Every finding on record at River Bend Nursing Center

Based on observation, interview and record review, the facility failed to meet food service standards for food storage and preparation when:Food labeling was not performed consistently,Worn kitchen equipment was still in use,An air gap was not found on the fruit/vegetable wash sink, andFive dirty and/or wet steam table pans were found stored in the cook's ready to use area.These failures had the potential of leading to food borne illnesses for the residents eating facility prepared meals. Findings:During the initial kitchen tour on 7/27/26 at 8:42 a.m., in the dry storage area, a large plastic container of soft, white powder was observed. The container did not have a label to indicate what it was, when it was opened, or when it would no longer be safe to use.During a subsequent interview on 7/27/26 at 8:46 a.m. with the Dietary Services Supervisor (DSS), the DSS confirmed that there was no label on the flour container which would be safe for 6 to 8 months per their storage guide. During the initial kitchen tour on 7/27/26 at 8:51 a.m., in the reach-in refrigerator was a container of cheese slices that indicated they were opened on 7/4/26 and were to be discarded on 7/21/26 but were still in the refrigerator. During a subsequent interview on 7/27/26 at 9:04 a.m. with the DSS, the DSS confirmed the American cheese slices and reviewed the storage guide. The storage guide indicated that various types of cheeses could be safely kept from anywhere from 1 week to 4 weeks (depending on the type of cheese). American cheese was not listed on the storage guide though the DSS stated she believed that they were still safe to eat.Review of facility provided Food Storage and Retention Guide indicated that Time/temperature Control for Safety Foods (TCS) were Food that requires time/temperature control for safety to limit pathogenic (disease causing) microorganism (tiny living cells) growth or toxin (poisonous substance) formation,Review of facility provided policy Receiving (Healthcare Services Group, Inc. and its subsidiaries, 2/2023) indicated in bullet 5 All food items will be appropriately labeled and dated either through manufacturer packaging or staff notation.Review of the US Food and Drug Administration's (FDA) 2022 Food Code section 3-501.17 on Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking indicated that Ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed.or discarded.2. During the initial kitchen tour on 7/27/26 at 9:34 a.m., the can opener was observed with a rusted area on the tip as well as a whitish coating. During a concurrent interview with the DSS, the DSS confirmed the rust and asked staff to rewash the can opener.During the initial kitchen tour on 7/27/26 at 9:47 a.m., two cutting boards (a blue board usually used for seafood and a green usually used for fruits, vegetables and herbs) were observed to have deep gouges on the cutting service. During a concurrent interview with the DSS, the DSS confirmed the deep grooves and indicated that the cutting boards should be replaced.Review of the US FDA 2022 Food Code section 4-501.11 on Good Repair and Proper Adjustment indicated that (A) Equipment shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (C) Cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate food when the container is opened.The cutting or piercing parts of can openers may accumulate metal fragments that could lead to food containing foreign objects and, possibly, result in consumer injury. No air gap seen on the f/v sink.Review of the US FDA 2022 Food Code section 4-501.12 on Cutting Surfaces indicated that Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced.Cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible (capable of being spread) through food may build up or accumulate. These microorganisms may be transferred to foods that are prepared on such surfaces.3. During the initial kitchen tour on 7/27/26 at 10:24 a.m., an air gap (break in pipe leading to the sewage line) was not observed on the fruit and vegetable wash sink. During a concurrent interview with the DSS, the DSS confirmed the observation.During a return to the kitchen on 7/29/2026 at 10:57 a.m. with the Director of Maintenance (DM), the DM also confirmed that an air gap had not been installed.Review of the US FDA 2022 Food Code section 5-202.13 on Backflow Prevention, Air Gap indicated that 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) .During periods of extraordinary demand, drinking water systems may develop negative pressure in portions of the system. If a connection exists between the system and a source of contaminated water during times of negative pressure, contaminated water may be drawn into and foul the entire system.4. During the initial kitchen tour on 7/27/26 at 10:37 a.m., steam table pans were stored and ready for use in the cook's station. Two of the small steam table pans were observed with a brown residue on the bottom and sides of the pans. Three of these small steam table pans were observed with a glossy film and drops on the inner surface.During a subsequent interview with the DSS on 7/27/26 at 10:41 a.m., the DSS stated that the pans should not have been put in the clean area due to the food, oil, and/or water residue.Review of facility provided policy titled Warewashing (Health Services Group, Inc. and its subsidiaries, 12/2024) indicated that All dishware, serviceware, and utensils will be cleaned and sanitized after each use. In bullet 4 of the procedures section it indicated that All dishware will be air dried and properly stored.Review of the US FDA 2022 Food Code section 4-901.11 on :Equipment and Utensils, Air-Drying Required indicated that After cleaning and sanitizing, equipment and utensils: (A) Shall be air-dried or used after adequate draining as specified . and (B) May not be cloth dried .Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. Cloth drying of equipment and utensils is prohibited to prevent the possible transfer of microorganisms to equipment or utensils.

Based on observation, interview, and record review, the facility failed to ensure that medication error rates remained below 5% when seven medication errors were identified out of 31 opportunities, resulting in a medication error rate of 22.58% for a census of 91.These failures placed Resident 66 and Resident 17 at risk for altered or delayed therapeutic drug responses and reduced medication effectiveness. Findings:1a. During a concurrent medication administration observation and interview starting on 7/27/26 at 9:22 a.m. with Licensed Nurse (LN 2), LN 2 was observed preparing and administering four medications for Resident 66. LN 2 stated that the medications were scheduled for 8 a.m. but were administered after 10 a.m.A review of Resident 66's Physician's Orders (PO) and Medication Administration Record (MAR) showed the following:a. Hydralazine hydrochloride (blood pressure medication) 50 mg (milligrams, unit of measurement) per tablet, give one tablet via G-tube (gastrostomy tube, a tube placed through the abdomen into the stomach to give food, water, and medicine when a person can't eat or swallow safely) every eight hours for high blood pressure; hold if systolic blood pressure (SBP) is less than 120 mmHg (millimeters of mercury, a unit to measure blood pressure).Medication was scheduled for 8 a.m. and given on 7/27/26 at 10:13 a.m.b. Metoprolol tartrate (heart and blood pressure medication) 25 mg/tablet, give 25 mg via G-tube twice daily for high heart rate (HR); hold if SBP is less than 100 mmHg or HR is less than 60.Medication was scheduled for 8 a.m. and given on 7/27/26 at 10:14 a.m.c. Levetiracetam (seizure medication) 100 mg/mL, give 10 mL (milliliters, unit of measurement) via G tube twice daily for seizures.Medication was scheduled for 8 a.m. and given on 7/27/26 at 10:13 a.m.d. Humulin R (Regular Insulin, diabetes medication) Injection solution 100 units/mL , inject 8 units subcutaneously three times daily.Medication was scheduled for 8 a.m. and given on 7/27/26 at 10:04 a.m.During an interview on 7/29/26 at 2:40 p.m. with the Director of Nursing (DON), the DON stated that medications should be given within one hour before and one hour after the scheduled time, and staff were expected to follow the administration schedule.A review of the facility's policy and procedure (P&P) titled Administering Medications, dated 3/26, indicated: Medications are administered in a safe and timely manner, and as prescribed. Medications are administered within one (1) hour of their prescribed time.1b. During a medication administration observation on 7/28/26 beginning at 8:32 a.m. with LN 3, LN 3 was observed combining and crushing three medications together and administered them altogether to Resident 17 via G tube. The three medications were:a. carvedilol tablet (Heart and blood pressure medication) 12.5 mg per tablet, 1 tablet given through the G-tubeb. empagliflozin ( Diabetes medication) 10 mg per tablet, 1 tablet given through the G-tubec. sacubitril-valsartan (Heart failure medicine) 49-51 mg per tablet, 1 tablet given through the G-tubeDuring an interview on 7/29/26 at 1 p.m. with the Consultant Pharmacist (RPh), the RPh stated that carvedilol, empagliflozin, and sacubitril valsartan should not be crushed together because there was no literature supporting that crushing medications and administrating them altogether no physical or chemical incompatibilities would occur. The RPh stated that nurses were expected to crush medications individually and administer each medication with flushes in between.According to the Journal of Parenteral and Enteral Nutrition, Volume 41, Issue 1, titled ASPEN [American Society for Parenteral and Enteral Nutrition] Safe Practices for Enteral Nutrition Therapy, <https://aspenjournals.onlinelibrary.[NAME].com/doi/epdf/10.1177/0148607116673053>, retrieved on 7/29/26, indicated, 8. Administer each medication separately through an appropriate access. 9. Avoid mixing together different medications intended for administration through the feeding tube given the risk for physical and chemical incompatibilities, tube obstruction, and altered therapeutic drug responses.A review of the facility's Policies and Procedures (P&P), titled Administering Medications through an Enteral Tube, dated 4/2026, indicated, The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube. 3. Administer each medication separately and flush between medications.

Based on observation, interview, and record review, the facility failed to ensure one of 24 sampled residents (Resident 13's) pain was managed when the scheduled pain medications were not administered as ordered.This failure resulted in Resident 13 experiencing unmanaged pain.Findings:A review of Resident 13's medical record indicated the resident had diagnoses that included secondary malignant neoplasm of the brain (cancer that had spread to the brain from another part of the body), spondylosis of the lumbosacral region (wear and tear arthritis of the lower back), a right tibia and fibula fracture (broken bones in the lower right leg), and was receiving palliative care services (comfort focused care for a serious illness).A review of Resident 13's Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 10/15, which indicated moderate cognitive impairment.During a concurrent observation and interview on 7/27/26 at 11:09 a.m. with Resident 13, the resident was awake. Resident 13 stated that she had pain in her legs, rated the pain at 15/10; however, no apparent grimacing or shortness of breath was noted. Resident 13 reported to Certified Nursing Assistant (CNA) 1 who responded to her call light that she was experiencing pain. CNA 1 stated she would notify Resident 13's nurse about her pain.A review of Resident 13's Order Summary Report (OSR) and Medication Administration History indicated the following pain medications:a. Methadone 10 mg (milligrams, unit of measurement )/mL (milliliters, unit of measurement), Give 0.5 mL by mouth every eight hours for pain management, scheduled at 8:00 a.m. Methadone was administered on 7/27/26 at 12:21 p.m.b. Morphine Sulfate Oral Solution 20 mg/mL, Give 1 mL by mouth every eight hours for pain or shortness of breath, scheduled at 8:00 a.m. Morphine was administered on 7/27/26 at 12:22 p.m.During an interview on 7/27/26 at 1:55 p.m., with Licensed Nurse (LN) 1, LN 1 stated she administered Resident 13's pain medications around noon and acknowledged the pain medications were scheduled for 8 a.m. LN 1 explained the delay in administering the pain medications was due to another LN calling off that morning, which resulted in an increased workload. A review of Resident 13's Nurse's Note written by LN 1, dated 7/26/26 at 3:56 p.m., indicated: AM [morning] medication administration ran long - MD [Medical Doctor] notified and received an okay to continue administering medications. Resident received her routine pain medications late (around noon). Resident does not appear to be in pain - no noted grimacing, guarding, or calling out. Resident is resting comfortably in bed, respirations are even and unlabored. Continue with current plan of care.During an interview and record review on 7/29/26 at 2:40 p.m., the Director of Nursing (DON) stated their expectation was for nurses to address and manage residents' pain. The DON stated that Resident 13 was on hospice care and had a fracture of the right tibia and fibula. The DON further stated that medications should be administered within one hour before or one hour after the scheduled time.A review of the facility's policy and procedure titled Administering Medications, dated 3/26, indicated: Medications are administered in a safe and timely manner, and as prescribed. Medications are administered within one (1) hour of their prescribed time.

Based on observation, interview and record review, the facility failed to maintain an effective infection prevention control program for 80 out of 91 residents when; 1. Staff did not follow Infection Control Practices for Resident 15, Resident 58, Resident 61; and 2. The portable and window type air conditioning (AC) unit filters were not cleaned and properly maintained for the 77 residents who resided in the hall. These failures had the potential to increase the risk of transmission and spread of infection for Resident 15, Resident 58, and Resident 61, and increased airborne contaminants for 77 residents who resided in the hall. Findings: 1.Resident 15 was admitted to the facility in early 2023 with diagnoses that included serious breathing problems, history of infections, resistance to multiple antibiotics, and a stage 4 pressure injury (wound caused by pressure that extends into the muscle or bone). During a review of Resident 15's Order Summary Report [OSR], dated 3/30/26, the OSR indicated, CONTACT PRECAUTIONS PER [name of county] R/T [related to] [High-contact resident care activities with colonized or infected MDRO (multidrug-resistant organism, bacteria that do not respond to many common antibiotics), increased risk of MDRO acquisition due to presence of wounds or indwelling medical devices). HAND HYGIENE AND PPE [personal protective equipment: gowns, gloves, mask] ANY TIME.every shift for prevention. During a review of Resident 15's Care Plan Report [CP], initiated on 11/4/23, the CP indicated, CONTACT PRECAUTIONS.Follow facility policy and procedure related to contact precautions.Staff will follow PPE protocol per guidelines. Resident 58 was admitted to the facility in early 2023 with diagnoses that included stroke, dependence on a ventilator, and being a carrier of a bacteria that were resistant to strong antibiotics During a review of Resident 58's CP, dated 5/30/24, the CP indicated, INFECTIOUS DISEASE: CONTACT PRECAUTION.Follow facility policy and procedure related to contact precautions.Staff will follow PPE protocol per guidelines. Resident 61 was admitted to the facility early 2023 with diagnoses that included stroke, urinary tract infection, resistance to multiple antibiotics, and being a carrier of a bacteria that were resistant to strong antibiotics. During a review of Resident 61's CP, dated 6/7/24, the CP indicated, INFECTIOUS DISEASE: CONTACT PRECAUTION.Follow facility policy and procedure related to contact precautions.Staff will follow PPE protocol per guidelines. During a concurrent observation and interview on 7/28/26 at 2:24 p.m., Certified Nursing Assistant (CNA2) was observed inside the shared room of Resident 15, Resident 58, and Resident 61. A sign outside the door indicated, STOP: CONTACT PRECAUTIONS EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. CNA 2 was observed inside the room without a gown. CNA 2 wore gloves, picked up three urinals filled with urine in one hand, and exited the room. CNA 2 walked with the three urinals to the shower room, entered the shower room and exited the shower room with three empty urinals, walked back to the room, and re- entered the room without sanitizing hands or putting on a gown. CNA 2 placed the empty urinals at each resident's bedside, emptied the trash, and brought the trash outside the room to the trash area. CNA 2 confirmed the above observations and stated she knew she was supposed to wear a gown but was in a rush. CNA 2 confirmed the sign outside the room indicated the residents were on contact precautions and stated she knew staff was supposed to follow the precautions. During a phone interview on 7/29/26 at 10:59 a.m. with the Infection Preventionist (IP), the IP stated residents on contact precautions required gown and gloves to be worn during care. The IP stated contact precautions were used to prevent MDRO and decrease or prevent the spread of infection and she expected PPE to be worn before entering a room, .it's automatically part of the uniform. The IP stated if urinals were removed from a room, they had to be removed one at a time and covered during transport. The IP indicated that the CNA should not have carried all three full urinals in one hand, uncovered, down the hall and should have put on a gown before entering the room to empty the trash; the IP stated, That is not correct practice. During an interview on 7/30/26 at 9:55 a.m. with the Director of Nursing (DON), the DON stated she expected staff to follow contact precautions to prevent infection and the spread of bacteria. During a review of the facility's policy and procedure (P&P) titled, CONTACT PRECAUTIONS, undated, the P&P indicated, It is the intent of this facility to use contact precautions for resident known or suspected to have serious illnesses easily transmitted by direct patient contact or by contact with items in the patient's environment. Contact precautions shall be used in addition to Standard precautions for resident with infections that can easily be transmitted by direct and indirect contact.Gloves should be removed before leaving the resident's room and hands should be washed immediately. A gown should be worn when entering the room if it is anticipated that clothing will have substantial contact with the resident, environmental surfaces, or items in the resident's roo (sic). 2. During an observation on 7/29/26 beginning at 9:49 a.m., two operating portable AC units located in two residents' rooms were observed with visibly soiled filters on the back of the units. The filters were heavily saturated with dark debris indicating they had not been adequately cleaned or maintained which could compromise the airflow and its cooling efficiency. During a concurrent observation and interview on 7/29/26 at 10:01 a.m. in another resident's room, the family member confirmed that the portable AC's filter was heavily soiled and stated, I've been here almost every day and I never seen it cleaned; they should have been cleaning that. A review of the facility document titled 'Weekly AC Filter Cleaning Schedule' indicated that AC logs were missing and that the last recorded cleanings ranged from 6/12/26 to 6/26/26. During a concurrent observation and interview on 7/29/26 at 10:17 a.m. with the Director of Maintenance (DM), the DM confirmed that the AC filter in the resident's room was heavily soiled and obstructed, which affected the portable AC's ability to circulate air effectively. The DM stated that the filters needed to be cleaned weekly and explained that he was on vacation for a month and did not have anyone to endorse the task to. The DM confirmed that all the AC units in the area of the facility had not been serviced for a month. Review of the Weekly AC Filter Cleaning Schedule log indicated that 33 residents rooms were affected housing a total of 77 residents. During an interview on 7/29/25 at 10:40 a.m. with the Assistant Director of Nursing (ADON), the ADON confirmed the findings described above and stated, It may be a source of infections for patients that has trach [tracheostomy, a surgical opening in the neck leading into the windpipe that holds a small tube to help a person breathe]. ADON further stated that the AC units were not able to blow cold air efficiently. During an interview on 7/29/26 at 11:46 a.m. with the Infection Preventionist (IP), the IP stated that if the AC units were not checked every month, dust would accumulate, and it could affect the health and condition of residents with tracheostomies because they would be breathing in dust. A review of the facility Policy and Procedures (P&P) titled, Departmental (Maintenance) – Plumbing, HVAC, and Related Systems revised on 2011 indicated, Inspect air-conditioning unit drains and filters weekly .Clean or discard filters in individual air-conditioning units in the resident rooms at least monthly.

Based on interview and record review, the facility failed to document in the medical record the information and education provided regarding the influenza (respiratory illness that is also known as the flu) and pneumococcal (pathogen that causes respiratory illness) vaccines for two of 24 sampled residents (Resident 27 and Resident 100), when Resident 27 and Resident 100's medical record showed no evidence that education was provided.This failure increased the risk for Resident 27 and Resident 100 to contract and transmit preventable illnesses. Findings:Resident 27 was admitted to the facility in May of 2026 with diagnoses that included type two diabetes (a chronic condition that causes a person to have persistently high blood sugar levels).A review of Resident 27's Minimum Data Set (MDS, a standardized assessment tool used in skilled nursing facilities), dated 7/3/26, indicated Resident 27 had a Brief Interview for Mental Status (BIMS, an assessment used to determine a resident's cognition level) score of 15/15 indicating Resident 27 was cognitively intact.A review of Resident 27's document titled, Immunization Details, dated 5/19/26, indicated Resident 27 refused the PCV 20 (a pneumococcal vaccine) vaccine but there was no documented evidence that, prior to refusal, education on benefits of vaccination or risks of not receiving the vaccination was provided to Resident 27.Resident 100 was admitted to the facility in July of 2026 with diagnoses that included respiratory failure.A review of Resident 100's MDS, dated [DATE], indicated Resident 100 had a BIMS score of 15/15 indicating Resident 100 was cognitively intact.A review of Resident 100's Immunization Details document, dated 7/13/2026, indicated that Resident 100 declined both the influenza and pneumococcal vaccines. The record also indicated that no educational information was provided to Resident 100 about these vaccines.During an interview on 7/29/26 at 8:30 a.m. with Resident 100, Resident 100 indicated that he was never educated on the the influenza and pneumococcal vaccines.During an interview on 7/29/26 at 8:43 a.m. with Resident 27, Resident 27 indicated that he was never offered the pneumococcal vaccine and that he would have taken it had it been offered and education provided to him.During an interview on 7/29/26 at 11:14 a.m. with the Infection Preventionist (IP), the IP indicated that education on vaccination was provided to residents regardless of if they refuse the vaccine. The IP further indicated that it was important for residents to receive the vaccines to prevent the spread of infections.During a concurrent record review and interview on 7/30/26 at 9:48 a.m. with the Director of Nursing (DON), Resident 27 and Resident 100's immunization information was reviewed. The DON confirmed that there was no documentation that education on the influenza and pneumococcal vaccines was provided to either Resident 27 or Resident 100. The DON indicated that she expected staff to educate residents on the vaccines then document it in the residents' record.During a review of the facility's policy and procedures (P&P) titled, Prevention and Management of Covid-19 [pathogen that causes covid infection], Influenza, and Other Respiratory Viral Infections, revised 2/1/24, the PNP indicated, Facility will educate and offer COVID-19, influenza, and pneumococcal vaccines to residents.

Based on interview and record review, the facility failed to ensure that services were provided in accordance with professional standards for 1 of 6 sampled residents (Resident 1) when staff did not administer a prescribed antibiotic (a medication used to kill or stop the growth of bacteria) medication as ordered by the physician.This failure had the potential to result in inadequate infection treatment and worsening symptoms for Resident 1.Findings:Resident 1 was originally admitted to the facility in March 2026 with diagnoses that included non traumatic intracerebral hemorrhage (bleeding inside the brain) and H. pylori gastritis (a stomach infection caused by Helicobacter pylori bacteria).A review of Resident 1's Hospital After Visit Summary (AVS), dated 3/17/26, the AVS indicated that the metronidazole (medication used to treat infections caused by bacteria or parasites) 500 mg (milligram, unit of measurement) every 6 hours was last given on 3/17/26 at 12:12 p.m.A review of Resident 1's Order Summary Report, with a start date of 3/17/26, indicated, Metronidazole Oral Tablet 500 mg. Give 1 tablet via PEG tube [a small tube that helps deliver food and medicine directly to the stomach when eating by mouth is not safe] every 6 hours for H. Pylori Gastritis.A review of Resident 1's Medication Administration Record (MAR) for March 2026, the MAR indicated that Resident 1 did not receive the prescribed metronidazole doses scheduled for 3/17/26 at 6 p.m. and 3/18/26 at 12 a.m.During a concurrent interview and record review on 3/30/26 at 3:45 p.m. with the Infection Preventionist (IP), the IP stated that the medication had not been given as indicated in Resident 1's Administration Notes dated 3/17/26 at 7:45 p.m. and 3/18/26 at 12:32 a.m. The Administration Notes indicated that the medication was pending pharmacy delivery.During a concurrent observation and interview on 3/30/26 at 4 p.m. with the Infection Preventionist (IP) Nurse in the medication room, the IP was observed checking the contents of the medication emergency kit (e kit), which contained metronidazole. The IP stated the nurse should have utilized the medication e-kit to administer the scheduled antibiotic if it was available. The IP further stated that if antibiotics were not administered appropriately, bacteria could become resistant to the medication.During an interview on 3/30/26 at 4:22 p.m. with the Director of Nursing (DON), the DON stated that if an antibiotic was not administered, it could delay the healing process, and an acute situation might occur. The DON stated the nurse should have used the ordered medication from the e kit.A review of the facility's policies and procedures titled Administering Medications (undated) indicated, Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescribed orders, including any required time frame.

Based on observation, interview and record review, the facility failed to ensure the needs of residents were accommodated for five of nine sampled residents (Resident 3, Resident 4, Resident 5, Resident 6 and Resident 7) when:Resident 3 and Resident 4 did not have a call light system that accommodated their special needs; and, 2. Resident 5, Resident 6, and Resident 7 did not have their call lights within reach.These failures had the potential to result in residents being unable to ask for needed assistance and not attaining their highest practicable physical, psychosocial, and emotional well-being.Findings:1.During a review of Resident 3's face sheet (front page of the chart that contains a summary of basic information about the resident), indicated Resident 3 was admitted to the facility November 2023 with multiple diagnosis including contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion) of left and right hand.During a review of Resident 3's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 1/5/26, the MDS indicated Resident 3 was dependent with Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During a review of Resident 4's face sheet, indicated Resident 4 was admitted to the facility February 2023 with multiple diagnosis including quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury).During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4 was dependent with ADLs.During a concurrent observation and interview on 2/25/26 at 12:07 p.m. with Licensed Nurse (LN) 1 in Resident 3's and Resident 4's room, Resident 3 and Resident 4 had their call lights placed on their chest. LN 1 confirmed Resident 3 and Resident 4 had mobility issues that prevented them from using their call light. LN 1 further stated she did not know how Resident 3 and Resident 4 would be able to use their call light if they needed help.During an interview on 2/25/26 at 12:38 p.m. with Director of Nursing (DON), DON confirmed Resident 3 and Resident 4 were not given accessible call lights. DON stated, Why would I give him (resident) an accessible call light if he can't move? We don't do assessments for accessible call lights. They can't press them anyways.During a review of the facility's policy and procedure (P&P) titled, Resident Rights revised December 2016, the P&P indicated, .Employees shall treat all residents with kindness, respect, and dignity.these rights include.a dignified existence.The facility did not provide a policy and procedure for Call Light accessibility upon request. 2.During a review of Resident 5's face sheet, the face sheet indicated Resident 5 was admitted to the facility December 2022 with multiple diagnosis including respiratory failure.During a review of Resident 6's face sheet, the face sheet indicated Resident 6 was admitted to the facility October 2022 with multiple diagnosis including anoxic (when the brain receives no oxygen at all) brain injury.During a review of Resident 7's face sheet, the face sheet indicated Resident 7 was admitted to the facility February 2026 with multiple diagnosis including Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements).During a concurrent observation and interview on 2/25/26 at 12:17 p.m., with LN 2 in Resident 5's and Resident 6's room, Resident 5 and Resident 6 were lying in bed, and their call lights were on the floor. LN 2 confirmed the call lights were not within the residents' reach. LN 2 acknowledged call lights on the floor were a safety issue.During a concurrent observation and interview on 2/25/26 at 12:21 p.m., with Respiratory Therapist (RT) in Resident 7's room, Resident 7 was lying in bed and her call light was on the floor. RT confirmed the call light was out of the resident's reach. RT acknowledged resident would not be able to use call light to get help.During a review of the P&P titled, Answering the Call Light, revised September 2022, the P&P indicated, .Ensure that the call light is accessible to the resident when in bed.

Based on interview and record review, the facility failed to ensure physician orders and consistent monitoring were followed in accordance with professional standards for Resident 1, when Resident 1's side effects were not consistently monitored and treatments not done as ordered by the physician.This failure had the potential to negatively affect Resident 1's health and their ability to achieve their highest practical well-being.Resident 1 was originally admitted to the facility in May 2024 with multiple diagnoses which included sepsis (extreme response to infection) due to methicillin resistant staphylococcus aureus (type of bacteria), urinary tract infection (infection in the urinary system), type 2 diabetes mellitus (condition where the body either doesn't produce enough insulin or doesn't respond properly to the insulin), cellulitis (skin infection) of left lower limb, pain in right hip, and dysphagia (difficulty swallowing foods or liquids). A review of Minimum Data Set (MDS, an assessment tool), dated 2/5/25, indicated Resident 1 had impaired cognition.A review of Resident 1's Order Summary Report, with start date 2/3/25, indicated, Preparation H [medication used to relieve the symptoms of hemorrhoids, such as itching, swelling, and discomfort] Rectal Ointment 0.25-14-74.9 % (Phenylephrine-Mineral Oil-Petrolatum) Insert 1 application rectally every day and night shift for skin maintenance.A review of Resident 1's Medication Administration Record (MAR-a legal document used to record medications given to the residents), for the month of February 2025, indicated ointment for skin maintenance was not applied on 2/4/25, 2/5/25, 2/6/25, 2/7/25, 2/8/25 and 2/9/25 as physician ordered. A review of Resident 1's Order Summary Report, with start date 2/5/25, indicated, MIDLINE [midline catheter is a thin, soft tube that is placed into a vein, usually in the arm]: Flush before and after administration of medications with 10ml [milliliters-unit of measurement] NS [normal saline] every shift.A review of Resident 1's MAR for the month of February 2025, indicated midline flushing was not done on 2/7/25, 2/8/25, 2/9/25, 2/12/25, and 2/15/25 as physician ordered. A review of Resident 1's Order Summary Report, with start date 2/5/25, indicated, MIDLINE: Monitor every shift for s/s [signs and symptoms] of infection every shift.A review of Resident 1's MAR for the month of February 2025, indicated monitoring for midline infection was not done on 2/7/25, 2/8/25, 2/9/25, and 2/15/25 as physician ordered. A review of Resident 1's Order Summary Report, with start date 1/31/25, indicated, monitor for s/s of constipation, delirium, over sedation, changes in mental status, and reduced respirations. every shift for OPIOID [drug used to reduce moderate to severe pain] use.A review of Resident 1's MAR for the month of February 2025, indicated monitoring for s/s of opioid use was not done on 2/3/25 as physician ordered. A review of Resident 1's Order Summary Report, with start date 1/31/25, indicated, monitor for s/s of dehydration, electrolytes [minerals that help regulate the body's fluid balance], AKI [acute kidney injury], edema [swelling], weight changes, and congestion. every shift for diuretic [medication that increases urine production] use.A review of Resident 1's MAR for the month of February 2025, indicated monitoring for s/s of diuretic use was not done on 2/3/25 as physician ordered. A review of Resident 1's Order Summary Report, with start date 2/19/25, indicated, MIDLINE: Cap Change every shift every shift.A review of Resident 1's MAR for the month of February 2025, indicated midline cap change was not done on 2/27/25 and 2/28/25 as physician ordered. During an interview on 8/20/25, at 2:05 p.m., with the Director of Nursing (DON), the DON confirmed the expectation was for nursing staff to follow physician's orders. During a concurrent interview and record review on 8/21/25, at 1:20 p.m., with Licensed Nurse 3 (LN 3), LN 3 reviewed Resident 1's February 2025 MAR and confirmed Resident 1 had missing dates for Preparation H treatment order, midline monitoring and flushing, monitoring s/s for opioid use, monitoring s/s for diuretic use and changing midline cap changes as physician ordered. LN 3 also reviewed Resident 1's medical chart and confirmed the physician was not notified on those dates and stated the physician was supposed to be notified when a medication or treatment was not given or if monitoring was not done. LN 3 further stated Resident 1 potentially could have had a change of condition or possible infection if monitoring and treatment was not done or documented. LN 3 stated, Anything could happen.could be change of condition. A review of the facility's document titled, Registered Nurse (RN), undated, indicated, Provide nursing services to residents in accordance with scope of practice, facility policies and professional standards of care.Monitor residents for development of acute changes of condition.conduct assessments and notify the provider as needed.Monitor the chronic health conditions of residents.Maintain documentation of all nursing care and services provided to the residents.Administer medications according to practitioner orders and report adverse consequences, side effects or any medication errors.A review of the facility's policies and procedures (P&P) titled, Administering Medications, revised 4/2019, indicated, Medications are administered in a safe and timely manner, and as prescribed.Medications are administered in accordance with prescribed orders, including any required time frame.If a dosage is believed to be inappropriate.the person preparing or administering the medication will contact the prescriber, the resident's Attending Physician or the facility's Medical Director to discuss the concerns.A review of the facility's P&P titled, Charting and Documentation, revised 7/2017, indicated, Documentation of procedures and treatments will include care-specific details, including:.e. Whether the resident refused the procedure/treatment.f. Notification of family, physician.

Based on interview and record review, the facility failed to ensure Resident 1 was free from significant medication error when Resident 1 did not receive prescribed antihypotensive medication (used to increase low blood pressure) in accordance with the physician's order.This failure had the potential to result in Resident 1 experiencing low blood pressure and other unnecessary side effects which could have negatively affected Resident 1's health.Resident 1 was originally admitted to the facility in May 2024 with multiple diagnoses which included hypotension (low blood pressure, means that the pressure of blood circulating around the body is lower than normal). A review of Minimum Data Set (MDS, an assessment tool), dated 2/5/25, indicated Resident 1 had impaired cognition. A review of Resident 1's Order Summary Report, with start date 1/31/25, indicated, Midodrine HCl [medication to treat low blood pressure (hypotension)] Oral Tablet 5 MG [milligrams-unit of measurement] (Midodrine HCl) Give 1 tablet by mouth two times a day for hypotension *HOLD for SBP [systolic blood pressure, the top number and refers to the amount of pressure experienced by the arteries while the heart is beating] GREATER THAN 120*.A review of Resident 1's Medication Administration Record (MAR, a legal document used to record medications given to the residents), for the month of February 2025, indicated Resident 1 did not receive the physician prescribed Midodrine medication on 2/1/25, 2/2/15, 2/6/25, 2/7/25, 2/8/25, 2/9/25, 2/11/25, 2/12/25, 2/17/25, and 2/20/25 as ordered. During an interview on 8/20/25, at 2:05 p.m., with the Director of Nursing (DON), the DON confirmed the expectation was for nursing staff to follow physician's orders. During a concurrent interview and record review on 8/20/25, at 3:43 p.m., with Licensed Nurse 2 (LN 2), LN 2 reviewed Resident 1's February 2025 MAR and confirmed Resident 1's SPB was lower than 120 and should have received prescribed antihypotensive medication on 2/1/25, 2/2/15, 2/6/25, 2/7/25, 2/8/25, 2/9/25, 2/11/25, 2/12/25, 2/17/25, and 2/20/25 as ordered. LN 2 also reviewed Resident 1's medical chart and confirmed the physician was not notified on those dates and stated the physician was supposed to be notified if a medication was not given. LN 2 further stated Resident 1's blood pressure could have continued to keep dropping and result in Resident 1 having a change of mentation and change in condition. A review of the facility's document titled, Registered Nurse (RN), undated, indicated, Administer medications according to practitioner orders and report adverse consequences, side effects or any medication errors.A review of the facility's policies and procedures (P&P) titled, Administering Medications, revised 4/2019, indicated, Medications are administered in a safe and timely manner, and as prescribed.Medications are administered in accordance with prescribed orders, including any required time frame.If a dosage is believed to be inappropriate.the person preparing or administering the medication will contact the prescriber, the resident's Attending Physician or the facility's Medical Director to discuss the concerns.

Based on observation, interview, and record review, the facility failed to ensure food preparation in accordance with professional standards for food service safety were provided for a census of 86, when:1. A kitchen staff's personal food item was found in refrigerator opened and expired;2. Low temperature dishwasher logs showed documentation of 200 parts per million (ppm - a unit of concentration to measure pollutants in water) for June, July, and August 2025; and 3. Kitchen staff did not know how to calibrate thermometers to determine food time/temperature control during lunch tray line. These failures had the potential to cause food-borne illnesses in a vulnerable population.1. During a concurrent observation and interview on 8/12/25 at 8:30 a.m., in the kitchen with the Certified Dietary Manager (CDM), the CDM confirmed a seafood item in an opened plastic container found in a cardboard box labeled, Liquid Cage Free Whole Eggs, was unlabeled with expiration date of 8/8/25 in the refrigerator door. The CDM stated this food item belonged to one of the kitchen staff. The CDM indicated that expectations were that all food items were labeled with a date, expired foods were thrown out, and kitchen staff were to use the staff refrigerators on the nursing units to keep personal food. CDM acknowledged personal food in the kitchen's refrigerator was cross contamination and could make the residents sick.During a telephone interview on 8/15/25 at 8:50 a.m., with the Registered Dietician (RD), the RD stated, that is not acceptable at all. RD indicated expectations were for staff to use the refrigerators on the nursing units to store their food, all food in refrigerators should be labeled with a name, dated when opened, and expired foods should be thrown out. The RD acknowledged that these practices prevent residents from getting sick from cross contamination of old food.During a review of the facility's policy and procedure (P&P) titled, Food Storage: Cold Foods, revision date 2/2023, the P&P stipulated, All Time/Temperature Control for Safety (TCS) foods.refrigerated, will be.stored in accordance with guidelines of the FDA Food Code.5. All foods will be stored wrapped or in covered containers, labeled and dated, and.in a manner to prevent cross contamination.2. During a concurrent observation, interview and record review on 8/13/25 at 9:30 a.m. in the kitchen with Dietary Aid 1 (DA 1), DA 2, and CDM, DA 1 was asked to demonstrate and explain the dishwasher procedure. DA 1 said the dishwasher was a low temperature washer and she did not know the cleaning chemical used. DA 1 performed a test strip at the end of the fourth cycle final rinse, and the results were 200 ppm. DA 1 presented the Dish Machine Log test strip documentation for August 2025. The documentation showed 200 parts per million (ppm) test strip results written daily for all three meals. DA 1, DA 2 and the CDM could not explain what 200 ppm meant and could not reference an instruction manual for answers. The CDM stated, I am not a dishwasher technician. During a concurrent observation and interview on 8/14/25 at 3 p.m., in kitchen with the CDM and the Dishwasher Service Technician (DST) to discuss the dishwasher sanitizing test strip results, the DST stated he did not look at the test strip results logged by the kitchen staff. The DST reviewed the documentation for August 2025 and stated the 200 ppm number was too high. The DST confirmed the ppm results should read 50-100. The CDM stated he had not provided training or in-services for kitchen staff on how to perform sanitizing test strips for the dishwasher. The CDM acknowledged residents could get sick from too much sanitizing chemical left on plates and could have created an adverse interaction with the food.During a telephone interview on 8/15/25 at 8:50 a.m., with the RD, the RD stated her spreadsheet for July 2025 showed the dishwasher's ppm was too high. The RD stated the sanitizing test results should be between 50 to 100. The RD acknowledged the dishes have to be disinfected correctly, the right concentration must be used so that residents do not get sick from possibly ingesting sanitizing solution when eating meals.During a review of the facility's policy and procedure (P&P) titled, LOW TEMP DISH MACHINE, no date, the P&P stipulated, .Step 4:.(Test sanitizer = 50-100 PPM).During a review of the facility's P&P titled, Warewashing , revised 2/2023, the P&P stipulated, 1. The Dining Services staff will be knowledgeable in the proper.handling of sanitized dishware.2. All dish machine water temperatures will be maintained in accordance with manufacturer's recommendations for.low temperature machines.3. During a concurrent observation and interview on 8/14/25 at 11:20 a.m., in the kitchen with the [NAME] and the Certified Dietary Manager (CDM), before the start of the lunch tray-line service, the [NAME] was asked to demonstrate and explain the procedure for thermometer calibration. The [NAME] grabbed a red thermometer from a cup located on the countertop at the end of the steam table area. The cup held two other thermometers, one black thermometer and one silver thermometer. The [NAME] went over to the pan of cooked lasagna positioned on stovetop and stuck his thermometer into the food. The [NAME] could not explain his actions and could not produce thermometer calibration instructions. The CDM approached [NAME] and told him to use the ice water bath. The CDM grabbed an approximate 2L (liter - a unit of measurement) clear plastic square shaped container, added cubed ice, and filled the container with 3/4 water from the sink. The CDM told the [NAME] to place his thermometer in the iced water to do the calibration. The [NAME] and the surveyor synchronized insertion of the digital thermometers into the same cubed iced plastic container of water. The thermometers were held in water. The surveyor's thermometer read 32 degrees after 10 seconds. After approximately 45 seconds, the [NAME] was asked to verbalized his thermometer reading, he said 32.5. The [NAME] stated he did not know about an ice water bath, and indicated he used a thermometer after foods were cooked. The CDM stated she performed the thermometer calibrations and documented the results on the log sheet. The CDM acknowledged that the [NAME] was not properly trained on how to perform thermometer calibration.During a concurrent interview and record review on 8/15/25 at 1:15 p.m. in CDM's office, the CDM presented the thermometer calibration instructions, found on the bottom of the calibration log sheet dated [DATE]. The CDM confirmed that per instructions, the crushed ice was not used during the thermometer calibration, timed 30 seconds were not identified by the Cook, or herself, during the calibration, and the [NAME] used a red thermometer instead of the black thermometer that is being calibrated and logged by the CDM. The CDM stated she had not provided training or in-services for kitchen staff on how to calibrate thermometers. The CDM acknowledged the importance to have accurate temperature food checks to prevent food borne illnesses in a vulnerable population related to undercooked foods.During a telephone interview on 8/15/25 at 8:50 a.m. with the RD, the RD stated the CDM provided all training for kitchen staff. The RD acknowledged the importance to have thermometers met food code regulations to avoid compromised residents from getting sick.During a review of the facility's P&P titled, Thermometer Calibration Log INSTRUCTIONS, dated 2/2025, the P&P stipulated, All thermometers in use should be tested.for accuracy and calibrated.Ice Point Method: 1.with crushed ice.2.Wait 30 seconds.3. If the temperature is at 32 *F, remove the thermometer. It is now ready for use.During a review of the facility's P&P titled, Food: Preparation, revised 2/2025, the P&P stipulated, .4. The .Cook(s) will be responsible for food preparation techniques which minimize the amount of time that food items are exposed to temperatures greater than 41 *F and/or less than 135 *F.10. Thermometers in use should be tested and calibrated.

Based on observation, interview, and record review, the facility failed to provide treatment in accordance with professional standards of care for forty (40) residents in a census of 86, when the licensed nurse (LN) did not have consistent practice in enteral tube (flexible tube inserted into the gastrointestinal tract to deliver liquid nutrition or medications directly to the stomach or small intestine) medication administration, and the facility provided two versions of the policy and procedure addressing the practice with the same revision date and modified text.These failures had the potential to expose the residents on enteral tubes to unsafe medication administration and the adverse side effects of the medications.During a concurrent observation and interview on 8/13/25 commencing at 4:27 p.m., a medication pass was conducted with LN 4. LN 4 prepared and administered seven medications for Resident 3. LN 4 combined and crushed together six medications: aspirin 81 mg (milligram unit of measurement, blood thinning medication), docusate sodium 100 mg (a stool softener medication), magnesium oxide 400 mg (a supplement medication), metoprolol tartrate 12.5 mg (a blood pressure medication), risperidone 1 mg (a medication used to treat psychiatric conditions), and famotidine 20mg (a medication used to tread high stomach acid). LN 4 stated that Resident 3 had an order that allowed medications to be crushed and combined together. LN 4 additionally prepared 5ml (milliliters, unit of measurement) of valproic acid 250mg/5ml (milligram/milliliter unit of concentration, a medication used for seizures or psychiatric conditions). LN 4 poured the valproic acid suspension into the measuring cup without shaking the medication prior to pouring. LN 4 entered Resident 3's room and administered 6 combined crushed medications diluted in water, followed by 5 ml of valproic acid without flushing in-between administrations through the PEG tube (percutaneous endoscopic gastrostomy tube, a tube inserted through a skin incision directly into the stomach) with 30 ml water flushes before and after administration. After administering the medications, LN 4 came out of the room and confirmed that she administered six combined and crushed medications, followed by valproic acid without flushing in-between. LN 4 also stated that she did not shake the valproic acid medication bottle prior to administration and showed the bottle with directions on the label to shake for 15 seconds prior to administration.During a review of Resident 3's Physician's Orders (PO), the PO indicated the following:1. Aspirin 81 Oral Tablet Chewable, give 1 tablet via PEG-Tube one time a day for Heart health. Start Date 10/10/2024;2. Docusate Sodium, oral tablet 100mg give via PEG-tube two times a day for bowel care. Start date- 05/12/2025;3. Magnesium Oxide, oral tablet 400mg, give 1 tablet via PEG-tube one time a day for supplement. Start date 10/10/2024;4. Metoprolol Tartrate tablet, give 12.5mg via PEG-Tube two times a day for Sinus Tachycardia. Start date 11/17/2024;5. Risperidone, oral tablet 1mg, give 1 tablet via PEG-Tube two times a day for continuousyelling/screaming. Start date 01/24/2025;6. Famotidine Tablet 20mg, give 1 tablet via PEG-tube every 12 hours for GI PPx (gastrointestinal prophylaxis). Start date 10/10/2024;7. Valproic Acid oral solution 250 mg/5ml, give 5 ml via PEG tube two times a day for moodswings and irritability. *shake well for 15 sec*. Start date 05/19/2025; 8. ENTERAL: May Crush Medications And Give Via GTube Unless Contraindicated -D/C [discontinue] Date- 08/13/2025 1714. The order was active since 10/10/24.9. ENTERAL: Flush before and after administration of medication, 30 ml, and 10 ml in between administration of each medication. Active [since] 10/10/24.10 ENTERAL: May Crush Medications And Give all together Via G-Tube Unless Contraindicated. Active 08/13/2025.During an interview on 8/14/25 at 4:47 p.m. with LN 4, LN 4 confirmed that Resident 3's chart did not have a specific order to combine and crush medications together at the time of medication pass observation on 8/13/25, but the chart did have an order to flush between each medication. LN 4 further confirmed that right after the med pass observation on 8/13/25 at 5:14 p.m. she obtained a new PO, which indicated, ENTERAL: May Crush Medications And Give all together Via G-Tube Unless Contraindicated. Active 08/13/2025. LN 4 added that the facility had a policy that allowed staff to combine, crush, and administer enteral medications together.During an interview on 8/14/25 with LN 6, LN 6 stated that facility nurses don't combine and crush medications together for enteral tube administration, and stated, Each medication is administered separately. LN 6 indicated she was not aware of the orders that would allow the practice of combining and crushing medications together for enteral administration.During an interview on 8/15/25 at 11:14 a.m. with LN 7, LN 7 stated that she administered each enteral medication separately.During a review of the facility's policy and procedure (P&P) titled, Administering Medications Through an Enteral Tube, revised November 2018, provided by the Administrator (Admin) during the facility survey prior to 8/14/25 noon time, the P&P step 3 under general guidelines indicated, Administer each medication separately and flush between medications.During a concurrent interview and P&P review on 8/14/25 at 1:15 p.m. with the Director of Nursing (DON), the DON stated that the previously provided P&P titled, Administering Medications Through an Enteral Tube, was outdated and she provided newer version with the same title and revision date as previously [ Administering Medications Through an Enteral Tube, revised November 2018]. The updated P&P step 3 under general guidelines indicated, Administer each medication separately and flush between medications, and or may administer all medications together with flush before and after administration.During an interview on 8/15/25 at 1:51 p.m. with the Admin, the Admin confirmed that he initially provided a copy of the Administering Medications Through an Enteral Tube P&P that was outdated, and DON had the most current version. Admin was not aware of the date this modified policy was implemented.During a concurrent interview and record review on 8/15/25 at 9:19 a.m. with the facility's Medical Director (MD), Resident 3's handwritten and signed order, dated 8/13/25 at 5:14 p.m. was reviewed. The order indicated, Enteral: may crush medications and give all together via G-tube [a type of enteral tube] unless contraindicated. The MD confirmed that he was the physician for Resident 3 and he wrote the order. The MD stated, It was common sense to administer each medication separately, and he did not think nurses in the facility were combining and crushing medications together.During an interview on 8/15/25 at 2:53 p.m. with the DON, the DON stated that the updated version of the P&P titled Administering Medications Through an Enteral Tube had a printed revision date of November 2018, but it was revised and modified sometime in 2023 to include language about combining and crushing medications together. The DON confirmed that she did not update the revision date on the policy at the time of revision. The P&P changes were based on consultation with the MD, and no review of professional standards or research literature was involved. The DON could not state the specific date when this policy was implemented. During a review of the National Library of Medicine, a recognized source for scientific and professional literature, the source indicated the following publication and quoted text: Open Resources for Nursing (Open RN); Ernstmeyer K, [NAME] E, editors. Nursing Skills [Internet]. Eau [NAME] (WI): [NAME] Valley Technical College; 2021. Chapter 15 Administration of Enteral Medications. Available from: https://www.ncbi.nlm.nih.gov/books/NBK593215/.Liquid medication, or appropriately crushed medication dissolved in water, is administered one medication at a time. Medication should not be mixed because of the risks of physical and chemical incompatibilities, tube obstruction, and altered therapeutic drug responses. Between each medication, the tube is flushed with 15 mL of water, keeping in mind the patient's fluid volume status.

Based on observation, interview, and record review, the facility failed to ensure necessary care and services were provided to meet the communication needs for three of 30 sampled residents (Resident 12, Resident 55, and Resident 60), when:1. Resident 12, non-English speaking resident, was not provided with any communication board or devices; and2. Resident 55 and Resident 60, non-verbal dependent residents, were not provided with any visual materials to express their needs. These failures had the potential to result in Resident 12, Resident 55 and Resident 60's inability to participate in daily tasks, make choices, or have their preferences and unmet needs heard. 1. During a review of Resident 12's admission Record (AR), dated 5/2025, the AR indicated Resident 12 had diagnosis of mild cognitive impairment. During a review of Resident 12's Physician's Order (PO) dated 5/28/25, the PO indicated Resident 12 had no mental capacity to make healthcare decisions. During a concurrent observation and interview on 8/13/25 at 10:35 a.m. inside Resident 12's room with Licensed Nurse 5 (LN 5), LN 5 confirmed Resident 12 did not speak English and there were no communication board or visuals available for use in her room. During a review of Resident 12's Communication Care Plan (CCP), dated 8/14/25, the CCP indicated, Communication: First Language Mandarin.Offer communication board for translation assist when desired.During an observation on 8/14/25 at 8:54 a.m. in Resident 12's room, Resident 12 was in bed, stared back and did not answer when spoken to in English. There were no visuals, picture boards, or symbols available at the bedside for Resident 12 to communicate her understanding or needs. During a concurrent observation and interview on 8/14/25 at 2:46 p.m. in Resident 12's room with the Infection Prevention (IP) Nurse, the IPN confirmed Resident 12 did not speak English and there were no communication board or devices available at the bedside. The IPN indicated that providing communication materials in her native language (Mandarin) meant advocating for her needs and would allow Resident 12 to get engaged and feel more connected. The IPN stated Resident 12 had the right to know what services and treatment she was getting while residing at the facility. 2. During a review of Resident 55's AR, dated 2/2025, the AR indicated Resident 55 had a traumatic brain injury (TBI, injury that occurs when an external force causes damage to the brain) and aphasia (a disorder that makes it difficult to speak). During review of Resident 55's PO, dated 2/21/25, the PO indicated Resident 55 had no mental capacity to make healthcare decisions.During a review of Resident 55's Activities of Daily Living (ADL) CP, revised 6/1/25, the ADL CP indicated, ADL functioning with self-care deficit.explain procedures before performing.During an observation on 8/13/25 at 8:54 a.m. in Resident 55's room, Resident 55 was in bed, eyes opened, unable to respond verbally but was able to move his right hand and made a thumbs-up when asked to acknowledge. There were no visual materials using pictures or symbols to outline daily routines and activities, boards with images, symbols, or words that Resident 55 could point to express needs, thoughts and emotions. During a concurrent observation and interview on 8/13/25 at 11:23 a.m., in Resident 55's room with LN 9, LN 9 confirmed Resident 55 was non-verbal and there were no communication board or visual pictures available for use. When asked what method LN 9 used to communicate with Resident 55 to explain procedures, services or treatment, LN 9 could not explain how she could communicate what nursing care or treatment Resident 55 was getting. During a concurrent observation and interview on 8/14/25 at 9:23 a.m. in Resident 55's room with the IPN, the IPN stated residents with speech, language, or communication difficulties should be provided with communication visuals or materials. The IPN added having available visuals or pictures could be effective for learning and retaining new skills, especially for tasks that are difficult to explain verbally. During a review of Resident 60's AR, dated 9/2014, the AR indicated Resident 60 had TBI and aphasia. During a review of Resident 60's PO, dated 4/30/20, the PO indicated Resident 60 had no mental capacity to make healthcare decisions.During a review of Resident 60's CCP, revised 6/25, the CCP indicated, Impaired communication related to TBI, as evidenced by (AEB) sometimes understood, sometimes understands, sometimes will speak in short sentences, usually non-verbal.have communication board at bedside and use PRN [PRN-as needed]. During an observation on 8/13/25 at 10:21 a.m. in Resident 60's room, Resident 60 was in bed, unable to answer verbally but smiled and blinked his eyes when asked to respond. There were no communication visuals available at the bedside. During a concurrent observation and interview on 8/13/25 at 11:23 a.m. in Resident 60's room with LN 9, LN 9 confirmed Resident 60 was non-verbal and there were no communication visuals available at the bedside. LN 9 stated communication board for non-verbal residents should be available so they could respond back by pointing at the pictures or visuals provided. LN 9 stated not understanding the needs of our non-verbal residents could compromise safety and could potentially lead to unmet needs. During an interview on 8/15/25 at 3:58 p.m. with the Director of Nursing (DON), when asked how staff communicated with non-verbal residents or non-English speaking residents, the DON stated the facility should have a communication plan or a device that fits the residents' needs, whether communication boards, visuals, utilizing interpretation lines or get family involvement. During a review of the facility's policy and procedure (P&P) titled, Translation and/or Interpretation of Facility Services, revised 11/20, the P&P indicated, The facility's language access program will ensure that individuals with Limited English Proficiency (LEP) shall have meaningful access to information and services provided by the facility. It is understood that in order to provide meaningful access to services provided by this facility, translation and / or interpretation must be provided in a way that is culturally relevant and appropriate to the LEP individual . Competent oral translation that is not available in written translation, and non-vital information shall be provided in a timely manner and at no cost to the resident through the following means .b: a communication board.A policy and procedure specific to communication access for non-verbal residents was requested but none was provided.

Based on observation, interview, and record review, the facility failed to ensure necessary services to maintain good grooming, nail care and oral hygiene were provided to five of 30 sampled residents (Resident 12, Resident 22, Resident 27, Resident 60 and Resident 77) who were unable to carry out activities of daily living (ADLs), when:1. Resident 12's toenails were long, untrimmed, curled inward and discolored;2. Resident 22's left big toenail was long, jagged, untrimmed and curled outward; 3. Resident 27 toenails were long, jagged, untrimmed, discolored and curled inward;4. Resident 60's fingernails and toenails were long, jagged and untrimmed, his nostrils had yellowish-colored substance, his upper and lower eyelids and eyebrows had white-colored-crust-dried substance, his teeth were discolored, and his lips were cracked and dry, dry and scaly skin; and, 5. Resident 77's left second finger was discolored, jagged, untrimmed and curled inward, her eyebrows and the crevice of her nose had whitish-yellowish-flaky substances, and her cheeks had food residue markings. These failures resulted in Resident 12, Resident 22, Resident 27, Resident 60, and Resident 77's unkempt appearance and compromised well-being. 1. During a review of Resident 12's admission Record (AR), dated 5/2025, the AR indicated Resident 12 was admitted in mid-2025 with diagnoses of mild cognitive impairment and diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 12's Physician's Order (PO), dated 5/28/25, the PO indicated Resident 12 had no mental capacity to make healthcare decisions. During an observation on 8/14/25 at 8:54 a.m., in Resident 12's room, Resident 12 was in bed, her toenails were long, jagged, untrimmed and had black substances underneath the nail beds.During a concurrent observation and interview on 8/14/25 at 2:46 p.m., in Resident 12's room with the Infection Prevention (IP) Nurse, the IPN confirmed the findings, and stated Resident 12's toenails had to be trimmed or should be referred to the podiatrist (medical specialists who help with problems that affect the feet or lower legs). The IPN indicated that toenails could harbor dirt, bacteria and fungi, leading to infections like athletes' foot and toenail fungus. The IPN stated that poor foot hygiene could increase the risk of infections, particularly residents with diabetes or weakened immune system. 2. During a review of Resident 22's AR, dated 5/2024, the AR indicated Resident 22 had diagnoses which included dementia (a progressive state of decline in mental abilities) and embolism (block in an artery caused by blood clots) of deep veins of lower left extremity (LLE).During a review of Resident 22's PO, dated 5/24/24, the PO indicated Resident 22 had mental capacity to make healthcare decisions. During a concurrent observation and interview on 8/14/25 at 10:15 a.m., in Resident 22's room, Resident 22 was in bed, her big left toenail was long, jagged, untrimmed, mycotic (caused by a fungus), and curled outward. Resident 22 stated her big left toenail hurt when it gets pushed or touched and wanted it to be trimmed. During a concurrent observation and interview on 8/14/25 at 10:15 a.m. in Resident 22's room with the IPN, the IPN confirmed the findings, and indicated Resident 22's big left toenail had to be trimmed. The IPN stated untreated mycotic and discolored toenails could lead to nail damage or loss, could get infected and spread to surrounding tissues. 3. During a review of Resident 27's AR, dated 5/2025, the AR indicated Resident 27 had diagnoses which included diabetes and peripheral vascular disease (PVD, a slow progressive narrowing of blood flow to the arms and legs).During a review of Resident 27's PO, dated 5/7/25, the PO indicated Resident 27 had mental capacity to make healthcare decisions. During a concurrent observation and interview on 8/13/25 at 12:06 p.m. in Resident 27's room, Resident 27's toenails were long, mycotic, jagged and untrimmed. Resident 27 indicated he wanted his toenails to be trimmed and cleaned. Resident 27 stated his toenails hurt when he wore his shoes.During a concurrent observation and interview on 8/14/25 at 9:31 a.m., in room [ROOM NUMBER]'s room with the IPN, the IPN confirmed the findings, and indicated Resident 27's long and untrimmed toenails created a warm, moist environment conducive to the growth of fungi which could eventually lead to nail infection. The IPN confirmed Resident 27's dirty, overgrown nails could cause discomfort when wearing shoes and were more prone to cause ingrown. The IPN stated regular cleaning and trimming of toenails could help maintain comfort.4. During a review of Resident 60's AR, dated 9/2014, the AR indicated Resident 60 had diagnoses which included diabetes, contracture (a stiffening/shortening at any joint, that reduces the joints range of motion) and blepharitis (an inflammation along the edges of the eyelids). During a review of Resident 60's PO, dated 4/30/20, the PO indicated Resident 60 had no mental capacity to make healthcare decisions.During an observation on 8/13/25 at 10:09 a.m. in Resident 60's room, Resident 60 was in bed, his fingernails and toenails were long, jagged and untrimmed, upper and lower eyelids and eyebrows had white-colored-crust-dried substance, nostrils had yellowish-colored substance, teeth were discolored, and the lips were cracked and dry. During a concurrent observation and interview on 8/14/25 at 2:57 p.m., in Resident 60's room, the IPN confirmed the findings for Resident 60, and stated regular cleaning of the fingernails and toenails helped prevent odors and reduced bacteria buildup which was crucial to overall fingers and feet health; by regularly cleaning the eyelids and eyelashes, it could prevent inflammation of the eyelids that could result from oil and debris buildup, by preventing infections daily eye hygiene contribute to long term health of the eyes; cleaning the nose daily is important for overall respiratory health, helps remove dust, allergens that could cause infection, regular nasal hygiene can reduce sinus infections and improve breathing. About keeping the mouth and lips moist and discolored teeth, the IPN indicated regular brush to remove food particles and bacteria that can thrive in a dry mouth, keeping the mouth and lips moist were crucial for both comfort and overall health. The IPN stated that good hygiene practices could reduce the risk of infections and illnesses and improve the overall quality of life. 5. 5. During a review of Resident 77's AR, dated 12/2024, the AR indicated Resident 77 had diagnoses which included diabetes and bed confinement status.During a review of Resident 77's PO, dated 12/23/24, the PO indicated Resident 77 had no mental capacity to make healthcare decisions.During an observation on 8/12/25 at 9:30 a.m. and 4:01 p.m., and on 8/13/25 at 8:22 a.m. in Resident 77's room, Resident 77 was in bed, her eyebrows and the crease of her nose had whitish-yellowish-crusted substances, cheeks had liquid food markings, and the left 2nd fingernail was discolored, curled inward, jagged and untrimmed.During a concurrent observation and interview on 8/14/25 at 9:09 a.m., in Resident 77's room with the IPN, the IPN confirmed the findings for Resident 77, and indicated that personal hygiene was crucial for maintaining overall health, preventing illness and enhancing social well-being; eliminates germs and bacteria, and reduces the risk of infections and good hygiene also contributed to improved self-esteem and positive social interactions. The IPN stated Resident 77's fingernail should be trimmed.During an interview on 8/15/25 at 9:18 a.m., with the Social Services Director (SSD), the SSD indicated nail care or trimming was part of the activities of daily living (ADL, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The SSD stated podiatry services was an additional or supplemental service and nurses were to submit to SSD the lists of residents that needed podiatry service. The SSD pointed out that nurses and nursing assistants should trim the residents' nails and toenails weekly while waiting for the podiatrist to come which was scheduled every two months.During an interview on 8/15/25 at 3:58 p.m., with the Director of Nurses (DON), the DON stated her expectations was that staff should provide the highest set of quality care to residents like showers, nail care, grooming and hygiene. During a review of the facility's policy and procedure (P&P) titled, ACTIVITIES OF DAILY LIVING, SUPPORTING, revised 3/18, the P&P indicated, Residents will be provided with care, treatment and services as appropriate to maintain and improve their ability to carry their activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. During a review of the facility's P&P titled, FINGERNAILS/TOENAILS CARE OF, revised 2/18, the P&P indicated, The purpose of this procedure is to clean the nailbeds, to keep nails trimmed and to prevent infections.

Based on observation, interview, and record review, the facility failed to ensure medications were stored securely for a census of 86, when:1. An open container of glucometer test strips was not labeled with the open date;2. One eye drop medication had no legible open date;3. Keys to the controlled substance cabinets and refrigerator were not secured.These failures had the potential for residents to receive medications or treatments that were unsafe or with reduced potency or accuracy, and increased risk of access to controlled substances by unauthorized individuals.During a concurrent observation and interview on 8/14/25 at 10:55 a.m. with Licensed Nurse (LN 6) in the hallway near room [ROOM NUMBER], the medication cart was inspected and found an open box of glucometer test strips that was not labeled with an open date. The directions on the box indicated use within 6 months after first opening. LN 6 confirmed the box should have been labeled with an open date. LN 6 was not able to state how long after opening test strips can be stored and used.During a concurrent observation and interview on 8/15/25 at 12:04 p.m. with the Assistant Director of Nursing (ADON) in Station #1 medication storage room, latanoprost (an eye drop medication) was found in the fridge labeled with open date 02/10 and refill date 3/11/25. The ADON confirmed the observation and indicated the area was used for storing active medications. The ADON confirmed the directions on the package indicated that the medication should be used within 6 weeks of opening and verified that the latanoprost had been more than 6 weeks from the opening date.During a concurrent observation and interview on 8/15/25 at 12:25 p.m. with LN 8 in Station #1's medication storage room, a set of keys was observed hanging in a plastic bag on the wall. The keys were tested and opened the drawers and the refrigerator storing the controlled substances. LN 8 confirmed the set of keys were not secured. During an interview on 8/15/25 at 3:52 p.m. with the Director of Nursing (DON), the DON confirmed that opened glucometer test strip containers should be labeled with the open date to ensure the strips are not used beyond the indicated number of days after opening for accuracy of testing. The DON stated the latanoprost eye drop medication container open date was not legible or accurate [open date predated refill date] and had to be discarded after a certain number of days. The DON stated that keeping keys unsecured to the controlled substances cabinets and the refrigerator inside the medication room increased the potential for unauthorized access. During a review of the facility's policy and procedure (P&P) titled, Storage of Medications, revised 11/ 2020, the P&P indicated, Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications.Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended.Schedule II-V controlled medications are stored in separately locked, permanently affixed compartments. Access to controlled medication is separate from access to non-controlled medications.

Based on observation, interview, and record review, the facility had a 25.81% error rate, with eight medication errors out of 31 opportunities observed during a medication pass for two of five residents (Resident 3 and Resident 76).These failures resulted in medications not being administered in accordance with the prescriber's orders and may have affected the residents' clinical conditions.During a concurrent observation and interview on 8/13/25 commencing at 4:27 p.m., a medication pass observation was conducted with Licensed Nurse (LN 4), LN 4 was observed preparing and administering seven medications for Resident 3. LN 4 combined and crushed together six medications: Aspirin 81 mg (milligram unit of measurement, blood thinning medication), docusate sodium 100 mg (a stool softener medication), Magnesium oxide 400mg (a supplement medication), Metoprolol tartrate 12.5 mg (a blood pressure medication), Risperidone 1mg (a medication used to treat psychiatric conditions), famotidine 20mg (a medication used to tread high stomach acid). LN 4 stated that Resident 3 had an order that allowed medications to be crushed and combined together. LN 4 further prepared 5ml (milliliters, unit of measurement) of Valproic Acid 250mg/5ml (milligram/milliliter unit of concentration, a medication used for seizures or psychiatric conditions). LN 4 poured Valproic Acid suspension into the measuring cup without shaking the medication prior to pouring. LN 4 came to Resident 3's room and administered 6 combined crushed medications diluted in water, followed by 5ml Valproic acid without flushing in-between administrations through PEG tube (percutaneous endoscopic gastrostomy tube, a tube inserted through a skin incision directly into the stomach) with 30ml water flushes before and after administration. After administering medications, LN 4 came out of the room and confirmed that she administered six combined and crushed medications, followed by valproic acid without flushing in-between. LN 4 also stated that she did not shake the valproic acid medication bottle prior to administration, and she showed the bottle with directions on the label to shake for 15 seconds prior to administration.During a review of Resident 3's Physician's Orders (PO), the PO indicated the following:1. Aspirin 81 Oral Tablet Chewable, give 1 tablet via PEG-Tube one time a day for Heart health. Start Date 10/10/2024;2. Docusate Sodium, oral tablet 100mg give via PEG-tube two times a day for bowel care. Start date- 05/12/2025;3. Magnesium Oxide, oral tablet 400mg, give 1 tablet via PEG-tube one time a day for supplement. Start date 10/10/2024;4. Metoprolol Tartrate tablet, give 12.5mg via PEG-Tube two times a day for Sinus Tachycardia. Start date 11/17/2024;5. Risperidone, oral tablet 1mg, give 1 tablet via PEG-Tube two times a day for continuousyelling/screaming. Start date 01/24/2025;6. Famotidine Tablet 20mg, give 1 tablet via PEG-tube every 12 hours for GI PPx (gastrointestinal prophylaxis). Start date 10/10/2024;7. Valproic Acid oral solution 250 mg/5ml, give 5 ml via PEG tube two times a day for moodswings and irritability. *shake well for 15 sec*. Start date 05/19/2025; 8. ENTERAL: May Crush Medications And Give Via GTube Unless Contraindicated -D/C [discontinue] Date- 08/13/2025 1714. The order was active since 10/10/24.9. ENTERAL: Flush before and after administration of medication, 30 ml, and 10 ml in between administration of each medication. Active [since] 10/10/24.During an interview on 8/14/25 at 4:47 p.m. with LN4, LN 4 confirmed that Resident 3's chart did not have a specific order to combine and crush medications together at the time of medication pass observation on 8/13/25, but it did have an order to flush between each medication.During a concurrent observation and interview on 8/14/25 commencing at 8:34 a.m., medication pass observation was conducted with LN 5, LN 5 prepared and administered ten medications for Resident 76. Preparation and administration included Polyethylene Glycol 3350 powder (a laxative medication). LN 5 measured Polyethylene glycol 3350 powder using a medication bottle cup with a white inner measurement mark. LN 5 poured powder to the top of the inner cap thread with about 1/4 of the distance to the top of the white inner cap exposed unfilled and diluted measured powder in 4 ounces (oz) of water before providing it to Resident 76 who took the medication orally. After administering medications, LN 5 returned to the medications cart and confirmed filling the Polyethylene glycol 3350 measuring cup to the top of the cap's thread and not covering the entire white inner cup. LN 5 confirmed that engraving on the inner cap indicated 17g [17 gram, unit of mass] with an arrow pointing to the edge of the white cup and not to the thread line. LN 5 also confirmed that directions on the bottle stated, fill to top of white section in cap which is marked to indicate the correct dose (17g). During a review of Resident 76's PO, the PO indicated, Polyethylene Glycol 3350 Give 17 gram by mouth two times a day for bowel care Mix with 4-8 oz of water, juice, coffee or tea. Hold for loose stools. Start Date- 04/30/2024.During an interview on 8/15/25 at 3:54 p.m. with the Director of Nursing (DON), the DON indicated that nurses should follow physician orders during medication administration, including flushing between each medication as directed, measuring medications correctly, and shaking them prior to administration as directed, and stated, Not following orders could affect the therapeutic effectiveness of the medications.During a review of the facility's policy and procedure (P&P) titled, Administering Medications Through an Enteral Tube, revised 11/2018, the P&P indicated, Verify that there is a physician's medication order for this procedure. Follow g-tube administration as ordered.

Based on observation, interview and record review, the facility failed to ensure the resident's environment was free from accidents or hazards for one of 30 sampled residents (Resident 61), when Resident 61 had a traumatic fall with injury. This failure resulted in Resident 61's decline in physical and psychosocial well-being.During a review of Resident 61's admission Record (AR), the AR indicated Resident 61 was admitted to the facility in late 2022 with diagnoses which included diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing) and hypertension (high blood pressure).During a review of Resident 61's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 6/1/25, the MDS indicated Resident was cognitively intact.During a review of Resident 61's Care Plan (CP), revised and updated 6/18/23, the CP indicated Resident 61 was at risk for falls and injury due to bilateral above the knee amputations, paraplegia and muscle wasting and interventions included frequent checks and keeping the environment free of hazards.During a review of Resident 61's eInteract Change of Condition Evaluation (eCoC) dated 1/3/25 at 9:36 a.m., the eCoC indicated, [Resident 61] had a fall from a shower bed during enter (sic) in shower room, assigned CNA [Certified Nursing Assistant] pulled shower bed from head side of shower bed because of bump before to enter shower room bed tilted down and resident fell, resident head hit floor and bump on left side of head.During a review of Resident 61's Emergency Department (ED) Provider Notes, dated 1/3/25, the ED Provided Notes indicated Resident 61 was brought in to the ED after a ground level fall when going from hospital bed and fell backward when transferring and was diagnosed with a traumatic intracerebral hemorrhage (brain bleed) and was admitted to the intensive care unit (ICU). During a review of Resident 61's eCoC dated 7/6/25 9:46 p.m., the eCoC indicated Resident 61's change of condition was reduced glenohumeral articulation with anterior glenoid rim acute fracture after Resident 61 reported pain to his left shoulder.During a concurrent observation and interview on 8/13/25 at 11:13 a.m. in Resident 61's room, Resident 61 was observed laying on his back in bed, with his left hand swollen and fingers curled into his palm, unable to make a fist. Resident 61 indicated he recently had a fracture to his left shoulder. Resident 61 stated, I had severe pain to that [left] shoulder and the x-ray showed there was a fracture. Resident 61 further stated, I was dropped on my head when I was on the shower bed going into the shower room about five months ago. The whole shower chair fell over. I don't trust going into the shower room anymore. I told the CNA [Certified Nursing Assistant] to not bring me into the shower room headfirst. I don't know if she was irritated or annoyed, or if she did it on purpose, but she pulled on the towel that was underneath me so hard I fell off and hit my head. A lot of people had to come and help me get off the floor. I was taken to the ER [emergency room] and I was diagnosed with a brain bleed. I've had a lot of problems since then that fall. During an interview on 8/14/25 at 4:58 p.m. with LN 2, LN 2 confirmed she was the LN who completed the eCoC on 7/6/25. LN 2 stated Resident 61 complained of severe pain to the left shoulder and an x-ray was ordered. LN 2 said the x-ray was done and the results showed a left shoulder fracture. LN 2 acknowledged she did not complete a full physical assessment or evaluation of Resident 61 and did not know how the left shoulder got fractured. LN 2 confirmed she did not alert the DON or Admin of the incident.During an interview on 8/15/25 at 10:18 a.m. with LN 3, LN 3 recalled the fall incident on 1/3/25. LN 3 indicated Resident 61 had a fall in the shower room and was sent to the emergency room (ER). Resident 61 was diagnosed with a brain bleed from the fall. On Resident 61's recent diagnoses of a left shoulder fracture on 7/6/25, LN 3 stated Resident 61 reported, my shoulder hurts. An x-ray was completed, and it was discovered that Resident 61 had fractured his left shoulder. During an interview on 8/15/25 at 1:51 p.m. with the Administrator (ADM), the ADM confirmed he was aware of the 1/3/25 fall but was unaware of the injury. The ADM stated the DON and Assistant Director of Nursing (ADON) should discuss the incidents and residents change of conditions during the morning IDT (interdisciplinary team) meetings. When questioned about Resident 61's recent diagnosis of a left shoulder fracture on 7/6/25 the admin stated he was unaware of the recent fracture. During a concurrent interview and record review on 8/15/25 at 2:53 p.m. with the DON and Regional Consultant (RC) the DON stated she was aware Resident 61 had a fall with injury on 1/3/25. The DON stated she knew how the fall occurred but did not conduct interviews with Resident 61 or other staff members who were involved. There was no evidence to show the shower floor had been assessed. The DON confirmed she did not initiate an incident report. The DON acknowledged she was aware of Resident 61's recent fracture to his left shoulder on 7/6/25. There was no evidence an incident report had been initiated. The DON agreed an injury would be classified as an injury of unknown origin without knowledge of how an injury occurred. The DON confirmed the incident should have been reported to the ADM.During a review of the facility's policy and procedure (P&P) titled, Accidents and Incidents - Investigating and Reporting revised 7/2017, the P&P indicated, All accidents or incidents involving residents, employees.occurring on our premises shall be investigated and reported to the Administrator. 1. The Nurse Supervisor/Charge Nurse and/or department director or supervisor shall promptly initiate and document investigation of the accident or incident. 2. The following data.shall be included on the Report of Incident/Accident form.c. The circumstances surrounding the accident or incident; d. Where the accident or incident took place; e. The name(s) of witnesses and their accounts of the accident or incident; f. The injured person's account of the accident or incident.k. Any corrective action taken; l. Follow-up information .5. The Nurse Supervisor/Charge Nurse and/or department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the Director of Nursing Services within 24 hours of the incident or accident. 6. The Director of Nursing shall ensure that the Administrator receives a copy of the Report of Incident/Accident form for each occurrence.

Based on observation, interview, and record review, the facility failed to protect residents from acquiring scabies (contagious skin infestation caused by mites), when the facility had three residents who tested positive for scabies (Resident 1, Resident 2, and Resident 3) and facility wide prophylaxis was not completed per public health recommendations. This failure had the potential for multiple vulnerable residents to acquire scabies and suffer the effects of infestation including infection. Findings: A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility in March 2023 with multiple diagnoses including cerebral infarction (stroke- disrupted blood flow to the brain causing brain tissue death), ventilator dependence (requires a mechanical ventilator to breathe), tracheostomy (opening in neck to provide airway for breathing), and heart failure (heart does not pump blood as well as it should). A review of Resident 1's Change in Condition Evaluation, dated 12/13/24, indicated .Patient was tested for scabies with Positive results .Interventions .Contact precautions . A review of Resident 1's Medication Administration Record [MAR], for 12/1/24 to 12/31/24, indicated order dated 12/13/24 .Bathe patient/resident in lukewarm water for ten minutes. Apply permethrin cream [medication to treat scabies]. Shower of 12-16 hours. Head to toe, scalp and face, every shift . Resident 1's MAR indicated treatment was completed as ordered. A review of Resident 2's Admission Record, indicated Resident 2 was initially admitted to facility in September 2012 with multiple diagnoses including respiratory failure, quadriplegia (paralysis of all four limbs), seizures, and heart failure. A review of Resident 2's Progress Note, dated 12/13/24, indicated .Lab Results for Scabies Examination confirmed Positive on 12/12/24 @2335 [at 11:35 p.m.]. Resident was previously on enhanced precautions, will now be contact precautions . A review of Resident 2's MAR, for 12/1/24 to 12/31/24, indicated order dated 12/13/24, .Permethrin External Cream 5 % (Permethrin). Apply to neck to toe topically two times a day for scabies .apply neck to toe, give resident a shower 12 hours after application of this medication . Resident 2's MAR indicated treatment was completed as ordered. A review of Resident 3's Admission Record indicated Resident 3 was admitted to the facility in October 2022 with multiple diagnoses including respiratory failure, paraplegia (paralysis affecting the legs), pressure ulcer stage 4 (tissue damage to skin layers, exposing, muscle tendon or bone, due to prolonged pressure to the skin) and amputation of right and left leg above the knee. A review of Resident 3's Change in Condition Evaluation, dated 12/13/24, indicated .Has Sarcoptes Scabiei Examination [scabies] .Lab sent result to show positive .Start treating all rashes with permethrin 2 doses . A review of Resident 3's MAR, for 12/1/24 to 12/31/24, indicated order dated 12/13/24, .Permethrin External 5 % (Permethrin) Apply to neck to toes topically two times a day for scabies .apply neck to toe and give resident a shower 12 hours after application of this medication . Resident 3's MAR indicated treatment was completed as ordered. A review of the Rash Case/Contact Line List Form: Resident/Employees, indicated three residents were positive for scabies and 29 residents monitored for rash or exposure to scabies. A review of an email sent to facility on 12/13/24 from the Yolo County Public Health Nurse (PHN) indicated .You will need to do a thorough assessment on all residents and staff to see if there are any additional symptomatic or suspected case of scabies .You will be expected to report on this current outbreak until it is deemed over, typically 2 incubation periods, unless otherwise specified by Health Officer .Please refer to CDPH [California Department of Public Health]'s Prevention and Control of Scabies Guidance and LA [Los Angeles] County PH [Public Health] Guidance for more information and infection control measures A review of an email sent to facility on 12/17/24 from the Yolo County Public Health Officer (HO) indicated .I strongly recommend that your facility complete a second round of treatment/prophylaxis for all residents and staff. One round of permethrin treatment is approximately 90% effective in killing scabies mites. This means that if you only provide a single round of treatment/prophylaxis .there is a 10% chance that not all mites will be eradicated, leaving the door open for recurrence of cases and potentially another outbreak. I imagine that you might be thinking, We did two rounds of treatment during the last scabies outbreak, and yet here we are again.during the last outbreak you had challenges getting enough permethrin to treat everyone at the same time, and many staff were not receptive to prophylaxis .I suspect that you have an infested staff person who has not been treated and is spreading scabies in the facility .Prophylaxis is recommended for residents and staff who are not symptomatic .While facility-wide treatment and prophylaxis requires much more work than just treating symptomatic residents, treatment of only symptomatic residents is very unlikely to stop the spread of scabies in the facility . During an interview on 12/24/24 at 10:05 a.m. with the Nursing Supervisor (NS), the NS stated a scabies outbreak was identified in the facility a few weeks ago. Three resident had positive tests after skin scrapings done by the wound doctor. The NS stated that the positive cases were in two different halls. The NS stated permethrin cream was used for all residents in the facility and all staff were offered the treatment. During an interview on 12/24/24 at 10:35 a.m. and a subsequent interview at 1:15 p.m. with the Infection Preventionist (IP), the IP stated the wound doctor performed skin scrapings on 12/12/24 for three residents, Resident 1, Resident 2, and Resident 3. The IP stated she was notified on 12/13/24 that the three residents had positive scabies tests and were treated on 12/13/24. The rest of the facility was treated on 12/15/24 after obtaining enough permethrin cream for all the facility. The staff were treated also. The IP stated that the HO recommended second permethrin treatment for all residents. The IP stated not all residents received a second treatment and most staff did not receive a second treatment. The IP stated the Director of Nursing (DON) made the decision to only retreat the Line List residents, not the whole facility because it was recommended but not required per Yolo County Public Health. The IP stated, Everyone should have been retreated, but a superior higher than me decided they did not want to retreat everyone. The IP stated residents on the Line List were retreated on 12/22/24. During an interview on 12/24/24 at 12:47 p.m. with Licensed Nurse (LN) 1, LN 1 stated she was aware of the scabies outbreak and all residents were treated initially, but not all residents were retreated. During an interview on 12/22/24 at 1:08 p.m. with Medical Doctor (MD), the MD stated that this is the second outbreak in the facility. The MD stated all residents should be treated head to toe and facility is doing constant surveillance for possible scabies. The MD stated the facility is following Yolo County Public Health recommendations. During a telephone interview on 12/27/24 at 12:28 p.m. with the DON, reviewed with the DON that HO recommended all residents be retreated to prevent another outbreak. The DON stated, Not all residents were retreated. It was just a recommendation, not mandated. The DON stated that this is the second outbreak, but not the same residents. The DON stated staff were to be treated if had rash, but no staff have reported a rash. The DON stated, Questionable residents were retreated. Everyone else was just a recommendation. If it was mandated they [Yolo County Public Health] should have stated that. During a telephone interview on 12/31/24 at 8:35 a.m. with PHN, the PHN stated the facility had a previous scabies outbreak in September or October 2024. The PHN stated the HO recommended facility- wide treatment and retreatment for all residents and staff for the current outbreak. The PHN stated the second treatment was not done due to DON push back. The PHN stated the HO made it clear to the facility what the recommendations were. The PHN stated they can only make recommendations but cannot mandate facilities. The PHN stated the facility will not retreat unless mandated. The PHN stated, If facility is not retreated, can easily spread again .Will get infestation a second time .Suspect a staff member is a carrier. A review of the facility's Policy and Procedure (P&P) titled Infection Prevention and Control Program, revised 10/18, 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 diseases and infections .:Outbreak management is a process that consists of .preventing the spread to others .reporting the information to appropriate public health authorities .The medical staff will help the facility comply with pertinent state and local regulations concerning the reporting and management of those with reportable communicable diseases .Important facets of infection prevention include .instituting measures to avoid complications or dissemination .following established general and disease-specific guidelines . A review of CDPH document titled Prevention and Control of Scabies in California Healthcare Settings, dated 8/20, indicated .Controlling the Outbreak .Control of a scabies outbreak involves a choice between treating only symptomatic cases and their known contacts or facility-wide (mass) prophylaxis of all possible contacts including asymptomatic patients/residents, HCP [Healthcare Providers], volunteers, and visitors. Treatment of only symptomatic cases and their identified contacts may result in silent, continuous transmission over a sustained period of time due to delay in onset of symptoms and delay in diagnosis and treatment. Failure to identify and treat even one contact can result in continued propagation of the outbreak. As a result, repeated prophylaxis of asymptomatic HCP and volunteers may be required .An outbreak that has likely been ongoing for a month or more is rarely controlled treating only symptomatic cases . Consultation with your local public health department is strongly recommended . A review of LA county document titled Scabies Prevention and Control Guidelines for Healthcare Settings, dated 7/19, indicated .Facility-wide (mass) prophylaxis of all patients/residents and at-risk HCW [Healthcare Worker] (HCW involved in direct patient/resident care or exposed to the patient/resident care environment) should be considered if positive skin scrapings are found in patients/residents or employees assigned to two or more areas of the facility where no direct link with an infested patient/resident or HCW can be established

Based on interview and record review, the facility failed to ensure the wound care plan was updated and revised timely for one of 3 sampled residents (Resident 1) when Resident 1's moisture related skin condition deteriorated to a pressure ulcer stage 4 (pressure injuries extended to muscle, tendon, or bone) to include interventions ordered by the physician. This failure had the potential to result in an inaccurate evaluation of the progress of wound healing for Resident 1. Findings: During a review of Resident 1's admission records, the records indicated Resident 1 was admitted in October 2022 and readmitted in January 2023 with diagnoses that included respiratory failure (not enough oxygen in the body), muscle wasting, diabetes (too much sugar in the blood), and reduced mobility. Resident 1's Minimum Data Set (MDS, an assessment tool) indicated Resident 1 had moderate cognitive impairment. During a review of Resident 1's IDT [Interdisciplinary Team] Skin Integrity Review, dated 9/10/24, the review indicated, WEEKLY WOUND EVALUATION: 9/10/24 SITE: Sacrococcyx [tailbone] .Reclassified from shear injury [tissue layers shift in opposite direction] to Pressure injury by wound MD [medical doctor] during wound rounds. The review further indicated the Sacrococcyx pressure ulcer was Stage 4. During a review of Resident 1's physician order, dated 9/24/24, the order indicated, WOUND ORDER: Pressure-Stage 4: WOUND VAC [uses suction to promote wound healing] .Ensure negative pressure is set at 125 mmHg [millimeters of mercury, a unit of pressure measurement] .one time a day every Tue [Tuesday], Thu [Thursday, Sat [Saturday]. During a review of Resident 1's physician order, dated 9/24/24, the order indicated, Monitor Wound Vac dressing patency and functionality. every shift. During a review of Resident 1's physician order, dated 10/5/24, the order indicated, WOUND ORDER: Sacrococcyx-Stage 4 Pressure: Cleanse area with normal saline [mixture of water and salt] and pat dry. Apply calcium alginate [absorptive, non-occlusive wound dressing] with honey and pack with AMD [antimicrobial, kills or stops growth of bacteria] gauze. Cover with foam dressing. one time a day. During a review of Resident 1's care plan, initiated on 5/20/24, the care plan indicated, The resident has a Skin shear/potential for skin tear of the sacrococcyx .Reclassified to Stage 4 Pressure 9/10/24. The care plan further indicated it was revised 10/11/24, but no revisions were made at the time when the wound was reclassified on 9/10/24, and when new interventions were ordered by the physician on 9/24/24 and 10/5/24. During an interview on 10/30/24 at 2:20 p.m. with the Director of Nursing (DON), the DON stated, the progression of MASD [Moisture Associated Skin Damage, skin erosion caused by prolonged exposure to moisture] to Stage 4 pressure ulcer was a change in condition. The DON confirmed the wound was reclassified from MASD to Pressure Ulcer Stage 4 on 9/10/24, and verified there were no revisions made and no interventions were added to the care plan not until 10/11/24. The DON stated, I don't think there was need for changes in the intervention .I think we had all the interventions we needed. During a review of the facility ' s P&P titled Wound Care, revised 10/2010, the P&P indicated, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing .Preparation .2. Review the resident's care plan to assess for any special needs of the resident . During a review of the facility ' s P&P titled Change in a Resident's Condition or Status, revised 4/2017, the P&P indicated, 2. A significant change of condition is a major decline or improvement in the resident ' s status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); .c. Requires interdisciplinary review and/or revision to the care plan . During a review of the facility ' s policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered, revised 12/2016, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical, psychosocial and functional needs is developed and implemented for each resident .13. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident ' s condition change .14. The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident ' s condition; b. When the desired outcome is not met .

Based on observation, interview, and record review, the facility failed to provide care according to professional standards of practice for one of three sampled residents (Resident 1), when the facility did not obtain instructions for follow up care for Resident 1 who had electrodes placed for an EEG (electroencephalogram- measures electrical activity in the brain) machine and appointment for removal of electrodes was missed. This failure had the potential to have caused the scalp skin injuries after the electrodes were removed at the facility. Findings: A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility initially in June 2013 with multiple diagnoses including dysphagia (difficulty swallowing) following cerebral infarction (stroke-lack of blood flow to the brain), quadriplegia (paralysis of all four limbs), and epilepsy (a seizure disorder). A review of Resident 1's Order Summary Report, active orders as of 10/4/24, indicated order 9/23/24, .medical device (EEG) Pressure injury (on scalp to forehead): - Cleanse with wound cleanser or normal saline and pat dry. Apply zinc oxide paste [medicated cream], and leave open to air, every shift for medical device injury apply calcium alginate [wound treatment] over Zinc paste if drainage noted from areas . A review of Resident 1's Progress Notes, dated 9/16/24, indicated .Resident was sent out for an Appointment: Neurology .son .will attend .Resident left facility at 6:30 am. Resident returned to facility at 9:10 am. Resident recieved [sic] an ambulatory EEG. Resident is required to wear the electrodes continuously for the duration of the testing either a 24hr [hour] or 48hr recording. The natus [sic] EEG box contains a microcomputer which will be recording brain activity . A review of Resident 1's Progress Note, dated 9/18/24 at 10:45 a.m., indicated .residents son/RP [Responsible Party] in facility in resident's room . A review of Resident 1's Change in Condition Evaluation, dated 9/19/24, indicated .seen skin damage when medical device electrodes patches (EEG) were removed from scalp as per hospital recommendation .multiple upper to front scalp and forehead open areas medical device (EEG) related PI [Pressure Injury-injury to skin and underlying tissue caused by prolonged pressure to area], medical device was applied by hospital a few days ago, seen skin damage when medical device electrodes patches (EEG) removed from scalp .Tissue quality appears to be 100% epithelial [superficial cells covering skin] with mild purulent [milky discharge from wound] drainage .Pt [patient] non verbal unable to communicate pain, facial grimacing noted during removal of electrode patches . A review of Resident 1's Progress Note, dated 9/20/24 at 1:47 a.m., indicated .Resident Son/RP/POA [Power of Attorney] called at 2338 [11:38 p.m.] rt [related to] the wounds present on scalp and forehead after EEG electrode removal on 09/19 PM [evening] shift. RP expressed he was not comfortable with his mother remaining in facility the duration of the night and requested a transfer to ED [Emergency Department]. RP was reassured by writer and RN on shift that resident's condition was stable, she is displaying her baseline indications of pain and that her wounds are being monitored closely and managed by treatments. RP maintained request. Request honored .resident sent out to [acute care hospital] . at 01:47 am . A review of Resident 1's After Visit Summary, dated 9/20/24, indicated .You were seen for healing scalp wounds secondary to EEG electrode removal. These wounds appear to be healing well and do not show any signs of infection . A review of Resident 1's Surgical Consult, dated 9/24/24, indicated .WOUND .Right Medial [toward the center] Scalp .Etiology: Iatrogenic Injury [injury caused by medical treatment] .Wound SIGNS OF INFECTION: None .The patient has a wound located at the right medial scalp .Length (cm-centimeter) 1.0 Width (cm) 1.0 Depth (cm) 0.1 .The wound is stable and requires continued topical wound dressing therapy . During a concurrent observation and interview on 10/4/24 at 2:07 p.m. with Certified Nursing Assistant (CNA) 1 of Resident 1, observed forehead and lower scalp with multiple areas with slight discoloration and white bandage with small amount of blood stain on top of head. CNA 1 confirmed multiple areas of discoloration on Resident 1's forehead and bandage on top of head. CNA 1 stated she had noticed the patches on Resident 1 and that she has cream applied to the patches. During an interview on 10/4/24 at 2:12 p.m. with Licensed Nurse (LN) 1, LN 1 stated Resident had an EEG machine placed about two weeks ago and was supposed to return for follow up appointment. LN 1 stated EEG department did not send paperwork for follow up. If had returned with paperwork she would have notified Social Services to arrange follow up appointment. Resident 1's Family Member (FM) reported that Resident 1 was to return for follow up appointment on 9/19/24. Reviewed with LN 1, Resident 1's hard copy chart at nursing station. LN 1 acknowledged there was no documentation in chart from appointment on 9/16/24. LN 1 stated Resident 1's EEG electrodes were removed by the Director of Nursing (DON). During an interview on 10/4/24 at 2:23 p.m. with the DON, the DON stated Resident 1 had a follow up appointment on 9/19/24 to remove the EEG electrodes but Resident 1's FM did not notify the facility of the appointment. On 9/19/24, the EEG department contacted facility and requested the EEG machine be returned that day. The DON stated she asked the EEG department if they could remove the electrodes at the facility. The DON stated she was instructed on how to remove the electrodes by the EEG department. The DON stated the electrodes were on multiple sites and were red. The DON stated if the electrodes had stayed on longer could have created pressure ulcers. The DON stated that paperwork did not come back with Resident 1 on 9/16/24 after appointment to have EEG machine placed and that the FM likely had the paperwork from the appointment. The DON, when asked what would have happened if the EEG department had not contacted the facility on 9/19/24, stated, Going to figure it out after three days. Would have been more involved if in charge of appointment, not [FM]. During an interview on 10/4/24 at 2:47 p.m. with the Social Services Director (SSD), the SSD stated Social Services arranged transportation for Resident 1 to EEG department appointment on 9/16/24 and FM went with her. The SSD stated usually comes back with paperwork or paperwork is faxed. If not received would follow up and request documentation. SSD stated on 9/19/24, Resident 1's family texted staff member and notified her of follow up appointment but it was not conveyed to social services to set up transportation to appointment. During a telephone interview on 10/4/24 at 3:03 p.m. with LN 3, LN 3 stated Resident 1's EEG machine was placed on 9/16/24. LN 3 stated after three or four days she observed a little drainage from electrode sites. The EEG department contacted facility on 9/19/24 to have EEG machine returned. The DON removed the electrodes on 9/19/24 and some of the skin had been peeled off. LN 3 stated Resident 1's FM was in the facility on 9/18/24 at 6:00 a.m. and reported to her that Resident 1 had an appointment on 9/18/24. The FM reported to her that he had handed paperwork to nurse on 9/16/24 but did not know the name of the nurse. LN 3 stated Resident 1's FM reported he had texted LN 5 about follow up appointment. LN 3 stated Resident 1's FM had not provided any paperwork to facility. During a telephone interview on 10/4/24 at 4:14 p.m. with LN 4, LN 4 stated Resident 1 went to appointment on 9/16/24 with FM to have EEG machine placed. LN 4 stated when Resident 1 returned, she asked FM if there was any paperwork. LN 4 stated Resident 1's FM showed her paper with instructions that said to remove in 24 to 48 hours. LN 4 stated she transcribed the information into a progress note and paperwork was returned to the FM. LN 4 stated she did not make a copy of the provided paperwork. LN 4 stated Resident 1's FM reported to her he had notified social services of follow up appointment. LN 4 stated she assumed that social services knew because FM stated he had spoken with social services. LN 4 also stated Resident 1's FM told her he had notified a nurse about the follow up as well. During an interview on 10/4/24 at 4:35 p.m. with the Administrator (ADM), the ADM stated Resident 1 had redness on the scalp and when electrodes were removed had an open area on the scalp. During a telephone interview on 10/4/24 at 4:53 p.m. with Patient Care Services (PCS) for EEG department, the PCS stated Resident 1 had appointment for EEG machine electrodes to be placed on 9/16/24. The PCS stated Resident 1 had a follow up appointment scheduled on 9/18/24 at 7:00 a.m.to remove the device. The PCS stated she spoke with Resident 1's FM on 9/18/24 who said he was still waiting for a ride at the facility and then placed multiple calls to him that day that he did not answer. The PCS stated Resident 1 did not show up for appointment on 9/18/24. The PCS stated she spoke with facility staff on 9/18/24 to reschedule but did not hear back that day. The PCS stated she called facility on 9/19/24 and spoke with staff who said they would notify the DON. The PCS stated the facility removed the electrodes on 9/19/24 on their own. The PCS stated she did not know who may have instructed the facility on how to remove the electrodes. The PCS stated on 9/16/24, paperwork with instructions on how to care for the EEG machine and follow up appointment was scheduled on 9/18/24, was sent with Resident 1. During an interview on 10/4/24 at 5:00 p.m. with the DON, the DON stated she was not aware that Resident 1's follow up was scheduled for 9/18/24 and not 9/19/24. When asked what the expectation of staff if resident does not return from appointment with instructions or any paperwork, the DON stated, [Resident 1's FM] wanted to manage the care and did not provide the information to the facility. During a telephone interview on 10/8/24 at 4:11 p.m. with LN 5, LN 5 stated Resident 1 had EEG machine placed on 9/16/24. LN 5 stated usually residents come back from appointments with paperwork. Resident 1's FM mentioned to LN 5 that the electrodes were supposed to be removed at the EEG department where they were placed. LN 5 stated Resident 1's FM had texted her about the initial appointment on 9/16/24 but no other texts and was not aware of any scheduled appointment on 9/18/24. When asked what should have happened if Resident 1 returned from appointment on 9/16/24 without any follow up information, LN 5 stated, Should have called the EEG department to get information about when to return. It is the SSD's job to set up transportation and arrange appointments. Should have gone through any paperwork upon return and see what the follow up is. Requested facility policy and procedures for Nursing Responsibilities, Nursing Communication, and Appointments. Policies were not provided.

Based on observation, interview, and record review, the facility failed to maintain timely and appropriate pharmaceutical services for one out of three sampled residents (Resident 1) when a prescribed medication was unavailable to be administered as ordered by the physician. This failure caused Resident 1 to experience worsening tremors, increased rigidity, loss of balance, confusion, and agitation due to not achieving the therapeutic dose. Findings: Resident 1 was admitted to the facility in early 2024 with diagnoses that included parkinsonism (brain condition that cause slowed movements, rigidity (stiffness), and tremors), fibromyalgia (a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory, and mood issues), muscle wasting, atrophy, and difficulty walking. During a review of Resident 1's Order Summary Report (OSR), dated 6/4/24, the OSR indicated, Rytary(R) Oral Capsule Extended Release 23.75-95 MG [mg, unit of measure] (Carbidopa-Levodopa) Give 2 capsules by mouth three times a day related to PARKINSONISM . During a review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 7/25/24, the MDS indicated Resident 1 had no memory impairment. During an interview on 9/16/24 at 4:39 p.m. with Resident 1, Resident 1 was lying in bed with the head of the bed slightly elevated. Resident 1 was alert, oriented, and well-groomed. When asked if she had any concerns, Resident 1 stated, I am worried that I may be running out of my medications again, and I don't want to have my symptoms exacerbated. My symptoms get so bad that I crawl like a dog. During an interview on 9/16/24 at 5:07 p.m. with Licensed Nurse (LN 1), LN 1 stated, Resident 1 only has two capsules of Rytary(R) remaining for tomorrow morning dose, and the pharmacy should deliver before noon when the next dose is due . During an interview on 9/17/24 at 11:11 a.m. with LN 2, LN 2 stated, . we get medications delivered to the facility at different times, 11 a.m. - noon, 6 p.m. - 7 p.m., and 3 a.m. Resident 1's medication has not yet been delivered. During an interview on 9/17/24 at 1 p.m. with Resident 1, Resident 1 stated they had not received their 1 p.m. dose of Rytary(R), as scheduled. Resident 1 further stated their tremors were worsening and they had increased rigidity, loss of balance, confusion, and agitation due to not achieving the therapeutic dose of the medication. During an interview on 9/17/24 at 1:30 p.m. with LN 2, LN 2 stated that Resident 1's Rytary(R) had not yet been delivered. LN 2 acknowledged this could worsen Resident 1's symptoms. During an interview on 9/17/24/at 2:15 p.m. with the DON, the DON stated, .Resident 1's medication has not arrived yet . The DON acknowledged that the medication should have been administered as prescribed by the physician or Resident 1 could start having withdrawal symptoms for not receiving her medication on time. During a review of records emailed on 9/18/24 at 1:13 p.m. by the DON, the DON indicated, .The resident did not receive the medication (Rytary(R)) on 9/17/24 at 1 p.m. The DON was unable to provide Resident 1's Medication Administration Record (MAR) with documentation of all missed doses of medications when requested by the Department. During a review of the facility's policy and procedure (P&P) titled, PROVIDER PHARMACY REQUIREMENTS, dated 2007, the P&P indicated, .Providing routine and timely pharmacy services . During a review of the facility's policy and procedure (P&P) titled, ORDERING AND RECEIVING NON-CONTROLLED MEDICATIONS, dated 2007, the P&P indicated, .Medications and related products are received .on a timely basis. Reorder routine .to ensure an adequate supply is on hand. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, revised 4/19, the P&P indicated, .Medications are administered within one (1) hour of their prescribed time .

Based on interview and record review, the facility failed to ensure one resident (Resident 1) of three sampled residents received Cardiopulmonary Resuscitation (CPR) when Resident 1 was found pulseless and not breathing by a Respiratory Therapist (RT) and Licensed Nurses (LN). This failure decreased the facility's potential to ensure a physician's order and Resident 1's request to receive care with the primary goal to prolong life was executed. Findings: A review of LN 1's Healthcare Provider card, dated [DATE], indicated LN 1 successfully completed the requirements for certification in adult CPR and automated external defibrillator (AED, a medical device used to analyze the heart's rhythm and, if necessary, deliver an electrical shock to help the heart re-establish an effective rhythm). This card also indicated an expiration date of [DATE]. A review of LN 2's Basic Life Support Provider document, dated [DATE], indicated LN 2 successfully completed the cognitive and skills evaluations for certification in CPR and AED program. This document also indicated an expiration date of ,d+[DATE]. A review of Resident 1's admission record indicated admission to the facility on [DATE], with diagnoses which included respiratory failure with hypoxia (a condition in which a person's respiratory system is unable to provide oxygen to tissues in the body in order to function) and congestive heart failure (a condition in which the heart is unable to pump blood adequately throughout the body). This admission record also indicated Resident 1's family member was her Responsible Party (RP, a person who is appointed to make healthcare decisions if or when Resident 1 was unable to). A review of Resident 1's Physician Orders for Life-Sustaining Treatment (POLST), dated [DATE], indicated licensed staff were to, Attempt Resuscitation/ CPR .[provide] Full Treatment- primary goal of prolonging life by all medically effective means . This POLST was signed by a physician on [DATE] and, verbal consent obtain [sic] by phone at [3:50 p.m.] [DATE] from RP with 2 nurses . A review of a facility document titled Consent to Treatment, dated [DATE], indicated, The Resident hereby consents to routine nursing care provided by this Facility as well as emergency care that may be required . A review of a Minimum Data Set (MDS, an assessment tool), dated [DATE], indicated, Does resident have a California POLST form in chart? .Yes .Item selected in California POLST Section A .Attempt resuscitation/ CPR .Item selected in California POLST Section B . 'Full Treatment' is the only box checked .POLST Section D- Signature of Physician .Yes .POLST Section D- Signature by .Decision Maker .Yes . A review of a MDS, dated [DATE], indicated Resident 1 had an ostomy (a surgically placed opening from the digestive or urinary system which allows the body to uncontrollably expel waste). The MDS also indicated Resident 1 was, .always incontinent [of urine] and Resident 1 was not on a, .toileting program currently being used to manage .bowel continence . A review of an order summary report, dated [DATE], indicated Resident 1 had a physician's order which indicated her POLST was, Full Code [licensed staff was to provide care with the primary goal of prolonging life by all medically effective means] .Order date XXX[DATE] . A review of Resident 1's Medication Administration Record (MAR), dated [DATE], indicated, POLST: Full Code . A review of a physician's note, dated [DATE] at 1 p.m., indicated, .The [RP] has been approached by Palliative Care [staff who specialize in medical care for people with serious illness] people at the facility where thepatient [sic] came from .however has insisted with continued aggressive care .pt [Resident 1] is full code . A review of a nurse progress note, dated [DATE] at 10:12 a.m. indicated, Upon making nursing round approximal at [9:58 a.m.] RT and nurse observed resident with out [sic] color, no pulse was noted, not breathing. resident [sic] lost bladder and bowel function. RT noted no breath sounds and no O2 [oxygen] saturations were present, no any [sic] pulses were present, no heartbeat detected. RN on unit at this times [sic] confirm death at 10:02 [a.m.] MD [Medical Director/physician] notified at 10:04 [a.m.], RP son notified at 10:09 [a.m.]. social [sic] services notified at 10:06 [a.m.]. DON [Director of Nursing] notified at 10:10 [a.m.]. Mortuary pick body at [1:45 p.m.]. A review of a nurse progress note, dated [DATE] at 12:41 p.m. indicated, [Resident 1] expired at [10:02 a.m.]. A review of Resident 1's medical chart on [DATE], indicated no documented evidence CPR was attempted or performed when licensed staff found Resident 1 pulseless and not breathing. In an interview on [DATE] at 12:48 p.m., the MD 1 confirmed Resident 1's code status was full code and staff did not initiate CPR for Resident 1. The MD 1 also stated, When there was no pulse nothing can be done for the resident . In an interview on [DATE] at 2:55 p.m., the Respiratory Therapy Supervisor (RTS) confirmed RT 1 was present when Resident 1 was found pulseless and not breathing. The RTS also confirmed no CPR had been initiated on Resident 1 at the time she was found. In an interview on [DATE] at 3:27 p.m., the RT 1 stated during his second visit to check on Resident 1, he saw Resident 1 was pale, the pulse oximeter monitor was not connected to Resident 1, and when he connected the pulse oximeter monitor to Resident 1 it was unable to get a reading. The RT 1 stated two nurses came to check on Resident 1 for a pulse, chest rise, and obtain vital signs, but were unable to get any vital signs. The RT 1 stated nobody started CPR on Resident 1. The RT 1 also stated the nurses called both the DON and the MD and were instructed not to do CPR. In an interview on [DATE] at 11:35 a.m., the LN 2 stated on [DATE] at 9:58 a.m., the RT 1 had told her he wanted LN 2 to check on Resident 1. The LN 2 stated when she assessed Resident 1, Resident 1 was cold with her mouth open, her hands were clenched, there was no heart rate, and no respirations. In an interview on [DATE] at 3:23 p.m., the LN 1 stated the LN 2 called her into Resident 1's room at approximately 10 a.m. on [DATE]. The LN 1 stated upon assessment, Resident 1 had no pulse and no respiration. The LN 1 stated the Unit Manager called the MD and the DON and was instructed not to perform CPR for Resident 1. In an interview on [DATE] at 10:31 a.m., the MD 2 stated he expected licensed staff to start CPR on a resident with a full code order who was found pulseless and not breathing because no one would know how long the resident had been in that situation unless the staff observed the moment the resident had a change in condition. The MD 2 also stated he expected emergency services to be called because the facility does not have the capability to perform advanced cardiac life support. The MD 2 further stated it would be difficult for a physician to pronounce death without assessing the resident's heart, lungs, and pupils. In an interview on [DATE] at 11 a.m., the Director of Nursing (DON, who is also a licensed nurse) stated any licensed nurse who was certified to perform CPR could perform CPR. When asked if she was able to pronounce death of a resident, the DON stated she was not a physician; therefore, she was unable to determine the death of a resident. A review of Resident 1's POLST, dated [DATE], indicated, First follow these orders, then contact Physician .A copy of the signed POLST form is a legally valid physician order .If patient has no pulse and is not breathing .Attempt Resuscitation/ CPR .To be a valid POLST form must be signed by (1) a physician .and (2) the patient or decisionmaker .Using POLST .Section A .If found pulseless and not breathing, no defibrillator (including automated external defibrillators) or chest compressions should be used on a patient who has chosen 'Do Not Attempt Resuscitation.' A review of the facility's policy and procedure titled Physician Orders for Life-Sustaining Treatment ., updated [DATE], indicated, .The POLST will be honored if received on admission and signed by both the resident and a physician in accordance with the guidelines .Because the POLST form is a physician order, emergency medical personnel are required to adhere to its instructions regarding CPR .The POLST form is printed on bright pink paper so it will be easily recognizable by all health care personnel . A review of the Uniform Determination of Death Act, approved by the American Medical Association on [DATE] and approved by the American Bar Association on [DATE], indicated, .Determination of Death .An individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead. A determination of death must be made in accordance with accepted medical standards.

Based on observation, interview and record review, the facility failed to ensure treatment and services were implemented to prevent the development of pressure ulcers for two residents (Resident 24 and Resident 30), for a census of 85. This failure resulted in the reopening of two Stage III pressure ulcers (full thickness skin loss extending into the fat layer) for Resident 30 and a Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle) for Resident 24. Findings: A review of an admission record indicated Resident 30 was admitted to the facility in November 2016 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a MDS (Minimum Data Set, an assessment tool), dated 5/12/21, indicated Resident 30 was totally dependent on and required two or more staff for physical assistance. It also indicated Resident 30 did not have any skin ulcers and was receiving a pressure reducing device for a chair and bed; was in a turning/repositioning program; and required the application of nonsurgical dressings. A review of Resident 30's progress note, dated 6/13/21, indicated, Reopening of wounds [right] Mid Lateral [side] foot measuring 1x 0.5 and also [right] Dorsal [top of foot] Lateral [side] foot measuring 1.5 x 1.2 . A review of Resident 30's Surgical Wound Care Specialist's (WCS) progress notes dated 6/18/21and 6/25/21, indicated a recommendation for LAL (Low Air Loss) mattress. A review of Resident 30's care plan, revised 7/8/21, indicated, Resident has a Pressure Ulcer Stage 3 Right Dorsal Lateral Foot .Interventions/Tasks [for staff to implement] .Pressure reduction mattress to bed as indicated . A review of Resident 30's care plan, dated 7/8/21, indicated, Resident has a Pressure Ulcer Stage 3 Right Mid Lateral Foot . Interventions/Tasks [for staff to implement] .Pressure reduction mattress to bed as indicated . During an observation conducted on 7/29/21 at 8 a.m. with the Wound Care Nurse (WCN), Resident 30 did not have a pressure reducing mattress. In an interview with the WCN on 7/29/21 at 8:27 a.m., the WCN confirmed Resident 30 did not have a pressure reducing mattress. In an interview with the WCS on 7/30/21 at 11:45 a.m., the WCS stated a pressure reducing mattress would put resident at less risk for contracting pressure ulcers. The WCS further stated the use of LAL mattress depended on facility protocol. In an interview with the Director of Nursing (DON) on 7/30/21 at 12:06 p.m., the DON stated he was not sure of the policy for the indication of LAL mattress. The DON further stated he would find out and get back with the department. The facility was unable to provide a policy regarding the indication of pressure reducing mattress upon request. A review of a facility policy titled, Pressure Ulcers/Skin Breakdown - Prevention of, revised 4/18, indicated, .The physician will order pertinent wound treatment, including pressure reduction surfaces . A review of Resident 30's care plan, revised 6/14/21, indicated, Resident at risk for development of pressure ulcer/skin breakdown due to: 6/13/21 reopening of wounds on right mid lateral foot . Interventions/Tasks [for staff to implement] .Assist in turning and repositioning if needed . A review of Resident 30's document titled Turn and Reposition, dated June 2021, indicated multiple instances when Resident 30 was not turned and repositioned every 2 hours as scheduled. A review of Resident 30's care plan, dated 7/8/21, indicated, Resident has a Pressure Ulcer Stage 3 Right Mid Lateral Foot . Interventions/Tasks [for staff to implement] .Turn and reposition frequently as indicated . A review of Resident 30's care plan, revised 7/17/21, indicated, Presence of: Reopen [sic] Wounds 6/13/21 . right lateral dorsal foot . Interventions/Tasks . Re position resident [every 2 hours] and prn [as needed] as indicated . In an interview on 7/30/21 at 8:53 a.m., the WCN stated Resident 30 should be repositioned every 2 hours. The WCN confirmed the documentation did not reflect Resident 30 was turned and repositioned every 2 hours as scheduled. The WCN also confirmed turning and repositioning every 2 hours was in Resident 30's care plan. In an interview on 7/30/21 at 12:06 p.m., the DON stated turning and repositioning should be done every 2 hours. The DON confirmed the documentation did not show Resident 30 was being turned every 2 hours. The DON further stated, As the saying goes, 'If it's not documented, it's not done.' A review of a facility policy titled Care Plans, Comprehensive Person-Centered, revised 12/16, indicated, . The comprehensive, person-centered care plan will . Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . A review of a facility policy titled Repositioning, revised 5/13, indicated, . Residents who are in bed should be on at least an every two hour (q2 hour) repositioning schedule . For residents with a Stage I or above pressure ulcer, an every two hour (q2 hour) repositioning schedule is inadequate . 2. A review of Resident 24's Admission Record indicated she was initially admitted to the facility in November 2020 with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a MDS, dated [DATE], indicated Resident 24 had no memory problems. A review of a MDS, dated [DATE], indicated Resident 24 had no pressure ulcers. A review of a MDS, dated [DATE] and 7/17/21, indicated Resident 24 had a stage 4 pressure ulcer, that was not present at the time of admission. A review of Resident 24's Braden Scale (a tool to assess pressure sore risk), done upon admission on 11/2/20 and 5/7/21, reflected she was confined to bed and at moderate risk for developing pressure sores. A review of Resident 24's Turn and Reposition reports dated April 2021, May 2021, June 2021, and July 2021 indicated multiple instances of documentation that did not reflect turning and repositioning occurred every 2 hours. A review of the Wound Care Doctor's Progress Note for Resident 24, dated 5/7/21, did not identify the left hip pressure ulcer. A review of the Wound Care Doctor's Progress Note for Resident 24, dated 5/14/21, identified the unstageable left hip pressure ulcer. A review of the Weekly Wound Evaluation for Resident 24, dated 5/14/21, indicated, Resident seen live by Wound Care Doctor on 5/14/21 Resident noted with left hip unstageable, Size [measured in centimeters, a unit of measure] 2 x 2 x UTD [unable to determine] 100 % Eschar [dead tissue] Lt [light] drainage. No [signs or symptoms] of [infection]/[CONDITION(S)] [a bacterial infection of the skin] . A review of the Weekly Wound Evaluation for Resident 24, dated 6/11/21, indicated, Resident seen live by Wound Care Doctor on 6/11/21 .Stage 4 left hip pressure 4.5 x 6 x UTD 70 % slough [dead tissue] 30 % Gr. [granulating] w/ Lt drainage A review of the Wound Care Doctor's Progress Note for Resident 24, dated 6/18/21, indicated, left hip wound is the same but more [CONDITION(S)] [redness] and tenderness . A review of the Weekly Wound Evaluation for Resident 24, dated 6/25/21, indicated Resident seen live by Wound Care Doctor on 6/25/21 Deteriorating Stage 4 of left hip pressure 5 x 6 x UTD 60 % slough 40 % Gr. w/Lt drainage .Resident was recommended to be sent out [to the hospital] for higher treatment A review of the Wound Care Doctor's Progress Note for Resident 24, dated 6/25/21, indicated left hip wound continues to deteriorate, more [CONDITION(S)], more induration [a deep thickening of the skin from swelling], Also multiple ulcerations in periwound [tissue surrounding a wound]. I think she might benefit from a higher level of care A review of Skilled Nursing Facility Orders from the hospital indicated Resident 24 was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Weekly Wound Evaluation for Resident 24, dated 7/24/21, indicated Resident seen live by Wound Care Doctor on 7/23/21 .Improving Stage 4 left hip pressure ulcer 4 x 8.5 x 2.8 20 % slough 80% Gr. w/Lt drainage . A review of Resident 24's care plan, initiated on 7/17/21, indicated, The Resident has a Stage 4 pressure ulcer Interventions/Tasks [for staff to implement] .Administer Treatments as ordered and monitor for effectiveness .Follow facility policies /protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] In an interview on 7/29/21 at 7:45 a.m., the WCN confirmed Resident 24 had a pressure ulcer on her left hip. The WCN stated Resident 24 had been positioned on top of a tube feeding clamp and that was what caused the pressure ulcer. The WCN also stated Resident 24 had recently been sent to the hospital for signs of infection and surgical wound debridement. She stated the left hip wound now measures 4 x 8.5 x 2.8. In an interview on 7/29/21 at 10:33 a.m., the Medical Doctor (MD) reviewed Resident 24's stage 4 left hip pressure ulcer. He stated diabetes and obesity contributed to the development of the wound. He stated the pressure ulcer was caused by immobility because she does not mobilize. In a concurrent observation and joint interview on 7/29/21 at 11:00 a.m. with the WCN and Resident 24, the Department observed the wound during a dressing change with resident consent. The WCN removed the dressing and replaced it. Resident 24 stated the hip pressure ulcer was due to laying on tube feeding tubing for four hours. Resident 24 stated the wound started right away and then just got worse. Resident 24 exhibited pain during the dressing change as evidenced by moaning even though she had been premedicated with pain medicine prior to treatment. When asked by WCN if she wanted to take a break, Resident 24 said, Just finish. The WCN stated the wound is a stage 4. In an interview on 7/29/21 at 11:45 a.m. the DON stated he was not sure of the cause of Resident 24's pressure ulcer. In an interview on 7/30/21 at 10:00 a.m., the WCS stated he was told the left hip wound was caused by laying on the gastrostomy tube connector. It started as a small ulcer but enlarged due to body build and panniculus (dense layer of fatty tissue). He stated the blood supply is poor in fatty tissue. The WCS stated he did not see the wound on 5/7/21 when he saw her. The first time he saw left hip wound was on 5/14/21. The WCS further stated the left hip wound was concerning to him and that she may need to go to the operating room for debridement (removal of dead tissue). A review of a care plan for refusal of repositioning was initiated after Resident 24 had one episode of refusing to turn and reposition on 7/21/21. A record review of progress notes did not indicate any non-compliance with wound care prior to 7/21/21 and thereafter. A review of the facility policy titled Pressure Ulcers/Skin Breakdown-Prevention of, revised 4/18, indicated, .The staff will identify factors contributing or predisposing residents to skin breakdown .Current approaches should be reviewed for whether they remain pertinent to the resident/patient's medical conditions, are affected by factors influencing wound development or healing and the impact of specific treatment choices made by the resident/patient or a substitute decision-maker. A review of the facility policy titled Repositioning revised 5/2013, indicated, The purpose of this procedure is to prevent skin breakdown, promote circulation and provide pressure relief for residents .Repositioning is a common, effective prevention for preventing skin breakdown, promoting circulation, and providing pressure relief Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning Residents who are in bed should be on at least every two hour (q2 hour) repositioning schedule. For residents with a Stage 1 or above pressure ulcer, an every two (q2 hour) repositioning schedule is inadequate .

Based on observation, interview, and record review, the facility failed to establish and implement an effective screening process for all individuals entering the building, to prevent the introduction and spread of COVID-19 infection (a contagious respiratory and vascular disease caused by severe acute respiratory syndrome coronavirus) to 54 of 77 residents when the facility did not have designated screeners on the morning and night shifts to identify symptomatic individuals entering the building. The facility's current screening tool, used for identifying symptomatic (having symptoms of COVID-19) individuals, did not contain all current signs and symptoms of COVID-19 per Centers for Disease Control (CDC) guidelines, staff were unaware of the required use of Personal Protective Equipment (PPE-is protective clothing, goggles, gloves to protect the wearer from exposure to infections) on the Yellow Zone (residents who have been exposed and have an unknown COVID-19 status are quarantined in this area) to prevent cross-contamination of residents who were negative for COVID-19 in the facility. These failures resulted in an increased potential for introduction and spread of COVID-19 into the building due to ineffective identification of individuals with potential symptoms of COVID-19 which had the potential to result in serious harm or possible death as a result of possible exposure to COVID-19 for 54 of 77 residents in the facility. Based on the above failure, an Immediate Jeopardy (IJ) was called on [DATE] at 10:24 p.m. On [DATE] at 10:24 p.m., the Administrator (ADM) and the Director of Nursing (DON) were informed of the IJ situation which had the potential to result in serious infection or death when facility staff performed self-screenings of themselves with an incomplete COVID-19 screening tool, staff were not using PPE according to the CDC guidelines, and staff were not understanding the requirements for the use of PPE in the Yellow Zone to prevent cross-contamination. These failures placed 54 of 77 residents in serious jeopardy due to the increased potential of transmitting COVID-19 to non-infected residents. The Administrator presented a Plan of Correction (POC) on [DATE] at 1:51 p.m. which was accepted by the Department. In an interview with the ADM and the DON on [DATE] at 1:51 p.m., the DON stated the facility will follow the POC immediately, which included assigning trained staff as screeners upon entry on each shift to actively screen individuals entering the building; completion and implementation of a revised screening tool with current signs and symptoms of COVID-19 per CDC guidelines, providing a plan for scheduled in-services to all staff on each shift regarding implementation of screeners and the use of the current CDC screening tool, and to provide in-service training of proper use of the PPE for the Yellow Zone with all staff on each shift. The ADM and DON were informed the immediacy of the IJ had been removed on [DATE] at 1:51 p.m. by the Department's surveyor who remained onsite during the IJ and confirmed the IJ was removed onsite. Findings: Review of the facility's COVID-19 Mitigation Attestation, signed by the ADM and dated [DATE] indicated, The (facility) screens and documents every individual entering the facility (including staff) for COVID-19 symptoms. Proper screening includes temperature checks . Upon entrance to the facility on [DATE] at 6:18 a.m., the facility was noted to have a census of 77 as confirmed by interview of the DON. The DON confirmed the facility had 23 COVID-19 positive residents, 6 COVID-19 positive residents who expired, and 54 residents with an unknown COVID-19 status in the Yellow Zone. Review of the facility's COVID-19 screening tool titled Daily Staff Screening Form, dated [DATE], indicated Staff Name .Temp (temperature) .Difficulty Breathing .New Cough .Sore Throat .Chills .New loss of taste or smell . The document did not cover the current CDC screening questions to assess staff for COVID symptoms upon entering the facility. An observation of the employees entering in the front door of the facility located near the admissions office was conducted on [DATE] at 6:18 a.m. The screening table was observed with papers scattered over the top and a pile of soiled hand wipes on top of the table to the right of the scattered papers. There was no hand sanitizer on the table and no disinfecting wipes available to clean the table being used by employees entering the facility at the change of shift. An observation was made on [DATE] at 6:20 a.m. of staff walking in the hallway with full PPE on, including gowns, masks, and shields. There was no observations of staff donning or doffing their PPE when entering or exiting resident rooms. In a concurrent interview with the Licensed Nurse 2 (LN 2), the LN 2 stated she was told it was ok to wear PPE on the Yellow Zone. The LN 2 confirmed the hallway behind the screen desk was considered the Yellow Zone. An observation and concurrent interview regarding the facility's screening process was conducted on [DATE] at 6:28 a.m. with the Licensed Nurse 1 (LN 1). The LN 1 performed the screening process on the Department's surveyor by taking the temperature and asking about signs and symptoms of COVID-19 per the facility screening tool. The LN 1 asked the surveyor if there were any symptoms, then the LN 1 stated she was not an assigned screener. There were no specific questions asked to provide comprehensive symptom screening for COVID-19, following the current CDC guidelines. During a subsequent observation on [DATE] at 6:32 a.m., a day shift staff was observed entering the facility with no mask on. The staff applied a mask at the time he entered the facility at the screening desk. The staff signed in on the screening sheet and entered without checking a temperature. The DON confirmed there were times when the staff entered without a mask and applied the mask at the time of entry at the screening desk. On [DATE] at 6:41 a.m. an observation was made of Licensed Nurse 2 (LN 2). The LN 2 was wearing a surgical mask under the N95 mask. (The N95 mask cannot seal against the face for adequate protection when there is a barrier on the face under the N95 mask). A concurrent interview was conducted with the LN 2. The LN 2 confirmed she was wearing the PPE incorrectly on the Yellow Zone in the facility. An observation of the medication nurse, LN 3, was made on [DATE] at 6:46 a.m. The LN 3 was wearing a N95 mask with a large black smudge over the front of the mask. The LN 3 confirmed the mask was soiled and should be changed. In an interview with the LN 2 (Charge Nurse for the night shift) on [DATE] at 7 a.m., the LN 2 stated employees enter through the front entrance and self-screen (staff screen themselves for signs and symptoms of COVID-19 and take their own temperatures) for symptoms of COVID-19. The LN 2 further stated the process was to enter through the front entrance, sign in at the screening table and screen themselves. In an interview with the LN 3 on [DATE] at 7:05 a.m., the LN 3 stated employees enter through the front entrance and self-screen by signing in and taking their own temperature. The LN 3 stated a staff person was assigned to the screening desk at 7 a.m. The LN 3 further confirmed there was no staff to provide staff screening between 6 a.m. and 7 a.m. In an observation and concurrent interview with the Certified Nursing Assistant 1 (CNA 1) (working on the day shift) on [DATE] at 8:03 a.m., the CNA 1 was observed entering a resident room on the Yellow Zone. The CNA 1 had no PPE on prior to entering the room. The CNA 1 confirmed she had not donned (applied or put on) PPE prior to entering the resident's room. The CNA 1 further stated she didn't think she had to don the PPE for the Yellow Zone. There was no signage observed to identify the Yellow Zone. In an observation and concurrent interview on [DATE] at 8:22 a.m. with the CNA 2, the CNA 2 was exiting a resident room on the Yellow Zone. The CNA 2 was doffing (removing) her PPE and holding the gown close to her body outside of the resident's room, in the hallway. The CNA 2 then placed the soiled PPE on top of the clean boxes of gloves sitting on top of the cart with clean PPE stored. The CNA 2 stated she didn't recognize the cross contamination on the Yellow Zone. There was no hand hygiene noted after the PPE doffing by the CNA 2. The CNA 2 confirmed she had not washed her hands or used hand sanitizer after doffing the PPE. Review of a facility policy dated [DATE] and titled, Coronavirus Disease (COVID-19)- Identification and Management of Ill Residents indicated, Clinical Care: .Screening and Monitoring: The Infection Preventionist (IP)is responsible for establishing and overseeing the active screening and monitoring efforts .Staff caring for residents with suspected or confirmed COVID-19 must strictly adhere to infection prevention and control practices outlined in Coronavirus Disease (COVID-19)-Infection Prevention and Control Measures . A review of the CDC guidelines titled, COVID-19 & IPC (Infection Prevention and Control in non-US Healthcare Settings updated [DATE], https://www.cdc.gov/coronavirus/2019-ncov/hcp/non-us-settings/guidance-identify-hcw-patients.html indicated, .facilities should define a standardized set of signs and symptoms (e.g., fever and/or cough/shortness of breath) to screen healthcare workers and patients for suspected COVID-19. A high level of suspicion is critical to ensure cases do not go unrecognized due to a substantial proportion of patients and healthcare workers presenting with atypical or minimal symptoms .watch for symptoms .fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting (and) diarrhea . In an interview with the ADM and the DON on [DATE] at 12 p.m., the DON confirmed the screening tool did not have all the current signs and symptoms of COVID-19. The DON further stated the tool would be modified. An interview was conducted with the DON on [DATE] at 12:25 p.m. The DON confirmed there was no one assigned to be the PPE coach to monitor the proper use of the PPE throughout the facility or in the Yellow Zone. Review of a facility policy revised [DATE] and titled, Personal Protective Equipment indicated, Personal protective equipment appropriate to specific task requirements is available at all times . PPE required for transmission-based precautions is maintained outside and inside the resident's room, as needed . Training on proper donning, use and disposal of PPE is provided upon orientation and at regular intervals . Employees who fail to use personal protective equipment when indicated may be disciplined in accordance with personnel policies .

Based on observation, interview, document and facility policy review, the facility failed to provide care and services to prevent the development of pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure on the skin) for 2 residents (Resident 22 and Resident 81) for a census of 89 when: 1. The facility failed to revise a care plan with interventions to prevent further skin breakdown once excoriation (an abrasive or tearing injury to the surface of the skin) was noted to the back of Resident 22's neck on 1/16/20. The facility failed to monitor and assess for further skin breakdown on Resident 22's neck from 1/16/20 until identified as a Stage III (full thickness wound) on [DATE]; and 2. The facility failed to revise a care plan with interventions for Resident 81 when the treatment to the coccyx was ineffective and the order was changed by the Physician on 6/2/19. The facility failed to continually assess and monitor the excoriation to the coccyx (tailbone area) from 6/2/19 to 1/6/20. These failures resulted in Resident 22 developing an avoidable Stage III pressure ulcer to the back of the neck where the [MEDICAL CONDITION] (tube surgically inserted into the trachea (windpipe) to supply oxygen directly into the airway) strap was wrapped to maintain the position of the [MEDICAL CONDITION] and Resident 81's excoriation area worsening to a Stage III pressure ulcer to the coccyx. Findings: 1. Record review revealed that Resident 22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a facility document dated 5/4/18 and titled, Braden Scale for Predicting Pressure Sore Risk, indicated a Score of 13, (13-14=Moderate Risk for skin breakdown). Review of a physician's orders [REDACTED]. DO NOT allow ventilator tubing to hang on pt's (patient/resident) chest. Please prop tubing using a towel roll. There was no documented evidence in the clinical record of implementation of the 5/4/18 physician's orders [REDACTED].>Review of Resident 22's Minimum Data Set (MDS-an assessment tool) dated 11/20/19 indicated, no pressure ulcers or skin breakdown. Resident 22 was assessed as at risk for pressure ulcers and required total staff assistance with all care needs. Review of Care Plans initiated 8/20/19 (one year and 3 months after admission to the facility) for Resident 22 indicated, .Requires full assistance with all mobility, transfers and positioning.Potential for altered skin integrity.Interventions: Monitor skin of the neck area for redness and discoloration every shift and PRN (as needed). Document and report changes in skin integrity.inform MD (Medical Doctor) timely. Further review of Care Plans for Resident 22 initiated 8/20/19 indicated, Self care deficit.unable to maintain self neat, clean, and odor free. Interventions: Showers twice a week, provide full assistance with all ADL (activities of daily living) care maintain neat, clean, and odor free. Full assistance with transfers per use of sling.Full assist bed mobility and repositioning to relieve pressure, offload skin and provide comfort. Record review of a Skin Integrity Care Plan for Resident 22, initiated on 8/20/19 (one year and 3 months after the physician's orders [REDACTED].risk for skin issues related to score of 13 on the Braden scale. Interventions: Assess skin status for change in appearance, new redness, pressure wounds.record and report to MD timely all changes. Review of a Care Plan initiated 11/21/19 indicated, High risk for breakdown due to thin frame and low weight. Patient is fully dependent, does not move limbs due to ALS, high risk for breakdown with thin frame, fragile skin and comorbidities. Monitor skin for all changes, document and report to MD timely. Review of a Care Plan initiated 1/16/20 indicated, .[MEDICAL CONDITION] and is prone to: Neck area excoriation. There were no documented interventions for the focus/identified risk of neck excoriation care plan for Resident 22. There was no documented evidence of the implementation of nursing assessments or monitoring of the skin (neck area) in Resident 22's clinical record. Review of a physician's orders [REDACTED]. Notify MD (Medical Doctor) for significant changes. There was no documented evidence in the clinical record of a Nurse's Progress Note, Physician's Progress Note, or any licensed professional addressing the full thickness, Stage III pressure ulcer to the back of Resident 22's neck where the strap was positioned to hold [MEDICAL CONDITION] position prior to the [DATE] physician's orders [REDACTED].>Review of a physician's orders [REDACTED]. Review of a Skin Integrity Care Plan for Resident 22 revised on 2/20/20 (after a full thickness wound-Stage III was identified to the posterior neck on [DATE]), indicated, Potential for impaired skin integrity and breakdown.risk for skin issues related to score of 13 on the Braden scale. Interventions: Assess skin status for change in appearance, new redness, pressure wounds.record and report to MD timely all changes. An interview was conducted on 2/26/20 at 11:50 a.m. with the Director of Nursing (DON). The DON confirmed he could not find the care plan for Resident 22 regarding the physician's orders [REDACTED]. On 2/26/20 at 1 p.m. an interview was conducted with the Wound Medical Doctor (WMD) and the WMD Supervisor (WMDS). The WMD and the WMDS confirmed the Stage III pressure ulcer on the back of the neck from [MEDICAL CONDITION] (a medical device) used for Resident 22 was an avoidable pressure ulcer acquired in the facility. Review of an undated wound photo in Resident 22's clinical record identified a Stage III pressure ulcer to the back of the neck just below the hair line with redness and swelling around the top of the wound. The wound measured approximately 3-1/2 inches in length and 1/2 inch in width, with possible depth to the wound (unable to measure with photo only). Based on interview of staff and record review, Resident 22 was in the hospital for a surgical consult of the wound and treatment during the survey process and no direct observation was obtained. Review of a facility policy revised July 2017 and titled Prevention of Pressure Ulcers/Injuries, indicated, .Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable.Conduct a comprehensive skin assessment upon admission, including: Areas of impaired circulation due to pressure from positioning or medical devices.Inspect the skin on a daily basis when performing or assisting with personal care or ADLs (Activities of Daily Living). 2. Record review revealed Resident 81 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed the Annual MDS assessment dated [DATE] indicated Resident 81 was rarely/never understood, had short term and long term memory problems. Resident 81 was totally dependent on staff with all Activities of Daily Living with one or two person assistance. Resident 81 was assessed as always incontinent (loss of bladder or bowel control). This MDS indicated under Skin Conditions a Yes for the question, Is this resident at risk of developing pressure ulcers/injuries? Review of a facility document titled Braden Scale for Predicting Pressure Sore Risk dated 8/3/19, [DATE], and 1/31/20 indicated a score of 11 (10-12 is considered High Risk for developing a pressure sore/ulcer). The assessment further indicated the following: skin is often very moist,.chairfast,.completely immobile,.nutrition adequate.Friction and shear were a problem: requires moderate to maximum assistance in moving.Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Review of Resident 81's physician's orders [REDACTED]. - On 2/9/19, an order for [REDACTED]. - On 6/2/19, an order for [REDACTED]. - On [DATE], an order for [REDACTED]. - On 1/19/20, an order for [REDACTED]. Review of Resident 81's Skin/Wound Note dated 6/2/2019 indicated, wound revaluation (sic) to excoriation to the coccyx, because no improvement noticed from previous treatment. MD notified and new treatment order receive (sic) and carried out. husband (sic) at the bedside and he is informed of the change. There was no documented evidence of any changes made in Resident 81's treatment order after 6/2/19 and prior to [DATE]. There was no Skin/Wound Note conducted for Resident 81 from the time the treatment order was changed on 6/2/19 and prior to the excoriation progressing to Stage III on [DATE]. Review of Resident 81's Nursing Progress Notes from 6/2/19 to 1/6/20 did not include documentation and/or monitoring of Resident 81's excoriation to the coccyx area. Record review of a Skin/Wound Note dated 1/7/20 for Resident 81 indicated, Noted preexisting Excoriation to coccyx skin damage is getting worse and is extending to both buttocks, and become MASD (Moisture Associated Skin Damage- erosion caused by prolonged exposure to moisture such as urine and/or stool). CNA's (Certified Nurse Assistants) reported that pt is a heavy wetter from both urine and stool and pt is up in reclining w/c (wheelchair) almost every day and for more than 2 hours, challenging to turn, change and offload pt while in w/c.MD (medical doctor) was in the facility and notified of the above skin issue and gave order to have wound eval from Wound MD. RP (responsible party), husband informed. Record review of a Skin Wound Note dated [DATE] indicated, Pt was being seen by Wound MD for coccyx wound, RP husband was at bedside.educated the importance of staying in bed to keep wound clean and dry.Wound MD also educated to Husband (sic) about considering having a (urinary) cath (sterile tube that is inserted into the bladder to drain urine) to control bladder incontinent (sic) and explained the risk for bladder infection vs (versus) benefit for bladder controlled (sic) to promote in wound healing. RP husband stated that wound (sic) be the last resort and he would be thinking about it and will let us know in future. Record review of a Surgical Consult Note dated 1/9/20 described the wound on the coccyx as follows: - Pressure Injury/ulcer; - EXUDATE (drainage, a liquid produced by the body in response to tissue damage): Moderate, Serous; - PERIWOUND: [DIAGNOSES REDACTED]tous (redness), Excoriated, Macerated (prolonged exposure to moisture), Unhealthy, Raw, Moisture Associated Skin Damage; - WOUND EDGE: [DIAGNOSES REDACTED]tous, Macerated; - TISSUE TYPES BY PERCENTAGE: 20% slough (necrotic tissue that needs to be removed from the wound for healing to take place), [AGE]% granulation (development of new tissue); - the size of the wound was documented as 5.0 cm x 2.5 cm x 0.2 cm; - The Assessment and Plan included information such as: .The wound is stable and requires continued topical wound dressing therapy.Patient needs to be kept clean and dry, needs barrier protection with [MED] (ointment used to treat minor skin irritation), or similar, and collagen with alginate. Frequent repositioning also essential. Patient's husband also provided wound care education.continue offloading: turn per facility protocol. Record review revealed a Skin Wound Note dated [DATE] indicated, .received final wound MD eval report from wound MD and new order received to coccyx wound. Previous Wound was called excoriated to coccyx and now wound MD called the wound is Stage III to coccyx. A concurrent interview and record review with the Director of Staff Development (DSD) was conducted on 2/20/20 at 11:14 a.m. The DSD confirmed the wound on Resident 81's coccyx area was facility acquired, the affected area started off as a Moisture Associated Skin Damage (MASD, skin erosion caused by prolonged exposure to moisture such as urine, stool, or sweat) and it progressed to Stage III on 1/9/20. The DSD further confirmed Resident 81 had no significant change in condition from June 2019 to December 2019. A concurrent observation and interview was conducted with the Wound Nurse 2 (WN 2) on 2/20/20 at 1:37 p.m. The WN 2 stated the wound on Resident 81's coccyx was the same as yesterday, no change noted. The WN 2 described the wound bed with adipose (fat) tissue. The WN 2 further stated the WMD performed a debridement on Resident 81's coccyx wound on [DATE]. A review of the Surgical Consult Note dated [DATE] indicated, .PREOPERATIVE INDICATIONS: Slough from chronic wound inflammation.ASSESSMENT AND PLAN:.The wound debrided today was at the coccyx. For this wound, there was confirmation of tissue deterioration necessitating continuing care and will likely need future debridement (removal of damaged tissue). In a follow-up interview with the DSD on [DATE] at 11:35 a.m. The DSD stated when a resident has excoriations, there should be daily monitoring of the affected area by licensed nurses when the treatment is provided. Review of Resident 81's Care Plan indicated the following: -On 3/22/19, a Care Plan for Potential for impaired skin integrity related to incontinence of bowel and bladder. The interventions included to: .check and change every 2 hours and as needed for incontinent care. Assess, record and report to MD timely all changes in skin integrity and appearance changes. -On 1/17/20, a Care Plan for Actual skin impairment AEB (as evidenced by) stage III PI (pressure injury) to coccyx area. The interventions included to: Wound Round with Wound MD weekly.Turn and reposition resident q (every) 2 hours and PRN (as needed). - On 1/29/20, a Care Plan for Presents with contractures of BUE (bilateral upper extremities) and BLE (bilateral lower extremities) with risk for impaired positioning due to contractures.RP desire to have patient out of bed for longer than 2 hours with risk of worsening wounds. RP refuses for facility staff to place foley catheter. There was no documented evidence Resident 81's Care Plan was revised on 6/2/19 when the treatment to the coccyx area was not effective and the order was changed by the Physician. There was no documented evidence of a Surgical Consult Note from 2/1/2020 to 2/18/2020. There was no documented evidence in the Nursing Progress Notes from 6/19 to 12/19 of Resident 81's being up in w/c for an extended period of time. The Progress Notes on 11/23/19, 11/25/19, [DATE], 11/30/19, 12/2/19, [DATE], 12/30/19, 1/1/2020, and 1/2/2020, indicated up in w/c. There was no specific amount of time indicated for the duration of Resident 81 being up in w/c for these days. There was no documented evidence in Resident 81's clinical records of the RP being informed of the risk for further skin breakdown if Resident 81 was up in wheelchair for extended period of time from 6/19 to 12/19. Record review of an Interdisciplinary Team (IDT) Note for Resident 81dated 1/21/20 indicated in part, .education: RP husband aware about pt's (patient's) skin condition and current treatment in place, care team aware about pt skin condition. seen (sic) by wound MD weekly, education provided to CNA (certified nursing assistant) on pt care. There was no IDT Note for Resident 81 after 6/2/19 when it was identified there was no improvement from the previous treatment and a new treatment order was obtained on the excoriation to the coccyx area. In a concurrent interview and record review conducted with the Assistant Director of Nursing (ADON) on 2/26/20 at 11:25 a.m., the ADON reviewed Resident 81's Physician's Progress Notes from 2/10/19 to [DATE]. The ADON confirmed the Physician did not have documentation of Resident 81's excoriation and/or the pressure wound on the coccyx. The ADON further stated the Physician wrote under skin assessment As in nursing assessment and the ADON was unable to explain the meaning of this statement. In an interview with the WMDS and the WMD on 2/26/20 at 1 p.m. The WMDS and the WMD confirmed there was no wound physician available in the facility from 2/1/2020 to 2/18/2020. The WMD stated she only observed Resident 81's wound on the coccyx one time since she started as a WMD in the facility. The WMD further stated she truly understands the question raised on why Resident 81 developed the Stage III pressure ulcer from an excoriation. A facility policy revised July 2017 and titled, Prevention of Pressure Ulcers/Injuries indicated, .Inspect the skin on a daily basis when performing or assisting with personal care or ADLs.Identify any signs of developing pressure injuries.Inspect pressure points (.coccyx.). Wash the skin after any episodes of incontinence. reposition resident as indicated on the care plan.

Based on observation, resident and staff interview, clinical record review, and facility policy review, the facility failed to provide a safe environment and adequate supervision to prevent accident hazards for 1 of 18 sampled residents (11), and 1 random resident (RR # 29) out of a census of 89 when: 1. Random Resident 29, who required continuous oxygen, was not assessed for smoking safety and was not supervised when cigarettes and lighter were being kept at the bedside along with an oxygen tank and an oxygen concentrator; 2. Resident 11, was not assessed for smoking safety, was observed smoking in the designated smoking area with no staff supervision and with burn holes in their clothing; and On 12/2/15, at 5:35 p.m., the Department made the determination of Immediate Jeopardy related to the facility's failure to provide adequate supervision during smoking and for allowing a resident to keep cigarettes and lighter at the bedside. The Department met with the Administrator, the Director of Nursing, the Quality Assurance Nurse, the Director of Staff Development, and the Social Services Manager, to advise of the Immediate Jeopardy. Random Resident 29 was identified as being at immediate risk for serious harm due to presence of cigarettes and lighter at the bedside while on continuous oxygen. Resident 11 was also identified as being at immediate risk for serious harm due to unsupervised smoking with no smoking apron and with burn holes in their clothing. The Immediacy was removed on 12/2/15, at 7:25 p.m., after submission and implementation of an immediate plan of correction which included removal of cigarette lighter from Random Resident 29, assigning one staff member each shift to supervise residents during smoking, performing a smoking safety assessment on residents who smoke, and inservice education of staff on the smoking policy and procedure. The Immediate Jeopardy was abated on 12/3/15, at 3:30 p.m., after all staff had received inservice education on the smoking policy and procedure. This failure had the potential for serious harm and/or death to Random Resident 29 and Resident 11 related to burns, and had the potential for serious harm and death to all residents, staff, and visitors due to fire if a cigarette lighter or a lit cigarette had been used near an oxygen source. Findings: 1. Random Resident 29 was admitted to the facility with multiple [DIAGNOSES REDACTED]. Random Resident 29 was alert and was able to communicate. During a review of the clinical record for Random Resident 29, the Smoking Contract and Consent, signed by the resident's conservator and witnessed by a staff member on 4/27/10, indicated, .By signing below, resident or representative .Consents and agrees to abide by the facility Smoking Policy . A copy of the facility's Smoking Policy was attached to the smoking contract. The Smoking Contract and Consent did not address if the resident was safe to smoke on their own. There was no smoking safety assessment documentation found in the clinical record. During an interview with the Social Services Manager (SSM) on 12/2/15, at 10:08 a.m., she reviewed the clinical record and was unable to find documentation of a smoking safety assessment. She stated residents who wished to smoke had to sign the Smoking Contract and Consent. She was not aware of any smoking safety assessment. During an interview with the Quality Assurance Nurse (QAN) on 12/2/15, at 11:35 a.m., she explained residents who were independent with smoking will have the Smoking Contract and Consent in their clinical record. Random Resident 29 did not have a smoking safety assessment because (Random Resident 29's) conservator said (they) may smoke on (their) own. During an interview with the Director of Nursing (DON) on 12/2/15, at 4:10 p.m., she said, We control their (residents') cigarettes and lighter. No lighter, no matches (are kept) in the room. The DON indicated the SSM kept the cigarettes, lighter, and matches. During a second interview with the SSM on 12/2/15, at 4:30 p.m., she stated Random Resident 29 kept their cigarettes and lighter at the bedside. During subsequent observations and interviews with Random Resident 29 on 12/2/15, at 4:35 p.m. and at 5:30 p.m., they had their nasal cannula on that was connected to an oxygen concentrator, and was receiving continuous oxygen. There was also a full portable oxygen tank at the bedside. Random Resident 29 said, I smoke five times a day. I keep my cigarettes and lighter while they showed their cigarettes and lighter being kept at the bedside. 2. Resident 11 was admitted to the facility with multiple [DIAGNOSES REDACTED]. Resident 11 was alert, was able to communicate, and used a wheelchair to move around the facility. During an observation on 12/1/15, at 9:20 a.m., Resident 11 was observed smoking in the designated smoking area with no staff supervision and with ashes on their shirt. Resident 11 did not have a smoking apron on. During a review of the clinical record for Resident 11, smoking safety assessment documentation was not found. During an interview with Licensed Nurse 1 (LN 1) on 12/2/15, at 9:40 a.m., she said, (Resident 11) smokes on (their) own and does not keep (their) cigarettes or lighter. She stated cigarettes were given to Resident 11 by staff and staff usually left after lighting their cigarette. LN 1 verified Resident 11 did not use a smoking apron when smoking and she was aware of burn holes in Resident 11's clothing. During an interview with the SSM on 12/2/15, at 10:08 a.m., she reviewed the clinical record and was unable to find documentation of a smoking safety assessment. She stated smoking assessments were done upon admission and Resident 11 did not smoke when they first came in. SSM provided a blank copy of the Smoking Contract and Consent with the facility's Smoking Policy attached. She said, No other assessment was done aside from this (Smoking Contract and Consent). The SSM verified she was aware of the burn holes in Resident 11's clothing. During an interview with the QAN on 12/2/15, at 11:35 a.m., she stated there was no other smoking assessment done aside from the Smoking Contract and Consent. She said, If not smoking on their own, a resident will not have a 'Smoking Contract and Consent' in their record. QAN added, Dietary staff monitors and supervises (Resident 11) when smoking. (LN 1) usually smokes with (them) outside. During an interview with Resident 11 on 12/2/15, at 9:50 a.m., Resident 11 said, I smoke on my own. When I smoke, they light it outside. They keep the cigarettes and lighter. Resident 11 stated the burn holes in their shirt were old. During an observation on 12/2/15 at 4:40 p.m., there was no smoking apron, no fire blanket, and no fire extinguisher found in the designated smoking area. During an interview with the Director of Nursing (DON) on 12/2/15, at 4:10 p.m., the DON ascertained the interdisciplinary team assessed residents if safe to smoke on their own and smoking was discussed upon admission. She reviewed the clinical record for Random Resident 29 and for Resident 11, and was unable to find documentation of a smoking safety assessment. She said, I haven't seen a safety assessment form. She confirmed residents who smoked independently signed a Smoking Contract and Consent attached to the facility's Smoking Policy, just like the one in Random Resident 29's clinical record. The undated facility policy titled Smoking Policy indicated, .In order to protect the lives and safety of all residents, we require that residents requesting smoking privileges be assessed upon admission, and periodically thereafter, regarding their risk/safety level .In no case will a resident be allowed to keep matches, lighters, or other smoking articles on their person, in their room, or anywhere on the facility property .

Based on observation, staff interviews, and documents review, the facility failed to maintain the highest practicable physical, mental, and psychosocial well-beings of one of 18 sampled residents (#8), and two random residents (RR#25, and RR#32) with a resident census of 89, when: 1a. Random Resident (RR) 25 was not properly assessed and intervened in timely manner when she fell , which resulted in ineffective treatment for [REDACTED]. 1b. Resident 8's pain management was not evaluated effectively. These two failures caused physical and mental anguish to the residents and affected their activities of daily living. 2. A Licensed Nurse failed to suction RR 32's airway, who was dependent on a ventilator machine for breathing. This failure had the potential to adversely affect the resident's respiratory status. Findings: 1a. RR 25 was admitted to the facility with multiple [DIAGNOSES REDACTED]. On 11/28/15, RR 25 had a fall incident and was sent to the acute care hospital on [DATE] for a right [MEDICAL CONDITION] (break). A surgery was performed on 12/1/15 to repair the fracture and on 12/9/15 the resident was returned to the facility. During an observation of medication administration on 11/30/15 at 8 a.m., Licensed Nurse (LN) 2 was observed administering a [MEDICATION NAME] (a narcotic pain medication) to RR 25 along with her other medications. RR 25 was observed lying on her left side holding on to the bed rail. RR 25's breakfast tray was placed on the left side of her bed. RR 25 stated that she did not want to eat her breakfast. During an interview with a Licensed Nurse (LN 7) on 12/2/15 at 10 a.m., she acknowledged that she was the nurse who took care of RR 25 when she started to complain of pain to her right lower extremity. She stated RR 25 was able to perform independently by herself from bed to wheelchair or to a bedside commode. However, on 11/28/15, LN 7 stated that RR 25 complained of right knee pain and she could not stand up on her own. When LN 7 asked RR 25 the reason RR 25 could not stand up on her own, RR 25 told her that she slid and put herself to the nearest bedside commode. LN 7 was then asked what other activities RR 25 was involved in prior to informing her that she could not stand up on her own. LN 7 stated that she was taken to the facility's gym for a therapeutic exercise the morning of 11/28/15. An interview with the Occupational Therapist (OT) was conducted on 12/2/15 at 10:15 a.m. She was questioned regarding RR 25's therapy program. She reviewed RR 25's file and stated that the resident was on a restorative program five days a week, and the expected goals for RR 25 to perform were omnicycle (stationary bicycle) exercise for 10 to 15 minutes and about 25 steps ambulation with a walker. During an interview with the CNA (CNA 1) on 12/2/15 at 10:45 a.m., she was questioned about RR 25's care needs. She stated that she worked as an RNA (Restorative Nursing Assistant) on 11/28/15. She stated RR 25 usually performed omnicycle exercise and ambulation with a walker. In the morning of 11/28/15, she took RR 25 to the facility's gym for the therapeutic exercises. CNA 1 stated the resident performed about 10 minutes of omnicycle exercise and ambulated 2 to 3 steps only with a walker and did not want to do it again. CNA 1 stated that the resident said to her, My legs hurt and I cannot walk anymore. CNA 1 stated that she took the resident back to her room and informed a nurse. A review of the nurse's notes revealed the following: > On 11/28/15 at 3 p.m.: Resident (went) to (her) room from activities (complained of) pain (to her right) knee and (could not) stand (on her) right leg. Resident (said) that before she (tried) to transfer (her)self to (wheelchair) from bed, she lost her balance and she started to slide out. She put (her)self on bedside commode and (felt) a pain (to her right) leg, (could) not stand on (her right) foot, ., very painful when move (right) leg, MD .notified . > On 11/28/15 at 3:15 p.m.: MD order received x-ray for (right) knee today . A review of the result of the right knee x-ray, taken on 11/28/15, did not reveal any fractures to the knee. However, RR 25 continued to complain of pain to the right lower extremity. A review of the Medication Administration Record [REDACTED]. Aleve Tablet 220 MG (milligram, a unit of measurement), give 1 tablet by mouth every 6 hours as needed for pain in feet or ankles. b. [MEDICATION NAME] Tablet 500 MG, give 1 tablet one time a day for leg pain (related to) [MEDICAL CONDITION]. c. [MEDICATION NAME] Tablet 500 MG, give 1 tablet by mouth every 4 hours as needed for mild pain scale 1-3 (out of 10 where 10 being the worst pain). The November, 2015 MAR indicated [REDACTED]for knee pain. LN 7 documented that the resident rated the pain as 6 out of 10 and was reassessed at 2:30 p.m. and the resident still has pain. During an interview with another Licensed Nurse (LN 8) on 12/2/15 at 4:25 p.m., she stated that she was the nurse who was assigned to take care of RR 25 on the evening shift of 11/28/15. When she was asked how RR 25 was when she took over the care from the day shift nurse, she stated, My main worry about the resident that night was her pain. Any touch to the knee she would holler .She was lying in bed and continued to complain of pain, from the knee down, even after the extra strength ([MEDICATION NAME]) given. That night she could not tolerate the turning or having the bed pan placed under her. LN 8 stated that the resident could not tolerate raising the head of the bed and preferred to be in a flat position. When LN 8 was asked to describe RR 25's emotional state that particular night, she said, (RR 25) was kind of dependent. She stated that the resident kept on telling her to stay with me. LN 8 said, She was frightened of not knowing why she was in pain. LN 8 stated that she stayed in RR 25's room most of her evening shift and provided reassurance to the resident. A review of LN 8's written documentation at the nurse's notes did not reflect what she stated during the interview (above). LN 8 wrote that on 11/28/15 at 5:24 p.m., X-ray results received. MD notified and (made)aware of results. Resident continues to (complain of) pain .No (new order) for pain medication received . A review of the November, 2015 MAR for the evening shift revealed the following: > 11/28/15 at 3:30 p.m.: [MEDICATION NAME] 500 mg given for knee pain. The resident rated the pain as (10 out of 10). The record indicated that the resident was re-assessed and the resident's pain level was at (8 out of 10). > 11/28/15 at 9 p.m.: [MEDICATION NAME] 500 mg given for knee pain of (10 out of 10) A re-assessment was performed and the resident's pain level was at (9 out of 10). LN 8 was interviewed again on 12/2/15 at 5:30 p.m. to provide clarification regarding her documentation that she wrote on 11/28/15 at 5:24 p.m. She was asked if she notified the physician again when the resident did not get any relief from the [MEDICATION NAME] 500 mg. She said, No, I did not. She was asked what the physician said when she informed him of the right knee x-ray result. LN 8 said, He just said thank you. She was asked if she informed any of her supervisors regarding the resident's condition. She said, Who would I talk to? When clarified if she sought any advice from a registered nurse (RN), LN 8 said, The RN at (the other unit) does not manage this unit. I was the charge nurse that night. I am in charge of this unit. An interview with a Medical Doctor (MD) was conducted on 12/2/15 at 1:15 p.m. He was asked regarding RR 25's physical condition. He stated that he did not see or examine RR 25 when he was made aware that the resident fell . He said, I didn't think there was a problem until I got another call. RR 25's clinical record indicated on the nurse's notes that the second time the physician was notified was on 11/29/15 at 1 p.m. A review of RR 25's clinical record revealed that pain to her right lower extremity was affecting her food intake and performing some of her activities of daily living independently. RR's clinical record indicated a record of the resident's percentage meal intake. The record showed a fluctuation of RR 25's meal intake for the 3 meals, from 11/17/15 to 12/1/15. However, starting the evening shift on 11/28/15, the record indicated that RR 25 refused or had minimal meal intake in all three shifts. The following documentation for RR 25's intake of meals were as followed:> 11/28/15 meal intake for dinner: 45%; > 11/29/15 meal intake for dinner: 30%;> 11/30/15 meal intake for breakfast: Refused; > 11/30/15 meal intake for lunch: 50%; > 11/30/15 meal intake for dinner: 15%; > 12/1/15 meal intake for breakfast: Refused. During an interview with LN 2 on 12/3/15 at 10:30 a.m., she stated that she was the day shift nurse who attended RR 25 on 11/29/15. LN 2 stated that RR 25 was in so much pain that she wanted to skip her meals. She also stated that RR 25 usually used the bed pan, but on 11/29/15 RR 25 was unable to move her right leg and she did not want to be turned so she had to use incontinent briefs for toileting purposes. A review of the resident's Activities of Daily Living (ADL), record for 11/28/15, 11/29/15, 11/30/15, and 12/1/15 revealed the following: a. Walk in Room - Self Performance: > Night shifts: Coded as 8 (defined as Activity Did Not Occur); > Day shifts: Coded as 8; > Evening shifts: Coded as a 4 ( defined as Total Dependence) on 11/28/15, 11/29/15, and 11/30/15. > Prior to 11/28/15 RR 25 was coded as 0 ( defined as Independent) for all shifts.b. Eating - Self Performance: > Day shifts: Coded as a 1 (defined as Supervision) on 11/29/15 and 11/30/15; > Evening shifts: Coded as a 3 (defined as Extensive Assistance) on 11/28/15, 11/29/15, and 11/30/15. > Prior to 11/28/15 RR 25 was coded as 0. c. Toilet Use - Self Performance:> Night shifts: Coded as a 3 on 11/30/15 and 4 on 12/1/15 (for 11/29/15 the record was left blank); > Day shifts: Coded as a 4 on 11/29/15 to 12/1/15; > Evening Shifts: Coded as a 3 on 11/28/15 to 11/30/15 and a 4 on 12/1/15. > Prior to 11/28/15 RR 25 was coded as 0 to 1. d. Toilet Use - Support Provided: (2: One Person Physical Assist; 3: Two Person Physical Assist)> Night shifts: Coded as a 3 on 11/30/15 and 12/1/15;> Day shifts: Coded as a 3 on 11/29/15, 11/30/15, and 12/1/15; > Evening Shifts: Coded as a 2 on 11/28/15 to 11/30/15 and a 3 on 12/1/15; > Prior to 11/28/15 RR 25 was coded as 0 to 1. e. Transferring -Self Performance: > Night shifts: Coded as an 8 on 11/30/15 and 12/1/15; > Day shifts: Coded as an 8 on 11/30/15 to 12/1/15; > Evening Shifts: Coded as an 8 on 11/30 to 12/1/15; > Prior to 11/28/15 RR 25 was coded as 0 to 2. f. Elimination - Bladder Elimination: (C = Continent; I = Incontinent) > Night shifts: C/I on 11/30/15 (prior to 11/28/15 RR 25 was coded as C); > Day shifts: C/I on 11/29/15, 11/30/15 and I on 12/1/15 (prior to 11/28/15 RR 25 was coded as C). A review of the Licensed Nurse's Notes revealed the following: > 11/29/15 at 6:30 a.m.: .Refused to use commode. Used briefs at night . > 11/29/15 at 1 p.m.: Resident is (complaining of right) leg pain (7 out of 10 pain). Gave her [MEDICATION NAME] 500 mg for pain. One hour later pain scale is still (7 out of 10) and now (both) legs pain. Asked the doctor if he can order something stronger. He gave an order for [REDACTED].(Resident) is (complaining of) pain still and gave her another dose at (2 p.m.) 500 mg of [MEDICATION NAME]. Pain is still there, slight decrease from (7 out of 10 to 5 out of 10). Resident is (complaining of) pain (at both) legs and more on (right) knee. Still waiting for the ordered [MEDICATION NAME] from Pharmacy. (Resident) is using briefs for bowel/bladder care . > 11/30/15 at 12:30 a.m: .Resident not sleep at this time .confused at times . Over 24 hours, after RR 25 lost her balance, there were no new physician orders [REDACTED]. However, the resident did not receive this pain medication until 6:30 p.m. on 11/29/15 (over 30 hours after losing her balance that resulted in pain). A review of the resident's November, 2015 MAR indicated [REDACTED]> 11/29/15 at 4 a.m.: [MEDICATION NAME] 500 mg by mouth given for complained of pain. > 11/29/15 at 10 a.m.: [MEDICATION NAME] 500 mg ( by mouth) given for (3 out of 10) pain on (right leg and knee). A re-assessment was done and the licensed nurse documented Not effective. > 11/29/15 at 2 p.m.: [MEDICATION NAME] 500 mg (by mouth) given for (7 out of 10) pain on (both legs). A re-assessment was not done. Instead the licensed nurse documented for re-assessment pending. > 11/30/15 at 8:12 a.m.: [MEDICATION NAME] one tablet for pain of (7 out of 10) to the right leg. The licensed nurse documented the re-assessment of pain that the pain was effective and it went down after the administration, but the resident rated the pain as (5 out of 10). > 11/30/15 at 2:15 p.m.: [MEDICATION NAME] one tablet for (7 out of 10) pain to the right leg and the licensed nurse documented the re-assessment of pain as pending. During an interview with LN 2 on 12/3/15 at 10:30 a.m., she stated that when she started her shift she was informed by the night nurse that RR 25 was awake during the night because of the pain caused by RR 25's incident of losing her balance. LN 2 stated that RR 25 was calling out in pain in her native language (the same language spoken by LN 2). LN 2 stated that the only pain medication in RR 25's physician orders [REDACTED]. LN 2 stated that she notified the physician to ask for stronger pain medication and received a physician order [REDACTED]. An interview with another Licensed Nurse (LN 1) on 12/3/15 at 10 a.m. was conducted. She confirmed that [MEDICATION NAME] 5/325 mg was available for use in the facility e-kits. An interview with the Director of Nursing (DON) was conducted on 12/2/15 at 10:03 a.m. She was asked what would have been her expectation regarding the nursing care for RR 25. She stated that her expectation was for the physician to have been notified of RR 25's continued pain and for the pain medication to have been retrieved from the e-kit upon order. A review of RR 25's clinical record did not reveal any new orders for pain medication for the resident until 12/1/15 at 3:05 p.m. (over 24 hours past the initial [MEDICATION NAME] order, which was not effective in controlling the resident's pain). A telephone order was obtained from the physician for [MEDICATION NAME] 5/325 mg 1 (tablet by mouth every 4 hours as needed) for moderate pain; [MEDICATION NAME] 5/325 mg 2 (tablets by mouth every 4 hours as needed) for severe pain; x-ray for (right) hip (urgent). The x-ray to the right hip was obtained on 12/1/15 and the result revealed the following: RESULTS: .Fracture at level of femoral stem .CONCLUSION: Displaced fracture . The resident was then transferred to the acute care hospital on [DATE] at 10:30 p.m. for further evaluation and treatment for [REDACTED]. condition. She stated, .If pain is not relieved the (nursing staff) should have informed the doctor . A review of the facility's undated policy and procedure titled Change in Resident's Condition revealed the following: PURPOSE: To clearly define guidelines for timely notification of a change in resident condition. POLICY: It is the policy of this facility that all changes in resident condition will be communicated to the physician. PROCEDURE: A. Acute Medical Change :1. Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior, will be communicated to the physician with a request for physician visit promptly and or acute care evaluation. The licensed nurse in charge will notify the physician AT ONCE . B. Routine Medical Change:1. All symptoms and unusual signs will be communicated to the physician promptly. Routine changes are a minor change in physical and mental behavior, . 1b. Resident 8 was admitted to the facility with multiple [DIAGNOSES REDACTED]. A review of Resident 8's clinical record revealed the following: > The resident's physician orders [REDACTED]. > MARs (Medication Administration Records), from June to November, 2015 indicated the following: a. For June 2015: Resident 8 received [MEDICATION NAME] 25 times for early morning administration for a pain level of 7 to 8 out of 10. b. For July 2015: Resident 8 received [MEDICATION NAME] 24 times for early morning administration. for a pain level of 7 to 8 out of 10. c. For August 2015: Resident 8 received [MEDICATION NAME] 16 times for early morning administration between 2 a.m. and 5 a.m. for a pain level of 7 to 8 out of 10. d. For September 2015: Resident 8 received [MEDICATION NAME] 23 times for early morning administration between 2 a.m. and 5 a.m. for a pain level of 7 to 8 out of 10. e. For October 2015: Resident 8 received [MEDICATION NAME] 20 times for early morning administration between 2 a.m. and 5 a.m. for a pain level of 7 to 8 out of 10. f. For November 2015: Resident 8 received [MEDICATION NAME] 20 times for early morning administration between 2 a.m. and 5 a.m. for a pain level of 7 to 8 out of 10.During an interview with LN 1 on 12/3/15 at 9:56 a.m., she stated that Resident 8 slept and then would wake up early and asked for pain medication. LN 1 stated that she thought Resident 8's pain wakes her up early. During an interview with Resident 8 on 12/3/15 at 2:25 p.m., she stated that she often woke up around 4 a.m. as her feet hurt. She stated that if she asks for pain medication at that time she gets it and it helps. On 12/3/15 at 8:45 a.m., the DON and the Consultant Pharmacist (CP) were interviewed together. CP stated that she had never identified regular use of as needed [MEDICATION NAME] pain medication for Resident 8 as an issue. The DON stated that a better approach would have been to evaluate Resident 8's pain management and discuss with physician to see what could be done to manage Resident 8's pain better. A review of the facility's policy titled Pain Management, dated 3/11, revealed the following: Purpose: To assure an accurate assessment of the resident's pain and respond in a timely manner with administration of medication or non-drug intervention as appropriate for the resident .If pain is new onset, changed in nature, not relieved with current medication etc., notify the physician for a review of medications, follow change of condition policy for contacting physician. A review of facility's policy titled Medication Regimen Review, dated 3/11, revealed .The resident's response to drug treatment is evaluated through the use of laboratory data, Medication Administration Record, [REDACTED]. 2. Review of random resident (RR) #32 clinical record revealed he was in a semi comatose (decreased level of consciousness) state, and dependent on a ventilator machine for breathing. On 12/2/15 at 11:45 a.m., the alarm sounded on RR#32's ventilator. Licensed Nurse (LN) #15 was observed going into RR #32's room responding to the alarm and proceeded to press several buttons on the ventilator control panel. After a minute, she was able to turn off the alarm. LN #15 was not observed at any time assessing the status of the resident. LN #12 was observed running from the room and returning with the Respiratory Care Practitioner (RCP) #1 who secured a [MEDICATION NAME] suction (instrument for suctioning secretions), cleared the secretions from the resident's airway, and reset the alarms on the ventilator. During an interview on 12/2/15 at 1 p.m., RCP #1 stated that the licensed nurse should have suctioned the resident. During an interview with the DON (Director of Nurses) on 12/3/15 at 5:15 p.m. She confirmed that nursing staff are trained to suction, and change tracheosotomy (tube inserted into the windpipe) dressings. Document review on 12/3/15 of a facility policy titled Suctioning, approved on 1/20/14, stated that, only licensed nurses are authorized to suction residents.