident 58 was restrained to a wheelchair. This failure resulted in Resident 58 being restricted from moving out of the wheelchair which had the potential for distress and physical injury. Findings: A review of Resident 58's medical record included diagnoses of Hemiplegia and Hemiparesis following cerebral infarction (paralysis and weakness on one side of the body, on one side, both resulting from impaired communication between the brain and muscles), and other abnormalities of gait and mobility, mood disorder due to known physiological condition with depressive features. A review of Resident 58's Minimum Data Set (MDS, an assessment tool), dated 12/24/24, indicated a brief interview for mental status score of 8 [BIMS, a tool used to assess cognition (knowing, learning, and understanding), a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact]. A review of Resident 58's Occupational Therapy and Plan of Treatment dated 12/18/24 indicated, Reason for Therapy: .pt [patient] has severe L [left] neglect [an attention disorder that causes difficulty paying attention to, or is unaware of, things on the left side] along with L hemiparesis [weakness on one side of the body] ,pt is also Chinese speaking only During an interview on 3/27/25 at 8:48 a.m. with Licensed Vocational Nurse (LVN) A, LVN A stated, it was not okay to put a resident in restraints on a wheelchair. During an interview on 3/27/25 at 9:05 a.m. with LVN B, LVN B stated, restraints were not used in the facility. During an interview on 3/27/25 at 10:16 a.m. with Certified Nurse Aide (CNA) D, CNA D stated, before 7 a.m. on 3/3/25, Resident 58 was in his wheelchair inside his room pointing at his abdomen. CNA D stated she did not check on Resident 58 and she proceeded to clock in for her shift. CNA D stated that Resident 58 did not speak English. During an interview on 3/27/25 at 10:41 a.m. with Director of Staff Development (DSD), DSD stated, CNAs were not allowed to use restraints on residents. During an interview on 3/27/25 at 10:51 a.m. with Social Services Director (SSD), SSD stated, I don't know if there is a policy that says we can restrain a resident. During a concurrent observation and interview on 3/28/25 at 10:50 a.m. with CNA D, CNA D demonstrated how to lock and unlock a gait belt (an assistive device which can be used to help safely transfer a person from a bed to a wheelchair and assist with sitting and standing) with metal buckle and stated it was not easy to unlock a gait belt. During a concurrent observation and interview on 3/28/25 at 11:14 a.m. with the Director of Nursing (DON), the DON stated that gait belts were used for transfers and ambulation (walking). The DON stated it was not right to restrain a resident in a wheelchair for safety. The DON demonstrated how to lock and unlock a gait belt with a plastic clip buckle and another with a metal clasp. The DON stated that CNA F used a gait belt with a plastic clip buckle to restrain Resident 58. The DON also stated, a confused resident would not be able to unlock a gait belt with a clip buckle. During a telephone interview on 3/28/25 at 11:49 a.m. with CNA F, CNA F stated that on 3/3/25 around 5:45 a.m., while Resident 58 was on a wheelchair, she put a gait belt around him and the wheelchair because Resident 58 goes around. CNA F stated she was new in the facility. CNA F also stated she did not remove the gait belt on Resident 58. During a telephone interview on 3/28/25 at 1:53 p.m. with CNA G, CNA G stated she found Resident 58 restrained to a wheelchair on the morning of 3/3/25. CNA G stated Resident 58 was in his room in a wheelchair asking his roommate for help and there was a language barrier. CNA G stated, I gave him my hand to try and get up and I noticed he cannot move up from the wheelchair. He was wearing a blue jacket, and when I opened the jacket, I found he was restrained. The restraint was covered by his jacket. I removed the restraint. A review of facility's undated Policy and Procedure (P&P) entitled, Use of Restraints, the P&P indicated, Restraints shall only be used for the safety and well-being of the resident and only after alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline and staff convenience, and that are not required to treat the resident's medical symptoms .'Physical restraint is defined as any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria: attached or adjacent to the resident's body; Cannot be removed easily by the resident; and Restricts the resident's freedom of movement or normal access to his/her body .2. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints .5. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following: a. The specific reason for the restraint .b. How the restraint will be used to benefit the resident's medical symptom, and c. The type of restraint and period of time for the use of the restraint 8. The following safety guidelines shall be implemented and documented while a resident is in restraints: b. Physical restraints shall be applied in such a manner that they can be speedily removed in case of fire or other emergency. Restraints with locking devices shall not be used. A review of facility's undated document entitled Resident Rights indicated, Employees shall treat all residents with kindness, respect, and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: .d. be free from corporal punishment or involuntary seclusion, and physical or chemical restraints not required to treat resident's symptoms; A review of facility's Policy and Procedure (P&P) entitled Dignity revised February 2021, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. 1. Residents are treated with dignity and respect at all times . 3. Residents may exercise their rights without interference, coercion, discrimination or reprisal from any person or entity associated with this facility.

Based on interview and record review the facility failed to follow their policy and procedure (P&P) for pre-admission screening and resident review (PASRR- screening for residents with mental disorder and residents with intellectual disability) screening was completed and submitted for one of two sample resident (Resident 24) with significant change in mental illness (MI-a wide range of conditions that affect resident's mood, thinking, and behavior). This failure had the potential for mentally ill sample resident not to receive benefit from specialized health care and services. Findings: Review of Resident 24 face sheet (FS- a document that gives a resident's information at a quick glance) indicated Resident 24 was initially admitted to facility on 5/21/2023 and readmitted on [DATE]. Resident 24's FS also indicated diagnoses including anxiety disorder (excessive, persistent worry and fear of everyday situations) dated 1/8/2025, and delusional disorders (a serious mental illness that causes resident can not tell what's real from what's imagined), dated 2/24/2025. Review of Resident 24's physician's order form dated 3/13/2025 indicated Resident 24's hospice (a program that gives special care to residents who are near the end of life) MD (medical doctor) ordered risperidone (a class of antipsychotic medication used to treat mental illnesses) 1 milligram (mg-a unit of mass in metric system equal to a thousandth of a gram) daily PM (every afternoon or evening)for delusional disorder m/b (manifested by- as evidenced by) auditory hallucinations (hearing voices or noises that aren't there) started on 3/13/2025. Further review of his order form also indicated medication order for risperidone 1 mg daily PM for Schizophrenia (a serious mental illness that affects how a resident think, feels and behaves) started on 2/28/2025 and discontinued on 3/14/2025. Review of Resident 24's minimum data set significant change in status (MDS SCIS- comprehensive assessment tool when resident's status changed significantly, either for the better or worse) assessment dated [DATE] indicated section N for medications indicated Resident 24 received antipsychotic medication during last 7 days. Section I for active diagnoses indicated anxiety and psychotic disorder (other than schizophrenia) under psychiatric/mood disorder for Resident 24. Review of documented PASRR dated 5/21/2023 copy provided by facility for Resident 24 indicated no serious mental illness, and no prescribed psychotropic medications for mental illness. Review of clinical documentation for Resident 24 indicated there was no documented PASRR assessment and submitted to state agency (an agency responsible for financing, providing physical and mental health services and support for low-income individuals and families in California) until 3/28/2025 with Resident 24's significant change in mental condition. Review of this PASRR indicated date completed on 3/28/2025, after this health facility evaluator nurse (HFEN-a registered nurse who conducts inspections, investigations, and surveys of health facilities to ensure compliance with state and federal laws and regulations related to resident's care) started investigation and requested facility for copy of PASRR with Resident 24's significant change in mental condition. During an interview with facility's director of nursing (DON) on 3/27/2025 at 10:14 a.m., DON confirmed documented PASRR assessment completed on 5/21/2023. DON also confirmed Resident 24 received new diagnoses of anxiety on 1/8/2025, delusional disorder on 3/13/2025, and started new order for antipsychotic medication risperidone on 2/28/2025 and there was no documented PASRR assessment completed after Resident 24's newly diagnosed MI and newly started antipsychotic medication. DON stated significant change in mental condition with new diagnoses of MI and newly started antipsychotic medication warranted for facility to do a new PASRR assessment and submit to the stae agency as per facility's policy. DON also stated facility should have followed P&P for completion of PASRR assessment and submitted to the state agency to receive healthcare and services as needed for Resident 24. During an interview with DON on 3/28/2025 at 2:04 p.m., DON confirmed facility completed PASRR on 3/28/2025 for Resident 24. DON stated facility should have completed and submitted new PASRR after Resident 24's significant change in mental condition on 2/28/2025 not after HFEN started investigation. Review of facility's P&P titled, Preadmission Screening Resident Review (PASRR) revised August 2007, the P&P indicated, This facility promptly notify the state mental health and /or mental retardation (MR-disorder characterized by significant intellectual impairment) or developmental disability authority, as applicable, if there is a significant change in the physical or mental condition of a recipient who is mentally ill or mentally retarded. This would warrant re-evaluation . A readmission is not subject to another PASRR Level 1 screening unless there is a change in his or her medical condition that may indicate a change in his or her MI (Mental illness)/ MR status.

Based on observation, interview, and document review, the facility failed to ensure food was stored and/or prepared under sanitary conditions when an opened bag of hamburger buns past their used-by date was found in the kitchen pantry. This failure had the potential to cause food borne illness. Findings: During an initial kitchen observation and interview on 3/24/25 at 9:12 a.m. with the Dietary Director (DD), an opened bag of hamburger buns containing six buns dated 3/6/25 was found in the dry storage room/pantry. The DD stated, bread could have been stored seven days from the labeled date. The DD also stated, the hamburger buns dated 3/6/25 must be discarded. A loaf of bread with a labeled date of 3/23/25 was also found beside the hamburger buns. The DD pointed at the sticker on the shelf underneath the loaf of bread which indicated Item: Bread Date: 3/23/25 Use By: 3/30/25. The DD verified there was no sticker for use by date for the hamburger buns dated 3/6/25. A review of facility's Policy and Procedure (P&P) entitled, Food Receiving and Storage dated 2001, the P&P indicated, Foods shall be received and stored in a manner that complies with safe food handling practices . A review of Duties and Responsibilities for Dietary Supervisor indicated, .Administrative Functions: Inspect food storage rooms, utility/janitorial closets, etc., for upkeep and supply control . A review of facility's Policy and procedure (P&P) entitled Refrigerators and Freezers revised November 2022, the P&P indicated, .9. Supervisors are responsible for ensuring food items in pantry, refrigerators, and freezers are not past 'use by' or expiration dates

Based on interview and record review, the facility failed to provide assistance to prevent an accident for one of three sampled residents (Resident 1). Resident 1's functional ability for bending and picking up objects on the floor was not assessed to determine the ability to bend and Rehab Aide A (RAA) did not provide assistance by holding the gait belt (a device that helps caregivers safely move and support patients who have mobility issues) during therapy exercise. This failure resulted in Resident 1 having a fall and was sent to the hospital with a forehead laceration (a cut in the skin or underlying tissue that's usually caused by blunt trauma). Findings: During a review of Resident 1's undated Facesheet (document used to reference a resident's medical and contact information), indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of need for assistance with personal care, other abnormalities of gait [pattern of limb movement when walking] and mobility. During a review of Resident 1's Fall Risk Evaluation, dated 7/19/24, evaluation indicated, Resident 1 was assessed to be at a Moderate Risk of fall (Scored 15). Fall risk evaluation also indicated, to evaluate residents balance while standing, sitting and during transitions. Resident 1 was not able to attempt the transfer without physical help. Resident 1 has impaired balance. On problem: Resident 1 was at risk for fall r/t[related to] generalized weakness. Resident 1 approach r/t impaired gait/balance was to use gait belt and physical therapy (PT) recommended devices. During a review of Resident 1's Fall Risk Care Plan dated 7/20/24 indicated, At risk for falls r/t generalized weakness, hx [history] of falls, DX [diagnosis of] Renal Cancer. The care plan tasks indicated to anticipate and meet resident's needs r/t impaired gait/balance. During a review of Resident 1's MDS (Minimum Data Set- an assessment tool) Section GG, dated 7/25/24, MDS indicated, for eating, toileting, bathing self, dressing upper and lower body, putting on footwear and personal hygiene, as Dependent-Helper does ALL of the effort. The MDS also indicated, P. Picking up object for ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor, it was indicated 88 which means Resident 1 was not attempted due to medical condition or safety concerns. During a review of Resident 1's MDS Section C dated 7/25/24, the MDS indicated, Resident 1's BIMS (Brief Interview for Mentals Status: assessment used to determine cognitive status: ability to reason and think about one's environment) a score of 14 which means cognitively intact (13-15 cognitively intact). During a review of Resident 1's Physical Therapy (PT) Evaluation & Plan of Treatment, dated 7/22/24, evaluation indicated, pt[patient] has been nonambulatory [sic] for over a year and half. picking up object-Not attempted due to medical conditions or safety concerns. During a review of Resident 1's Physical Therapy Treatment Encounter Note dated, 7/23/24, note indicated, Other Picking up object=Not attempted due to medical conditions or safety concerns. During a review of Resident 1's Physical Therapy Treatment Encounter Note dated, 7/24/24, note indicated, Other Picking up object=Not attempted due to medical conditions or safety concerns. During a review of Resident 1's Physical Therapy Treatment Encounter Note dated, 7/25/24, note indicated, Other Picking up object=Not attempted due to medical conditions or safety concerns. During a review of Resident 1's Physical Therapy Treatment Encounter Note dated, 7/26/24, note indicated, Response to Tx [treatment]: .can be impulsive at times. Other Picking up object=Not attempted due to medical conditions or safety concerns. During a review of Resident 1's Physical Therapy Treatment Encounter Note dated, 7/29/24 note indicated, Response to Tx. Resident 1 demo'd [demonstrated] impulsivity and had x1 [one time] LOB [loss of balance] episode while sitting in WC [wheelchair], attempting to reach anteriorly [front of body] and fell on to floor. During a review of Resident 1's SBAR [Situation, Background, Assessment, and Recommendation, is a structured communication framework that can help teams share information about the condition of a resident to the Doctor], dated 7/29/24 indicated Resident fell while doing therapy, (with therapy staff). Resident fell from wheelchair to the floor face down. Assessment done by UM [unit manager] and LN [licensed nurse], Laceration to left side of forehead (2.9 centimeter), redness to neck and both knees. Steri-strips [plastic bandages covered in a gentle skin glue that helps pull the edges of the wound together] applied to forehead. The primary care provider responded with the following feedback and the recommendations was to send the resident [Resident 1] to ER (emergency room ) for further evaluation. Time of 1640 [4:40p.m.]. Record review of Resident 1's After Visit Summary (AVS) from Acute Hospital dated 7/29/24, AVS indicated, Reason for visit Fall.Diagnosis Forehead laceration, sutured.suture removal in 7 days. During a review of Resident 1's Progress note dated 7/29/24, at 8:51 p.m., note indicated, Resident [1] came back from hospital @2050 [8:50 p.m.], per [hospital] report, [Resident 1] has 4 sutures to the L [left] side of forehead laceration. During an interview on 8/14/24, at 10:34 a.m., with Rehab Aide A (RAA), RAA stated he was assisting Resident 1 for her scheduled Physical Therapy session on 7/29/24 and when Resident 1 fell on the floor. RAA also stated he was preparing the cones for Resident 1's physical therapy exercise, which included staying seated in the wheelchair and reaching to the floor to pick up the object/cone from the floor. RAA stated, the Physical Therapy Assistant (PTA) was working remotely and monitored the therapy via an iPhone, which was held by the Director of Rehab. RAA stated he was standing on the right side of Resident 1 and the PTA was instructing Resident 1 what to do. The PTA stated to Resident 1 to reach forward to pick up the cone, Resident 1 reached forward and fell forward out of the wheelchair onto the floor face first. RAA stated, he was not fast enough to catch Resident 1 before she fell . RAA stated, he was not sure of what level of assistance should have been provided for Resident 1. RAA stated, he was not holding onto Resident 1's gait belt at the time of fall. During an interview on 8/14/24, at 11 a.m., with Director of Rehab (DOR), DOR stated, she was present during the fall on 7/29/24 and was holding the camera for the PTA to observe Resident 1. DOR stated, on the day of the fall 7/29/24, she was assisting Resident 1 with therapy. DOR stated, the PTA was working with Resident 1 remotely and RAA was assisting Resident 1. DOR was unable to explain what Resident 1 was doing during the time of the fall. During an interview on 8/16/24 at 11:25 a.m., with PTA, PTA stated she was working remotely with Resident 1 and when Resident 1 fell on [DATE]. The RAA assisted her on 7/29/24 during therapy exercise. PTA stated, the DOR was there to assist Resident 1 related to impulsive behavior from prior therapy exercise. PTA stated, the DOR was not providing care, and DOR was holding the iPhone pointed at Resident 1 in front of her. PTA stated, she was not aware of the exact assistance Resident 1 required, but it should have been found in the therapy notes. PTA stated she was not able to see if Resident 1 was wearing a gait belt when Resident 1 fell on [DATE]. During an interview on 8/16/24, at 3:16 p.m., with Resident 1, Resident 1 stated regarding her fall The cones were too far away. Resident 1 stated, It was their fault. During an interview on 9/9/24, at 1:25 p.m., with DOR, DOR stated, she understands that the Physical Therapist did not evaluate Resident 1's ability to pick up an object because it was likely unsafe at the time of assessment. DOR stated, on 7/29/24 The RAA should have held onto the gait belt during the therapy exercise. During a review of the facility's Policy and Procedure (P&P) titled, Falls and Fall Risk, Managing, dated 2018, the P&P indicated, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. During a review of the facility's P&P titled, Telehealth Policy and Procedure, dated 2024, the P&P indicated, To establish guidelines for the use of telehealth in delivering therapy services within a skilled nursing facility (SNF), ensuring these services are provided safely, effectively, and in compliance with legal and ethical standards.

Based on interview and record review, the facility failed to provide services according to professional standards of practice for 1 of 2 sampled residents (Resident 1). When staff failed to: 1. Document to keep Resident 1's oxygen saturation (a measure of how much hemoglobin: protein responsible for transporting oxygen, is currently bound to oxygen) greater 90% as prescribed by the physician; 2. Notify the physician regarding Resident 1's change of condition and there was no physician order for transfer to the acute care hospital. These failures had the potential to affect his medical condition and address the residents needs during the transfer to the acute care hospital. Findings: 1. During a review of Resident 1's Order Summary Report dated, 4/24/24, Report indicated, Oxygen: At 3 L/min [liters per minute] via NC [nasal cannula] qs [every shift] to keep 0xygen sats [oxygen saturation] >90%. every shift for sob [shortness of breath]. During a concurrent interview and record review on 5/13/24, at 11:51 a.m., with Director of Nursing (DON), Resident 1's Treatment Administration Record (TAR) dated 4/26/24 was reviewed. The TAR indicated, Resident 1's oxygen saturation was not marked as checked for the evening shift. DON stated, it was not charted that it was completed, and the nurse should have charted that they checked the oxygen. 2. During a review of Resident 1's Progress notes dated 4/28/24 indicated, Patient back from [acute care hospital] ER [emergency room ] via ambulance as per report from paramedic, and there was nothing wrong with the patient findings negative of blood clot. Patient and family aware. During a concurrent interview and record review on 5/13/24, at 11:58 a.m., with DON, Resident 1's Change in Condition Evaluation dated 4/28/24 was reviewed. The evaluation indicated, swelling on lateral border of left forearm. 3 Review Findings and Provider Notifications this section was left blank with no Physician notification documented. DON stated, the Evaluation was not completed by the nurse. Licensed nurses should have notified the physician during the change of condition and to get an order to transfer Resident 1 to the acute care hospital. During a review of Resident 1's Progress notes dated 4/28/24 indicated there was no documentation the physician was notified during Resident 1's change in condition. During a concurrent interview and record review on 5/13/24, at 11:58 a.m., with DON, indicated Resident 1's Physician Orders undated was reviewed. DON confirmed there was no physcian order for transfer to acute care hospital. DON stated she did not see an order to transfer Resident 1 to acute care hospital. During a review of the facility's policy and procedure (P&P) titled, Documentation of Medication Administration, dated 2022, the P&P indicated, 1. A nurse. documents all medications administered to each resident on the resident's medication administration record. During a review of the facility's policy and procedure (P&P) titled, Oxygen administration dated 2020, the P&P indicated, After completing oxygen setup, or adjustment, administration of oxygen will be recorded in the resident's medical. [sic]. During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status dated 2007, the P&P indicated, Our facility shall promptly notify the resident, his or her attending Physician and representative (sponsor) of changes in the resident's medical/mental condition.

Based on observation, interview and record review, the facility failed to implement proper infection control practices for 1 of 2 sampled residents (Resident 2) when Resident 2 ' s oxygen tubing and humidifier was not replaced and labeled according to facility policy. This failure had the potential for Resident 2 to develop an infectious disease from old oxygen tubing. Findings: During a concurrent observation and interview on 5/13/24, at 11:22 a.m., with Registered Nurse (RN) A, in Resident 2 ' s room, Resident 2 was receiving oxygen via oxygen tubing through a nasal cannula (tube that provides oxygen directly to the nose). The oxygen tubing did not have a date when it was last replaced. The humidifier container on the oxygen machine did not have a date on it when it was last replaced. RN A confirmed there was no date on the tubing and no date on the humidifier. She stated licensed nurses should have change and label the date every week. I have no way of knowing how old the tubing is. During a review of Resident 2 ' s Order Summary Report May 2024, report indicated, an order for O2[oxygen] at 2lit/min[liters per minute] via NC [nasal cannula] to keep SPO2 [oxygen saturation] above 90%, active 4/11/24. During an interview on 5/13/24, at 11:55 a.m., with Director of Nursing (DON), DON confirmed the nurses should have change the tubing and humidifier every week and put their initial and the date the tubing was replaced on a label or tape. During a review of the facility ' s policy and procedure titled, Oxygen Administration, dated 2020 indicated, 2. Oxygen tubing and humidifier will be changed and labeled every 7 days and as needed.

Based on observation, interview, and record review, the facility failed to ensure services were provided to meet the professional standard of practice for four out of five sampled residents (Resident 24, 34, 4, and 3) who had a pacemaker (implanted device for a heart condition, a battery-powered device implanted inside the heart to restore a normal heartbeat) when: 1. Resident 24 had no documentation of apical pulse checks and no pacemaker malfunction monitoring, no pacemaker-related information in the medical records, no medical identification card regarding pacemaker, and no care plan regarding the pacemaker management, 2. Resident 34 had no care plan to manage the pacemaker care; 3. Resident 4 had no medical identification card regarding pacemaker; and 4. Resident 3 had no documentation of pacemaker information. These failures had the potential to compromise those residents' health and safety. Findings: 1. A review of Resident 24's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including acute on chronic diastolic (congestive) heart failure (a chronic condition in which the heart didn't pump blood as well as it should), stage 5 chronic kidney disease (end-stage renal disease), dependence on renal dialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally), unspecified pneumonia, acute respiratory failure with hypoxia (a state in which oxygen was not available in sufficient amounts at the tissue level to maintain adequate homeostasis), presence of cardiac pacemaker, and dependence on supplemental oxygen. During an interview with Licensed Vocational Nurse (LVN) B on 11/30/23 at 10:15 a.m., LVN B acknowledged that she did not check Resident 24's apical pulse to monitor pacemaker malfunction. During a concurrent interview and record review with Registered Nurse (RN) E on 11/30/2023 at 10:22 a.m., RN E reviewed Resident 24's medical record and confirmed there were no documentation of apical pulse checks and pacemaker malfunction monitoring, no care plan to manage the pacemaker care, no pacemaker related information in medical record. RN E stated the licensed nurses should have checked Resident 24's apical pulse daily, monitored for signs and symptoms of pacemaker malfunction every shift, kept pacemaker information in the medical records, provided a medical indetification card with pacemaker information, and developed a care plan to manage pacemaker care. During an interview with Registered Nurse (RN) C on 11/30/2023 at 2:18 p.m., RN C acknowledged she did not know the paced rate and did not check Resident 24's apical pulse. RN C further stated she should have known the paced rate and checked the apical pulse to monitor pacemaker malfunction. RN C also confirmed there was no medical identification card with Resident 24. During an interview with the Director of Nursing (DON) on 11/30/2023 at 3:20 p.m., the DON stated licensed nurses should have develop a care plan to manage pacemaker care, check apical pulse, and monitor the signs and symptoms of the pacemaker malfunction. The DON further stated Resident 24 was a dialysis resident who went out for dialysis three times a week and the facility should have provided a medical identification card with pacemaker information. 2. A review of Resident 34's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including the presence of a cardiac pacemaker. During a concurrent interview and record review with the DON on 11/30/2023 at 3:22 p.m., the DON reviewed Resident 34's care plan and confirmed there was no care plan to address the pacemaker care. The DON further stated the licensed nurses should have developed a care plan to address the pacemaker management. 3. A review of Resident 4's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including the presence of a cardiac pacemaker. During an observation and concurrent interview with Resident 4 in her room on 11/30/2023 at 1:47 p.m., Resident 4 had a pacemaker on her left upper chest and she stated that she had no medical identification card with pacemaker information. During an interview with the DON on 11/30/2023 at 3:24 p.m., the DON confirmed the above observation and stated the facility should have provided a medical identification card with pacemaker information to Resident 4 for emergency purposes. 4. A review of Resident 3's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including the presence of a cardiac pacemaker. During a concurrent interview and record review with the DON on 11/30/2023 at 3:26 p.m., the DON reviewed Resident 3's medical record and confirmed there was no documentation of Resident 3's pacemaker information in her medical record. The DON stated staff should have documented the pacemaker information in Resident 3's medical record and medical identification card upon admission. During a review of the facility's undated policy and procedure (P&P) titled Pacemaker, Care of a Resident with, the P&P indicated, .monitor the resident for pacemaker failure by monitoring for signs and symptoms of bradyarrhythmia .make sure the resident has a medical identification card that indicates he or she has a pacemaker. The medical record must contain this information as well .for each resident with a pacemaker, document the following in the medical record and on a pacemaker identification card upon admission: name, address, and telephone number of the cardiologist, type of pacemaker, manufacturer, and model, serial number, date of implant and paced rate. During a review of the facility's policy and procedure (P&P) titled Baseline Care Plan effective date:7/01/2023, the P&P indicated . to assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed with forty-eight hours of the resident's admission .

Based on observation, interview and record review, the facility failed to ensure proper medication storage and labeling of medications when: 1. three personal water bottles were kept in the medication room; 2. unlabeled used medication in the refrigerator; 3. discontinued medications were not discarded. These deficient practices had the potential for unsafe, ineffective and risk the misuse of medications. Findings: During the inspection and observation of the facility's Medication Storage room [ROOM NUMBER] on 11/27/23 at 8:00 a.m., the following were identified: 1. three personal water bottles, one opened and two unopened personal water bottles, were kept in the medication storage room, 2. one used medication in the medication refrigerator, Admelog Solostar (insulin lispro, fast-acting insulin, used to control blood sugar spikes), 100 unit (the concentration of insulin)/milliliter (ml, unit of volume), inject 5 units subcutaneously (beneath or under, all layers of the skin), 3 times daily with meals, discard 28 days after opening, not labeled with open and discard date and 3. discontinued medications were still not discarded. During an interview with the director of nursing (DON) on 12/01/23 at 1:10 p.m., DON verified the three personal water bottles should have not be kept in the medication storage room, the used medication in the medication refrigerator, Admelog Solostar, 100 unit/ml, inject 5 unit should have been labeled with open and discard date, and discontinued medications must be discarded right away. Review of the facility's policy and procedure titled, Storage of Medications, revision date 11/28/23 indicated, It was the policy of this facility that all drugs and biologicals are stored in a safe, secure and orderly manner. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. The facility should not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. Review of the facility's policy and procedure titled, Labeling of Medication Containers, revision date 11/28/23 indicated, It was the policy of this facility that all medications maintained in the facility shall be properly labeled in accordance with current state and federal regulations. Labels for individual drug containers shall include all necessary information, such as: . the date that the medication was dispensed, . the expiration date when applicable . Review of the facility's policy and procedure titled, Discontinued Medications, revision date 11/28/23 indicated, It is the policy of this facility that staff shall destroy discontinued medications or shall return them to the dispensing pharmacy in accordance with facility policy. Discontinued medications must be destroyed or returned to the issuing pharmacy in accordance with established policies.

Based on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained in the kitchen when: 1. Undated and unrefrigerated bottle of sauce in the dry storage area; 2. Dented can in the dry storage area; 3. Two kitchen staffs did not completely cover their hair while handling food; 4. Ice machine had a black substance inside; and 5. Food prep sink drain was too close to the floor drain. These failures had the potential to cause food contamination and spread food-borne illness to residents who received their food from the kitchen. Findings: 1.During a concurrent kitchen observation and interview on 11/27/23 at 10:53 a.m. with the Registered Dietician (RD), there was a bottle of opened bottle of sauce without an open date in the dry storage area. The food label on the bottle also indicated, refrigerate after opening. The RD confirmed the above observations and stated the bottle was open with no open date. During a review of the facility's policy and procedure (P &P) titled, Food Storage dated 2017, the P&P indicated, When a food package was opened, the food item should have been marked to indicate the open date. This is used to determine when to discard the food. During a review of the facility's P &P titled, Food Safety and Sanitation dated 2017, the P&P indicated,4. Food storage. a. Stored food handled to prevent contamination and growth of pathogenic organisms. Refrigerated food was stored at or below 41 F. 2. During a concurrent kitchen observation and interview 11/27/23 at 10:49 a.m. with the RD, there was one large, dented can in the dry storage area. The RD confirmed the above observations and stated the dented can should have been taken out and placed in the designated area. During a review of the facility's P &P titled, Food Safety and Sanitation dated 2017, the P&P indicated, Bulging or leaking cans, cans with severe dents on the seams, or broken containers of food will not be used. Review of the United States Food and Drug Administration's 2022 Food Code indicated, pitted, or dented cans may present a serious potential hazard. 3. During a kitchen observation on 11/29/23 at 8:45 a.m., a Dietary Cook and a Cook Aide were preparing food to serve to the residents. Both staffs did not have their hair inside of their hair nets. During an interview on 11/29/23 at 9:38 a.m., with the Dietary Supervisor, confirmed the above observation and stated staff should have had their hair completely covered while handling food. During a review of the facility's P &P titled, Food Safety and Sanitation dated 2017, the P&P indicated, 2. Employees. C. Employee are required to have their hair styled so that it does not touch the collar, [ .] Hair restraints are required and should cover all hair on the head. 4.During a concurrent observation of the ice machine and interview on 11/27/23 at 11: 10 a.m. with the Maintenance Supervisor (MS), there was a brown substance on the outside of the water curtain. The MS confirmed above finding, he stated he cleaned the ice machine once a month, the last cleaning was on 11/4/23, and it was due for a cleaning. During a concurrent observation and interview on 11/27/23 at 3:37 p.m. with the MS, the kitchen staffs were continuing using the ice from the ice machine, requested the MS to reopen the ice machine over, observed black matters at the bottom of the splash shield which touched the ice, wiped with a white napkin, the black matters stained the entire napkin with black substance. The MS stated the ice machine should have not a black substance. During a review of the facility's P &P titled, Ice Machines and Ice Storage Chest revised 2012, the P&P Indicated, 3. Our facility has established procedure for cleaning and disinfecting ice machines and ice storage chests which adhere to the manufacturer's instruction. During a review of facility provided document titled Indigo Ice Machines Installation, Operation and Maintenance Manual rev 2/6/17, the manual indicated, Section 4 Maintenance. Cleaning and Sanitizing. General. Clean and sanitize the ice machine every six months for efficient operation. [ .] An extremely dirty ice machine must be taken apart for cleaning and sanitizing. 5. During an observation on 11/27/23 at 3:32 p.m., in the kitchen with the MS, the food prep sink drain (an air gap is the unobstructed vertical space between the water outlet and the flood level of a fixture) was touching the dirty water in the floor drain. During an interview 11/29/23 at 10:25 a.m., with the MS, he verified the sink drain should have been at least one inch above the floor drain. During a review of the facility's P&P titled, AIR GAP DRAINAGE date 11/2017, the P&P indicated, 3. The air gap of any drainage pipe shall measure two times the diameter of the pipe. 5. Air gaps provide an empty unobstructed vertical space that prevents potable and non -potable water from intermingling. During a review of the Food and Drug Administration (FDA) Food Code 2022, section 5-202.13, titled, Backflow Prevention, Air Gap, it indicated, An air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch). And section 5-202.14, titled, Backflow Prevention Device, Design Standard, it indicated, A backflow or back siphonage prevention device installed on a water supply system shall meet American Society of Sanitary Engineering (A.S.S.E.) standards for construction, installation, maintenance, inspection, and testing for that specific application and type of device.

Based on observation, interview and record review, the facility failed to ensure, infection control practices were implemented when: 1. Licensed Vocational Nurse (LVN) B did not remove gloves, sanitize (to reduce or remove pathogenic agents) hands and put on new gloves, after she fixed the plastic liner of the trash can before handing the inhaler to Resident 115, 2. Registered nurse (RN) C did not change gloves, sanitize hands and put on new gloves, after she picked up the pills of Resident 7 that fell on the floor, then discarded them, and administer the new medication pills, 3. Foley catheter bag (bag that is connected to the foley catheter, where the urine that drains through the catheter is collected) of Resident 265 was touching the floor, and; 4. The maintenance supervisor (MS) did not do hand washing upon entering the kitchen. These failures could result in the spread of infection and cross-contamination that could affect the 58 residents residing in the facility. Findings: 1. During the medication administration observation of Resident 115 with licensed vocational nurse B (LVN B) on 11 /29/23 at 10:10 a.m., LVN B was administering Resident 115, Advair Diskus inhaler (used to control and prevent symptoms of wheezing and shortness of breath), 250-50 microgram (mcg, which is a weight-bsed measurement)/dose, 1 inhalation every 12 hours. LVN B already did hand hygiene and had her gloves on, but then she fixed the plastic liner of the trash can beside her and then handing the Advair Diskus inhaler to Resident 115, Resident 115 took the inhaler, LVN B did not wash her hands, and change the gloves During an interview with LVN B on 11/29/23 at 3:10 p.m., LVN B verified she should have taken off the gloves, did hand hygiene and then put on new gloves, before giving the Advair Diskus to Resident 115. During an interview with the director of nursing (DON) on 12/01/23 1:10 p.m., DON verified LVN B should have removed her gloves, do hand hygiene and put on new gloves before giving the Advair Diskus inhaler to Resident 115. 2. During the medication administration observation of Resident 7 with registered nurse C (RN C) on 11/29/23 at 5:10 p.m., RN C was about to crush the 2 tablets of 10 milligram (mg, a unit of measurement of mass) Baclofen (it can treat muscle spasms). The 2 tablets of Baclofen fell on the floor and RN C picked the 2 tablets on the floor with her sanitized and gloved hand. RN C then discarded the tablets, then got 2 new tablets of Baclofen, 10 mg and crushing the 2 new Baclofen tablets, removed her gloves, hand hygiene, and then putting on new gloves. During an interview with RN C on 11/29/23 at 5:20 p.m., RN C verified she should have removed her gloves, hand hygiene, and put on new gloves, after she picked up the 2 tablets of Baclofen on the floor. During an interview with infection preventionist (IP) on 11/30/23 at 4:14 p.m., IP verified that RN C should have removed her gloves, then do hand hygiene, and put on new gloves. During an interview with the DON on 12/01/23 1:10 p.m., DON verified that RN C should have removed her gloves, hand hygiene, and put on new gloves. Review of the facility's policy and procedure titled, Handwashing - Hand Hygiene, effective date 1/1/23, indicated, This facility considers hand hygiene, the primary means to prevent the spread of infections. All personnel should follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: . before preparing or handling medications, . before donning sterile gloves, . after contact with objects . in the immediate vicinity of the resident, after removing gloves .The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Review of the facility's policy and procedure titled, Personal Protective Equipment - Using Gloves, effective date 1/1/23, indicated, To guide the use of gloves. To prevent the spread of infection . Use non-sterile gloves primarily to prevent the contamination of the employee's hands when providing treatment or services to the patient . 46553 3. During an observation on 11/27/23 at 9:31 am., with Resident 265's in her room, the indwelling (inside the body) urinary catheter (the catheter drains urine from the bladder into a bag outside the body) was touching the floor and was not covered by privacy bag (provides catheter bag users an inconspicuous [not visible} way to hide a urine collection bag). During an interview on 11/27/23 at 9:45 a.m., with LVN A she verified the indwelling urinary catheter was not covered and touching the floor. LVN A stated the indwelling urinary catheter should have not touching the floor. During an interview on 11/30/23 at 1:51 p.m., with the DON stated it should have not touching the floor During a review of the facility's P &P titled, Catheter Care-Urinary , dated 7/1/2020, indicated, Infection control #2. b. Be sure the catheter tubing and drainage bag are kept off the floor 4. During a kitchen observation on 11/29/23 at 3:25 p.m., the MS entered to the kitchen, he did not wash his hands and applied new pair of gloves. During an interview on 11/29/23 at 3:25 p.m., with MS confirmed he did not wash his hands before entering the kitchen and he applied new pair of gloves. During an interview on 11/29/23 at 9:40 a.m., with Kitchen Supervisor (KS) stated the staff should have washed their hands upon entering the kitchen to prevent cross contamination in the kitchen. During an interview on 12/01/23 at 9:14 a.m., with IP, stated the staff should have washed their hands when entering the kitchen to prevent infection. During a review of the facility's P &P titled, Hand Washing , dated 2017, indicated, Employee will wash hands as frequently as needed throughout the day using proper hand washing procedures .when to was hands when entering the kitchen

Based on interview and record review, the facility failed to develop and implement a care plan to monitor one of three residents (Resident 1) who was on high risk medication. Resident 1 was on [MEDICATION NAME], a high risk medication. ([MEDICATION NAME] is an anticancer drug also used for [MEDICAL CONDITION] arthritis (RA), chronic disorder causing swelling and pain in joints). The facility failed to adequately monitor Resident 1 consistent with the manufacturer's guidelines, standards of practice, or Resident 1's [MEDICAL CONDITION] Arthritis care plan. Resident 1's physician ordered stat lab test yet the facility failed to follow up on the results and advise Resident 1's physician of the out of range findings. The lab results reflected a need for prompt medical attention. These failures resulted in Resident 1's transfer to an acute hospital with [DIAGNOSES REDACTED]. Findings: Review of Resident 1's closed record indicated she was an [AGE] year-old female, who was admitted to the facility on [DATE] for physical and occupational rehabilitation services, following a laminectomy (surgical procedure to remove the posterior arch of the vertebra (backbone). Resident 1's post hospital [DIAGNOSES REDACTED]. that perform a variety of function within the body), other chemicals that are off range and can adversely affect brain function), [MEDICAL CONDITIONS], diabetes (high blood sugar), and [MEDICAL CONDITION] arthritis. Review of Resident 1's admission minimum data set (MDS, an assessment tool), dated [DATE], indicated Resident 1's cognition (mental process) was intact. She required extensive assistance in activities of daily living. She was continent of bowel and bladder. an order for [REDACTED]. Review of Resident 1's acute hospital's history and physical (H&P) dated [DATE], under list of current medications, listed [MEDICATION NAME] 4 tablets per week. Review of Resident 1's physician's admission orders [REDACTED]., a unit of measure) one tablet orally daily, and [MEDICATION NAME] 200 mg. one tablet orally daily. According to the DailyMed website (https://daily med.nlm.nih.gov), a website operated by the U.S. National Library of Medicine (NLM) that publishes up-to-date accurate drug labels (package insert) to health care providers and the general public, [MEDICATION NAME] comes with a black box warning (the strongest warning that the food and drug administration (FDA) requires, and signifies that medical studies indicate a significant risk of serious or even life-threatening adverse effects. During a telephone interview with registered pharmacist C (RPh C) on [DATE] at 3:10 p.m., he stated the manufacturer of [MEDICATION NAME] was Quality Test/PAR and the National Drug Code (NDC) # [DATE]. Review of the black box warning on [MEDICATION NAME] indicated the following warnings: [MEDICATION NAME] should be used only by physicians whose knowledge and experience include the use of antimetabolite therapy because of the possibility of serious reactions (which can be fatal). [MEDICATION NAME] should be used only in life threatening neoplastic disease, or in patients with psoriasis or [MEDICAL CONDITION] arthritis with severe, recalcitrant, disabling disease which is not adequately responsive to other forms of therapy. Deaths have been reported with the use of [MEDICATION NAME] in the treatment of [REDACTED]. Patients should be closely monitored for bone marrow, liver, lung, and kidney toxicities. Patients should be informed by their physicians of the risks involved and be under a physician's care throughout the therapy. Review of the section on Information for Patients from the DailyMed website indicated both the physician and pharmacist should emphasize to the patient that the recommended dose is taken weekly in [MEDICAL CONDITION] arthritis and psoriasis, and that mistaken daily use of the recommended dose has led to fatal toxicity. Review of the section on Laboratory Tests from the DailyMEd website indicated patients should be closely monitored so that toxic effects are detected promptly. Baseline assessments should include a complete blood count with differential and platelet counts, hepatic enzymes, renal function tests and a chest x-ray. Review of the section on Adverse Reactions from the DailyMed website indicated the most frequently reported adverse reactions include ulcerative stomatitis, leukopenia (low blood cells), nausea, and abdominal distress. Other frequently adverse effects are malaise, undue fatigue, chills, and fever, dizziness and decrease resistance to infection. Review of the section on Over dosage from the DailyMed website indicated Leucovorin is indicated to diminish the toxicity and counteract the effect of inadvertently administered over dosages of [MEDICATION NAME]. Review of the section on Dosage and Administration from the DailyMed website indicated Adult [MEDICAL CONDITION] Arthritis, recommended starting dosage schedules: 1) single oral doses of 7.5 mg once weekly; 2) Divided oral dosages of 2.5 mg at 12 hour intervals for 3 doses given as a course once weekly. Review of the section on How Supplied from the DailyMed website indicated [MEDICATION NAME] Tablets, USP contain an amount of [MEDICATION NAME] sodium equivalent to 2.5 mg of [MEDICATION NAME] and are yellow, round, uncoated, scored, flat tablets with diameter of 6 mm and embossed with code (ORN57) on one side; NDC [DATE] (Bottle of 36); NDC [DATE] (Bottle of 100). Review of the section on Patient Information from the DailyMed website indicated the most common side effects of [MEDICATION NAME] include mouth sores, low white blood cells, nausea, upset stomach, feeling poorly, tiredness, chills, fever, dizziness, higher chance of infections, diarrhea, vomiting, hair loss and easy bruising and to stop taking [MEDICATION NAME] and call your doctor right away if your get diarrhea, mouth sore, fever, dehydration, cough, bleeding, shortness of breath, any signs of infection or a skin rash. Review of facility pharmacy's Black Box Warning Policy and Procedure dated ,[DATE] indicated Pharmacy will place a black box warning notification on the prescription label and Nursing to document in the care plan the black box warning when a resident is on a medication with a black box warning. Review of Resident 1's care plans indicated there were no care plans for Resident 1's [MEDICATION NAME], a medication that needs black box warning. During an interview with the registered nurse C (RN C) on [DATE] at 12 noon, she stated I don't recall (Resident 1's) [MEDICATION NAME] came in with a black warning information and if it would, we would have a (comprehensive) care plan for it. She recalled it came in an ordinary bubble pack with no black box warning. Review of Resident 1's Medication Administration Record [REDACTED]. daily from [DATE] to [DATE], except for three undocumented days. This indicated Resident 1 received a total of 36 tablets when Resident 1's H&P from the acute care hospital indicated 24 tablets based on her dosage of 4 tablets every week. During a telephone interview with the registered pharmacist B (RPH B) on [DATE] at 2:30 p.m., he stated he stated he did not see the recommendation for black box warning for [MEDICATION NAME] but when he checked the system, he finally saw the black box warning for [MEDICATION NAME]. When asked if pharmacy should have sent a black box warning to the facility, RPH B replied, if it is indicated, pharmacy will fax to facility. During a telephone interview with registered pharmacist A (RPH A) on [DATE] at 1:15 p.m., she stated some of the side effects of the [MEDICATION NAME] are vomiting, diarrhea, and gingivitis (swollen gums). Review of Resident 1's nurse's notes dated [DATE] indicated Resident 1 had three loose stools (bowel movement) in the morning. The licensed nursed called the physician and received a telephone order dated ,[DATE] 18 for a stat complete blood count (CBC), and comprehensive metabolic panel (CMP, a panel of tests that show a snapshot of the body's chemistry, blood sugar level, kidney, and liver function). The physician also ordered a urinalysis with culture and sensitivity (UA with C&S, a test to find out the bacteria that cause the infection and the antibiotic that would be most appropriate to treat the infection), and a stool for ,[MEDICAL CONDITION]. difficille ([MEDICAL CONDITION], bacteria that causes inflammation of the bowels). Review of Resident 1's Comprehensive Care Plan for [MEDICAL CONDITION] Arthritis dated [DATE] under Interventions indicated: Medication and treatments as ordered, Laboratory/Diagnostic works as ordered by the physician, Notify the MD, RP, the results of the lab works for prompt intervention. Review of Resident 1's laboratory results dated [DATE] indicated negative result for [DIAGNOSES REDACTED]. Review of Resident 1's lab results taken last [DATE] and their reference range (within normal limits) are as follows: CMP Panel: Glucose:135 High (H) (,[DATE] mg./dl (unit of measurement used to measure blood)); BUN:45 H (,[DATE] mg/dl); Creatinine: 1.42 H (0.6 - 0.88 mg/dl); BUN/Creatinine ratio: 31 H ((,[DATE]); Chloride: 111 H (,[DATE] mmol/L (millimoles per liter, measurement, substance that contain molecule or atoms); Protein, Total: 5.7 L (low) (6XXX,[DATE].1 g/dl); [MEDICATION NAME] (a form of protein): 3.4 L (3XXX,[DATE].1 g/dl). CBC: (including differential/total) WBC: 3.0 L (3XXX,[DATE].8 thousand /uL (unit per liter); RBC (red blood cell): 2.70 L (3XXX,[DATE].10 million/uL); Hemoglobin (red protein that caries oxygen in the blood): 8.3 L (11XXX,[DATE].5 g/dl); Hematocrit (ratio of the volume of red blood cells to the total volume of blood): 25.2 L (,[DATE]%); Absolute lymphocytes: 510 L (,[DATE] cells/uL); Absolute monocytes (largest type of WBC, influence the process of adaptive immunity. During a telephone interview with the customer service representative (CSR) of the laboratory service provider on [DATE] at 9:45 a.m., CSR stated according to their record, the results were sent to the facility at 7:14 p.m. on [DATE]. He stated the results were refaxed to the facility on [DATE] per the facility's request. Review of Resident 1's nurse's notes dated from [DATE] to [DATE], indicated there was no follow-up on the status of the stat laboratory ordered on [DATE], and there was no documentation the physician was notified of the stat lab results. Review of Resident 1's physician's Progress Notes dated [DATE] Late entry note for post discharge [DATE], indicated she got report on stool for [MEDICAL CONDITION]. toxin negative. I did not get the reports on other labs ordered. During an interview with licensed vocational nurse A (LVN A) on [DATE] at 1 p.m. she stated she took care of Resident 1 at least once. She stated Resident 1 has a sore like a blister on her lip with minimal bleeding, but could not remember if it was the upper or lower lip. LVN A stated she did not do an oral assessment because Resident 1 could not open her mouth fully because of the sore. During an interview with certified nursing assistant D (CNA D) on [DATE] at 1:55 p.m., she stated Resident 1 had three to four loose stools but could not recall the exact date it occurred or when the episodes of loose stools started. These observations were not documented in Resident 1's medical record. During an interview with CNA E on [DATE] at 1:20 p.m., she stated Resident 1 had frequent stools (two to three times per shift) but it did not occur daily. She stated the stools were not diarrhea or watery stools but had the consistency of an oatmeal. These observations were not documented in Resident 1's medical record. Review of Resident 1's MAR for ,[DATE] indicated Resident 1 received [MEDICATION NAME] (anti-diarrhea medication) on [DATE] at 2 p.m. and [DATE] at 2 p.m. for diarrhea. Review of Resident 1's Nurse's Notes dated [DATE] written at 11 a.m. RN F noted small blister on resident lower lip, ,[DATE] pain noted; written at 1 p.m., placed a call again to MD regarding resident's sores on lower lip; and written at 3 p.m., received a call from MD with orders for [MEDICATION NAME] . During a telephone interview with registered nurse B (RN B) on [DATE] at 4:20 p.m., he stated Resident 1 complained of diarrhea and abdominal cramping on [DATE] at 3 p.m. He notified the physician with orders to repeat [MEDICAL CONDITION] test, a gastrointestinal consult (GI consult), and an order to give Pepto-Bismol (antidiarrheal). He stated on [DATE], the day before Resident 1's transfer to the hospital, Resident 1 appeared weak and stayed in bed. Resident 1 also refused her morning medications on [DATE]. RN B stated Resident 1's responsible party (RP, a person who is responsible for decisions related to the resident's care) requested Resident 1 be sent to the hospital for further evaluation. Resident 1 was transferred to the acute hospital on [DATE] at 3:45 p.m. Review of Resident 1's physician discharge summary from the facility dated [DATE], indicated under Condition of Discharge, Abdominal pain/ cramps/ diarrhea/ lip ulcer. need to rule out infection/ [MEDICAL CONDITION]/ any drug reaction, Patient on [MEDICATION NAME]. Review of Resident 1's acute hospital's history and physical (H&P) dated [DATE], indicated Resident 1 came in with chief complaint of diarrhea and abdominal pain, numerous sores in her mouth that were painful, cracking, and bleeding and make it difficult for her to eat. The laboratory report indicated Resident 1 had absolute [DIAGNOSES REDACTED] (ANC, abnormally low count of [DIAGNOSES REDACTED]s, white blood cells (WBC) important to fight infection) of 250 cells. ANC is calculated by multiplying the total WBC count by the percentage of segmented [DIAGNOSES REDACTED]s plus the band forms of the [DIAGNOSES REDACTED]s in the CBC differential. The laboratory report also indicated WBC count cells of 500 per milliliter (ml., a unit of measure), and [MEDICAL CONDITION] (low platelet count) of 31,000 (normal count ranges from 150,000 to 450,000 platelets per microliter of blood). The H&P also indicated Resident 1 recalled that her [MEDICATION NAME] dose was four tablets every Tuesday and that she did not realize she was now taking once a day. Resident 1's H&P assessment indicated Acute and severe [DIAGNOSES REDACTED] and [MEDICAL CONDITION] of recent onset, diffuse abdominal pain, distention, tenderness and diarrhea, subacute onset and negative for [DIAGNOSES REDACTED], in the presence of evidence of mucositis and [DIAGNOSES REDACTED] and Resident 1 received 25 mg. of Leucovorin and the [MEDICATION NAME] was stopped. Review of Resident 1's acute hospital's Discharge Summary dated [DATE] indicated Resident 1 died on [DATE]. Discharge [DIAGNOSES REDACTED]. Death due to acute and severe [DIAGNOSES REDACTED], 3. [MEDICATION NAME]- induced [MEDICAL CONDITION] and [DIAGNOSES REDACTED], 4. Mucositis, 5. [MEDICAL CONDITION] Arthritis, and Deterioration due to acute illness. Review of Resident 1's death certificate indicated the cause of death included: a. Acute [MEDICAL CONDITION], b. [MEDICAL CONDITION], c. [DIAGNOSES REDACTED], d. [MEDICAL CONDITION] Arthritis.

Based on interview and record review, the facility failed to develop and implement a care plan to monitor one of three residents (Resident 1) who was on high risk medication. Resident 1 was on [MEDICATION NAME], a high risk medication. ([MEDICATION NAME] is an anticancer drug also used for [MEDICAL CONDITION] arthritis (RA), chronic disorder causing swelling and pain in joints). The facility failed to adequately monitor Resident 1 consistent with the manufacturer's guidelines, standards of practice, or Resident 1's [MEDICAL CONDITION] Arthritis care plan. Resident 1's physician ordered stat lab test yet the facility failed to follow up on the results and advise Resident 1's physician of the out of range findings. The lab results reflected a need for prompt medical attention. These failures resulted in Resident 1's transfer to an acute hospital with [DIAGNOSES REDACTED]. Findings: Review of Resident 1's closed record indicated she was an [AGE] year old female, who was admitted to the facility on [DATE] for physical (focused on strength, mobility) and occupational (focused on activities daily living) rehabilitation (rehab) services, following a laminectomy (surgical procedure to remove the posterior arch of the vertebra (backbone). Resident 1 was also treated for [REDACTED]. [DIAGNOSES REDACTED].,that perform a variety of function within the body), other chemicals that are off range and can adversely affect brain function), [MEDICAL CONDITIONS], diabetes (high blood sugar), and [MEDICAL CONDITION] arthritis. Review of the admission minimum data set )MDS, an assessment tool), dated [DATE], indicated Resident 1's cognition(mental process) was intact. She required extensive assistance in activities of daily living. She was continent of bowel and bladder. an order for [REDACTED]. Review of Resident 1's acute hospital's history and physical (H&P) dated [DATE], under list of current medications, listed [MEDICATION NAME] 4 tablets per week. Review of the physician's admission orders [REDACTED]., a unit of measure) one tablet orally daily, and [MEDICATION NAME] 200 mg., one tablet daily. According to the DailyMed website ( https://daily med.nlm.nih.gov ), a website operated by the U.S. National Library of Medicine (NLM) that publishes up-to-date accurate drug labels (package insert) to health care providers and the general public, [MEDICATION NAME] comes with a black box warning ( the strongest warning that the food and drug administration (FDA) requires, and signifies that medical studies indicate a significant risk of serious or even life-threatening adverse effects. During a telephone interview with registered pharmacist C (RPh C) on [DATE] at 3;10 p.m., he stated the manufacturer of [MEDICATION NAME] was Quality Test/PAR and the Mational Drug Code (NDC) # [DATE]. Review of the black box warning on [MEDICATION NAME] indicated the following warnings: [MEDICATION NAME] should be used only by physicians whose knowledge and experience include the use of antimetabolite therapy because of the possibility of serious reactions (which can be fatal). [MEDICATION NAME] should be used only in life threatening neopalstic disease, or in patients with psoriasis or [MEDICAL CONDITION] arthritis with severe recalcitrant, disabling disease which is not adequately responsive to other forms of therapy. Deaths have been reported with the use of ethereal in the treatment of [REDACTED]. Patients should be closely monitored for bone marrow, liver, lung, and kidney toxicities. Patients should be informed by their physicians of the risks involved and be under a physician's care throughout the therapy. Review of the section on Information for Patients from the DailyMed website indicated both the physician and pharmacist should emphasize to the patient that the recommended dose is taken weekly in [MEDICAL CONDITION] arthritis and psoriasis, and that mistaken daily use of the recommended dose has led to fatal toxicity. Review of the section on Laboratory Tests from the DailyMEd website indicated patients should be closely monitored so that toxic effects are detected promptly. Baseline assessments should include a complete blood count with differential and platelet counts, hepatic enzymes, renal function tests and a chest x-ray. Review of the section on Adverse Reactions from the DailyMed website indicated the most frequently reported adverse reactions include ulcerative stomatitis, leukopenia (low blood cells), nausea, and abdominal distress. Other frequently adverse effects are malaise, undue fatigue, chills, and fever, dizziness and decrease resistance to infection. Review of the section on Over dosage from the DailyMed website indicated Leucovorin is indicated to diminish the toxicity and counteract the effect of inadvertently administered over dosages of [MEDICATION NAME]. Review of the section on Dosage and Administration from the DailyMed website indicated Adult [MEDICAL CONDITION] Arthritis, recommended starting dosage schedules: 1) single oral doses of 7.5 mg once weekly; 2) Divided oral dosages of 2.5 mg at 12 hour intervals for 3 doses given as a course once weekly. Review of the section on How Supplied from the DailyMed website indicated [MEDICATION NAME] Tablets, USP contain an amount of [MEDICATION NAME] sodium equivalent to 2.5 mg of [MEDICATION NAME] and are yellow, round, uncoated, scored, flat tablets with diameter of 6 mm and embossed with code (ORN57) on one side; NDC [DATE] (Bottle of 36); NDC [DATE] (Bottle of 100). Review of the section on Patient Information from the DailyMed website indicated the most common side effects of [MEDICATION NAME] include mouth sores, low white blood cells, nausea, upset stomach, feeling poorly, tiredness, chills, fever, dizziness, higher chance of infections, diarrhea, vomiting, hair loss and easy bruising and to stop taking [MEDICATION NAME] and call your doctor right away if your get diarrhea, mouth sore, fever, dehydration, cough, bleeding, shortness of breath, any signs of infection or a skin rash. Review of facility pharmacy's Black Box Warning Policy and Procedure dated ,[DATE] indicated Pharmacy will place a black box warning notification on the prescription label and Nursing to document in the care plan the black box warning when a resident is on a medication with a black box warning. Review of Resident 1's care plans indicated there were no care plans for Resident 1's [MEDICATION NAME], a medication that needs black box warning. During an interview with the registered nurse C (RN C) on [DATE] at 12 noon, she stated I don't recall (Resident 1's) [MEDICATION NAME] came in with a black warning information and if it would, we would have a (comprehensive) care plan for it. She recalled it came in an ordinary bubble pack with no black box warning. Review of Resident 1's Medication Administration Record [REDACTED]. daily from [DATE] to [DATE], except for three undocumented days. This indicated Resident 1 received a total of 36 tablets when the acute care hospital had prescribed only 24 tablets based on her dosage of 4 tablets every week. During a telephone interview with the registered pharmacist B (RPH B) on [DATE] at 2:30 p.m., he stated he did not see the recommendation for black box warning for [MEDICATION NAME] but when he checked the system, he finally saw the black box warning for [MEDICATION NAME]. When asked if pharmacy should have sent a black box warning to the facility, RPH B replied, if it is indicated, pharmacy will fax to facility. During a telephone interview with registered pharmacist A (RPH A) on [DATE] at 1:15 p.m., she stated some of the side effects of the [MEDICATION NAME] are vomiting, diarrhea, and gingivitis (swollen gums). Review of the nurse's notes dated [DATE], indicated Resident 1 had three loose stools (bowel movement) in the morning. The licensed nursed called the physician and received a telephone order for a stat (from the Latin word statum, meaning immediately) complete blood count (CBC), comprehensive metabolic panel (CMP, a panel of tests that show a snapshot of the body's chemistry, blood sugar level, kidney, and liver function). The physician also ordered a urinalysis with culture and sensitivity ( UA with C&S, a test to find out the bacteria that cause the infection and the antibiotic that would be most appropriate to treat the infection), and a stool for ,[MEDICAL CONDITION]. difficille ([MEDICAL CONDITION], a bacteria that causes inflammation of the bowels). Review of Resident 1's Comprehensive Care Plan for [MEDICAL CONDITION] Arthritis dated [DATE] under Interventions indicated: Medication and treatments as ordered, Laboratory/Diagnostic works as ordered by the physician, Notify the MD, RP, the results of the lab works for prompt intervention. Review of Resident 1's laboratory results dated [DATE] indicated negative result for [DIAGNOSES REDACTED]. Review of Resident 1's lab results taken last [DATE] and their reference range (within normal limits) are as follows: CMP Panel: Glucose:135 High (H) (,[DATE] mg./dl (unit of measurement used to measure blood)); BUN:45 H (,[DATE] mg/dl); Creatinine: 1.42 H (0.6 - 0.88 mg/dl); BUN/Creatinine ratio: 31 H ((,[DATE]); Chloride: 111 H (,[DATE] mmol/L (millimoles per liter, measurement, substance that contain molecule or atoms); Protein, Total: 5.7 L (low) (6XXX,[DATE].1 g/dl); [MEDICATION NAME] (a form of protein): 3.4 L (3XXX,[DATE].1 g/dl). CBC: (including differential/total) WBC: 3.0 L (3XXX,[DATE].8 thousand /uL (unit per liter); RBC (red blood cell): 2.70 L (3XXX,[DATE].10 million/uL); Hemoglobin (red protein that caries oxygen in the blood): 8.3 L (11XXX,[DATE].5 g/dl); Hematocrit (ratio of the volume of red blood cells to the total volume of blood): 25.2 L (,[DATE]%); Absolute lymphocytes: 510 L (,[DATE] cells/uL); Absolute monocytes (largest type of WBC, influence the process of adaptive immunity. During a telephone interview with the customer service representative (CSR) of the laboratory service provider on [DATE] at 9:45 a.m., CSR stated according to their record, the results were sent to the facility at 7:14 p.m. on [DATE]. He stated the results were refaxed to the facility on [DATE] per the facility's request. Review of Resident 1's nurse's notes dated from [DATE] to [DATE], indicated there was no follow-up on the status of the stat laboratory ordered on [DATE], and there was no documentation the physician was notified of the stat lab results. Review of Resident 1's physician's Progress Notes dated [DATE] Late entry note for post discharge [DATE], indicated she got report on stool for [MEDICAL CONDITION]. toxin negative. I did not get the reports on other labs ordered. During an interview with licensed vocational nurse A (LVN A) on [DATE] at 1 p.m. she stated she took care of Resident 1 at least once. She stated Resident 1 has a sore like a blister on her lip with minimal bleeding, but could not remember if it was the upper or lower lip. LVN A stated she did not do an oral assessment because Resident 1 could not open her mouth fully because of the sore. During an interview with certified nursing assistant D (CNA D) on [DATE] at 1:55 p.m., she stated Resident 1 had three to four loose stools but could not recall the exact date it occurred or when the episodes of loose stools started. These observations were not documented in Resident 1's medical record. During an interview with CNA E on [DATE] at 1:20 p.m., she stated Resident 1 had frequent stools (two to three times per shift) but it did not occur daily. She stated the stools were not diarrhea or watery stools but had the consistency of an oatmeal. These observations were not documented in Resident 1's medical record. Review of Resident 1's MAR for ,[DATE] indicated Resident 1 received [MEDICATION NAME] (anti-diarrhea medication) on [DATE] at 2 p.m. and [DATE] at 2 p.m. for diarrhea. Review of Resident 1's Nurse's Notes dated [DATE] written at 11 a.m. RN F noted small blister on resident lower lip, ,[DATE] pain noted; written at 1 p.m., placed a call again to MD regarding resident's sores on lower lip; and written at 3 p.m., received a call from MD with orders for [MEDICATION NAME] . During a telephone interview with registered nurse B (RN B) on [DATE] at 4:20 p.m., he stated Resident 1 complained of diarrhea and abdominal cramping on [DATE] at 3 p.m. He notified the physician with orders to repeat [MEDICAL CONDITION] test, a gastrointestinal consult (GI consult), and an order to give Pepto-Bismol (antidiarrheal). He stated on [DATE], the day before Resident 1's transfer to the hospital, Resident 1 appeared weak and stayed in bed. Resident 1 also refused her morning medications on [DATE]. RN B stated Resident 1's responsible party (RP, a person who is responsible for decisions related to the resident's care) requested Resident 1 be sent to the hospital for further evaluation. Resident 1 was transferred to the acute hospital on [DATE] at 3:45 p.m. Review of Resident 1's physician discharge summary from the facility dated [DATE], indicated under Condition of Discharge, Abdominal pain/ cramps/ diarrhea/ lip ulcer. need to rule out infection/ [MEDICAL CONDITION]/ any drug reaction, Patient on [MEDICATION NAME]. Review of Resident 1's acute hospital's history and physical (H&P) dated [DATE], indicated Resident 1 came in with chief complaint of diarrhea and abdominal pain, numerous sores in her mouth that were painful, cracking, and bleeding and make it difficult for her to eat. The laboratory report indicated Resident 1 had absolute [DIAGNOSES REDACTED] (ANC, abnormally low count of [DIAGNOSES REDACTED]s, white blood cells (WBC) important to fight infection) of 250 cells. ANC is calculated by multiplying the total WBC count by the percentage of segmented [DIAGNOSES REDACTED]s plus the band forms of the [DIAGNOSES REDACTED]s in the CBC differential. The laboratory report also indicated WBC count cells of 500 per milliliter (ml., a unit of measure), and [MEDICAL CONDITION] (low platelet count) of 31,000 (normal count ranges from 150,000 to 450,000 platelets per microliter of blood). The H&P also indicated Resident 1 recalled that her [MEDICATION NAME] dose was four tablets every Tuesday and that she did not realize she was now taking once a day. Resident 1's H&P assessment indicated Acute and severe [DIAGNOSES REDACTED] and [MEDICAL CONDITION] of recent onset, diffuse abdominal pain, distention, tenderness and diarrhea, subacute onset and negative for [DIAGNOSES REDACTED], in the presence of evidence of mucositis and [DIAGNOSES REDACTED] and Resident 1 received 25 mg. of Leucovorin and the [MEDICATION NAME] was stopped. Review of Resident 1's acute hospital's Discharge Summary dated [DATE] indicated Resident 1 died on [DATE]. Discharge [DIAGNOSES REDACTED]. Death due to acute and severe [DIAGNOSES REDACTED], 3. [MEDICATION NAME]- induced [MEDICAL CONDITION] and [DIAGNOSES REDACTED], 4. Mucositis, 5. [MEDICAL CONDITION] Arthritis, and Deterioration due to acute illness. Review of Resident 1's death certificate indicated the cause of death included: a. Acute [MEDICAL CONDITION], b. [MEDICAL CONDITION], c. [DIAGNOSES REDACTED], d. [MEDICAL CONDITION] Arthritis.

Based on interview and record review, the facility failed to ensure the resident environment for one of one sampled resident (1) was free of accident hazards. Resident 1 had a prior history of hospitalization in July 2012 after a suicide attempt when he cut both wrists. On 2/16/13 at 6:10 p.m. certified nurse assistant A (CNA A) provided Resident 1 had a manual razor which he used to cut his left wrist. Resident 1 was transferred to the emergency department where his wound required sutures but the resident refused. Findings: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS; an assessment tool) dated 2/16/13 indicated Resident 1 was intact in his cognition, and required extensive assistance in his activities of daily living. Resident 1's health record indicated his physician assessed him to have the capacity to understand and make decisions and the resident was his own responsible party. Record review indicated the director of nursing service (DNS) wrote a comprehensive assessment on 2/13/13 which included an assessment titled "suicidal ideation" (when a patient talks or writes of killing themselves). The DNS mentioned in this assessment Resident 1's physician wrote a history and physical dated 12/26/12 where he noted Resident 1's suicide attempt in July 2012 when Resident 1 cut both of his wrists. The DNS assessment indicated Resident 1 communicated with the staff by writing on a writing pad and pen because he was unable to speak. On 2/14/13 at 8:30 a.m. a licensed nurse informed the DNS Resident 1 wrote on his writing pad, "I want to die". The DNS wrote in her assessment "there was no imminent threat of suicide attempt". The DNS also wrote a care plan dated 2/14/13 titled Comprehensive Care Plan Depression - Suicidal Ideation which specified Resident 1's problem as depression, manifested by written suicidal ideation of "I want to die" and "I made a mistake". Interventions in this care plan included: (a) to remove all weapons, contraband (knives, sharps) within the resident's reach, sharp objects, that can inflict body harm and (b) staff to be aware of Resident 1's ideation. Licensed nurse B (LN B), the 2/16/13 evening shift charge nurse, wrote the nurse's note dated 2/16/13 at 6:10 p.m. indicating Resident 1 used the call light to ask his nurse assistant (CNA A) to hand him his electronic razor. The electronic razor was not operable after several attempts by the resident who then asked for a manual razor. Resident 1 was quoted in the note as referencing the manual razor "looks like a little knife". LN B wrote in his next nurse's note dated 2/16/13 at 6:15 p.m. that CNA A checked on Resident 1. At that time, CNA A noticed the left wrist of Resident 1 was bleeding and notified LN B who entered Resident 1's room. LN B documented the left wrist incision as "approximately 4 cm. in length". LN B documented that Resident 1 wrote on his writing pad: "I'm angry. I'm such a bad person. I know I'm stupid". Resident 1 also wrote "I want to die because I don't count and no one cares about me or what I do. I can't swallow without great pain. I need to die to escape pain". During an interview on 4/18/13 at 10:30 a.m. CNA A stated the 2/16/13 evening shift was the first time she was assigned to care for Resident 1. CNA A stated nobody told her Resident 1 had a history of [REDACTED]. CNA A stated she handed Resident 1 a manual razor after Resident 1 told her his electronic razor was not working. CNA A stated she then responded to another resident in another room. CNA A stated that after a few minutes, she returned to check on Resident 1. CNA A stated upon entering Resident 1's room, she saw Resident 1 scratching his left wrist with the manual razor. CNA A stated Resident 1's cutting strokes were fast and she noticed bleeding from the left wrist. During a telephone interview on 4/19/13 at 11:00 a.m. LN B stated the staff involved in Resident 1's care was made aware that sharp objects that could inflict body harm were to be kept away from Resident 1. LN B stated that it was a "busy night" on 2/16/13, when after CNA A handed Resident 1 a manual razor she responded to an alarm which warned of another resident's potential fall. During an interview on 4/18/13 at 1:00 p.m., the administrator (ADM) stated the facility did not conduct training for staff regarding residents at risk for suicide behavior or attempts. The ADM stated Resident 1 did not pose imminent threat of committing suicide because he looked "happy". Record review indicated Resident 1 was transferred to the emergency department of the acute care hospital for treatment and evaluation on 2/16/13 at 7:49 p.m. LN B wrote in the nurse's note dated 2/16/13 at 6:15 p.m. Resident 1 was placed on one-to-one monitoring for safety "secondary to danger to self". During record review on 4/26/13 of emergency department's 12 pages of faxed documents related to Resident 1's 2/16/13 admission, the emergency department physician (MD 1) documented Resident 1 sustained a 5-cm. left wrist laceration requiring suturing, but the resident refused when the plastic surgeon (MD 2) offered. During a telephone interview with MD 1 on 4/26/13 at 3:40 p.m., she stated she recalled the resident's attempted suicide and the left wrist required sutures but the resident refused.