Every finding on record at Riverbank Post-Acute

Based on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program to provide a safe and sanitary environment for one of four sampled residents (Resident 1) when a bloody bandage and trash was found on the floor of Resident 1's room on 7/22/2026 and on 7/20/2026 Resident 1 was found to have ants on his bed, neck and shoulder. This failure resulted in an unsanitary environment and had the potential to result in cross contamination (the process by which germs are unintentionally transferred from one substance or object to another, with harmful effect). During a concurrent observation, interview, and record review with Resident 1 on 7/22/2026, at 10:30 a.m., Resident 1 stated the nurse woke him up Monday morning (7/20/2026) saying he had ants on him. Resident 1 stated there were ants on his pillow, shoulder, neck, and in his hair. Resident 1 stated he felt anxious when he realized he was covered in ants. Resident 1 stated he felt helpless because he couldn't get the ants off himself. Resident 1's room was observed with a bloody bandage on the floor, a used tea bag, dried food, a wet wipe, and paper trash. Resident 1 stated housekeeping had cleaned his room after the ants were found but he did not remember housekeeping coming in since then to clean the floor. Resident 1 stated he was nervous that the ants would come back because he couldn't get himself up to get them off him. During a record review of Resident 1's Face Sheet (front page of the chart that contains a summary of basic information about the resident) and BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident), dated 7/2/2026, the Face Sheet indicated Resident 1 was a [AGE] year-old male admitted to the facility on [DATE] with a medical history including cerebral infarction (blockage in a brain blood vessel causing insufficient blood flow and oxygen to a part of the brain), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), anxiety, depression, and chronic pain. Resident 1's BIMS indicated a score of 13 (no impairment). During a concurrent observation and interview with Housekeeper (HK) 1 on 7/22/2026, at 10:40 a.m., HK 1 stated staff found ants on Resident 1 while he was in his bed the morning of 7/20/2026. HK 1 stated housekeeping had cleaned the room, sanitized the mattress, called pest control to spray the room, and nursing staff had taken Resident 1 out of the room and showered him. HK 1 observed the trash on Resident 1's floor and stated she saw a bloody bandage, a used tea bag, dried food, a wet wipe, and paper trash. HK 1 stated housekeeping was supposed to clean the rooms in the morning and as needed and deep clean each room once a month. HK 1 stated if staff leave bloody bandages and food on the floor, it can attract ants or other pests and pests can spread infections. HK 1 stated there was no housekeeper staffed for that side of the facility that day and she had not had time to clean that room yet. During a concurrent observation and interview with Resident 3 on 7/22/2026, at 10:50 a.m., Resident 3 was lying in bed. Resident 3 stated he heard the resident next door had ants on him on Monday morning (7/20/2026) because staff were talking about it in the hallway and the nurse came into his room freaked out. Resident 3 stated it would be gross if ants got on him and he was worried because if ants were on him, he would not be able to get them off by himself. During a concurrent observation and interview with Resident 4 on 7/22/2026, at 10:55 a.m., Resident 4 was lying in bed in the same room as Resident 3. Resident 4 stated he had also heard about the ants and stated that having ants on him would be gross but at least he could brush them off. During a review of Resident 3's Face Sheet and BIMS, dated 5/29/2026, the Face Sheet indicated Resident 3 was a [AGE] year-old man admitted on [DATE] with a medical history including Morbid (severe) Obesity, Acute (sudden) and Chronic (long term), Respiratory Failure with hypercapnia (too much carbon dioxide in the blood from not being able to breath out all the way), Chronic obstructive pulmonary disease with acute exacerbation, acute and chronic respiratory failure with hypoxia, Diabetes, kidney disease, methicillin resistant Staphylococcus aureus infection (an infectious bacteria that has evolved so current antibiotics can't kill them), Acute kidney disease, Gout (a painful joint disease where sharp crystals form in the joints), and basal cell carcinoma (Cancer) of the skin of scalp and neck, and need for assistance with care. Resident 3's BIMS indicated a score of 15 (no impairment). During a review of Resident 4's Face Sheet and BIMS, dated 4/15/2026, the Face Sheet indicated Resident 4 was a [AGE] year-old man admitted on [DATE]. Resident 4's BIMS indicated a score of 13 (no impairment). During a concurrent interview and record review on 7/22/2026, at 11:10 a.m., with the Licensed Vocational Nurse (LVN) 1, LVN 1 stated she had heard of an ant infestation in Resident 1's room two days ago and on the other side of the facility a few weeks ago. LVN 1 stated that administration had instructed staff to get rid of uneaten food, keep rooms clean, and keep snacks sealed to prevent ants from coming into the rooms. LVN 1 stated the trash on the floor and the bloody bandage was an infection control issue. During an interview on 7/22/2026, at 11:35 a.m., with LVN 2, LVN 2 stated the facility had ant infestations two or three times in the last few months. LVN 2 stated administration had told staff the ants were after the residents' snacks and to keep residents food sealed or cleaned up and thrown away. LVN 2 stated she had seen a few ants around the facility and had told housekeeping or a Certified Nurse Assistant (CNA) to clean them up. LVN 2 stated she had had to wait on housekeeping many times in the past because they say they were short staffed. LVN 2 stated the items on the floor such as bloody bandage and trash could attract ants or other pests that could get on the residents, spread infection, crawl into their mouths or eyes, and could bite them. LVN 2 stated she would feel scared and helpless if she had ants crawling on her. During an interview on 7/22/2026, at 12:00 p.m., with CNA 1, CNA 1 stated she had seen ants around the facility and had cleaned them up and told maintenance. CNA 1 stated the nightstands, bed tables, and floors should always be clean because ants were attracted to food and milk. CNA stated some residents were upset that they can't keep their snacks right with them. During a concurrent interview and record review on 7/22/2026, at 12:10 p.m., with the Administrator (ADM) and the Director of Nursing (DON), the facility's policy and procedure (P&P) Pest Control, dated May 2008, and the facility's P&P Cleaning and Disinfecting Residents' Rooms, dated August 2013, were reviewed. The ADM stated the facility had two ant infestations in the last couple months. The ADM stated the facility had determined the cause of the ants to be residents either throwing food on the floor or keeping food open at bedside. The ADM stated the facility instructed staff to keep nightstands, bed tables, and floors clean and put food away sealed. The ADM stated his expectation was for housekeeping and all staff to keep the residents' rooms clean. The ADM and DON stated a bloody bandage, a used tea bag, and a piece of dried food as well as paper trash should have been cleaned and disposed. The DON stated the facility should be cleaning Resident 1's room more frequently to prevent ants since the facility is aware he throws items on the floor. The ADM stated Resident 1 could get agitated and was known for kicking staff out of his room. The ADM stated staff could still clean the floor and the roommate's side of the room if a resident didn't want staff cleaning on his or her side. The DON stated leaving bloody bandages and food on the floor created a risk of infection and could attract pests like ants. The ADM and DON stated they would not want the floor of their house to look like Resident 1's bedroom floor nor would either of them be ok with that many ants on their body.During an interview on 7/22/2026, at 12:30 p.m., with the Housekeeping Director (HKD), The HKD stated her expectation was for the rooms to be deep cleaned once a month, cleaned every morning, and checked throughout the day for the need to be cleaned. The HKD stated the residents in that room were known to throw things on the floor, so trash was expected to be on the floor. The HKD stated food and bandages on the floor could attract ants and were an infection control issue. During a concurrent interview and record review on 7/23/2026, at 9:03 a.m., with the Infection Preventionist (IP), the facility's policy and procedure (P&P) titled, Pest Control, dated May 2008, and the facility's P&P titled, Cleaning and Disinfecting Residents' Rooms, dated August 2013, were reviewed. The IP stated her expectation is for housekeeping to clean all floors daily and as needed. The IP stated a consequence of not cleaning well enough or frequently enough is that food will get left on the floor and attract ants. The IP stated that leaving a bloody bandage on the floor was an infection control issue. The IP reviewed the P&Ps and stated by leaving the trash on Resident 1's floor, the facility had not followed their policy and procedures. During a review of the facility's P&P titled, Pest Control, dated May 2008, indicated, Our facility shall maintain an effective pest control program.1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects.garbage and trash are not permitted to accumulate. During a review of the facility's P&P titled, Cleaning and Disinfecting Residents' Rooms, dated August 2013 indicated, The purpose of this procedure is to provide guidelines for cleaning and disinfecting residents' rooms.Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled.

Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice when Licensed Nurses did not complete an accurate physical assessment upon admission for one of three sampled residents (Resident 1) when Resident 1 was admitted to the facility on [DATE] with bilateral (both sides of the body) nephrostomy tubes (thin, flexible tube placed through the skin of a person's back into the kidney to drain urine into an outside bag) and an abdominal accordion drain (a small tube placed into an abscess [pocket of pus/infection] to drain fluid using a collapsible plastic bulb that creates gentle suction) site that were not documented.This failure had the potential to negatively affect Resident 1's health when her bilateral nephrostomy tubes and the accordion drain were not documented in the resident's medical record causing a delay in treatment, including no site monitoring or dressing changes from 3/20/26 until 3/26/26.During an interview on 4/13/26 at 11:30 a.m. with Certified Nursing Assistant (CNA) 5, CNA 5 stated Resident 1 was at the facility for a short time. CNA 5 stated she remembered taking care of Resident 1, emptying her nephrostomy tubes frequently. CNA 5 stated Resident 1 also had an accordion drain.During a review of Resident 1's admission Record, undated, the admission record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included psoas muscle (hip flexor muscle) abscess, malignant neoplasm of bladder (bladder cancer), encounter for surgical aftercare following surgery on the genitourinary system (the body's urinary and reproductive system), and artificial openings of urinary tract system (surgical procedure that creates a stoma [artificial opening] to drain urine when the bladder is no longer able to do so).During a review of Residents 1's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 1's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 14 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1 was not cognitively impaired.Resident 1's Order Summary Report (OSR), undated, indicated . Nephrostomy: Assess STOMA site for s/sx [signs and symptoms] of infection (i.e. redness, swelling, tenderness, drainage, warm to touch) QS [every shift] & notify MD if any. 3/26/26. NEPHROSTOMY: Cleanse nephrostomy stoma site with NS and pat dry, apply dry dressing to Left and Right nephrostomy site QOD [every other day] and PRN [as needed]. 3/26/26. TREATMENT: ACOORDION DRAIN-Cleanse stoma site with NS, pat dry, apply dry dressing QOD and as needed if soiled or dislodged. 3/26/26.During a concurrent interview and record review on 4/13/26 at 11:38 a.m. with the Treatment Nurse (TN), the TN stated a CNA had paged her to Resident 1's room on 3/26/26 because the resident's family was requesting her dressings be changed to the nephrostomy tubes and drain site. The TN stated she was unaware Resident 1 had nephrostomy tubes or drain site dressings because they were not identified or documented on admission. The TN stated when she checked Resident 1, she discovered bilateral nephrostomy tubes from the residents back, each had a split gauze over the tube exit site and was secured with tape, and the resident also had an accordion drain in the lower abdomen. Resident 1's admission Assessment, dated 3/21/26 was reviewed and indicated, . Catheter/Ostomy. ileostomy/Urostomy [not checked] . Nephrostomy/urostomy [not checked] . Other Relevant Dx[diagnosis]/Concerns [left blank] . Additional nurses notes . voiding well and using bedpan . Resident 1's Skin Assessment, dated 3/20/26, indicated, . Special Equipment. Other. If other, specify [left blank] . Type of skin problem. Surgical site. Other. If other, specify [left blank] . Resident 1's Skin Assessment, dated 3/20/26, indicated, . Special Equipment. Other. If other, specify [left blank] . Type of skin problem. Surgical site. Other. If other, specify [left blank]. The TN stated the nephrostomy tubes and drain were not documented on the admission assessment or skin assessment. The TN stated when she saw Resident 1 on 3/26/26, she had reviewed the physician orders and was unable to find any dressing changes or site monitoring orders. The TN stated she contacted Resident 1's physician and received new orders to change the dressings every other day and to monitor the sites for signs and symptoms of infection. Resident 1's Skin Assessment, dated 3/26/26, written by the TN, indicated, . Special Equipment. Other [box checked]. If other, specify. accordion drain and nephrostomy tubes. Type of skin problem. Surgical site. Present on admission. patient noted with left and right nephrostomy tubes, sites are clean, normal skin color, no redness, no s/sx [signs or symptoms] of infection. cleansed with NS [normal saline] and applied dry dressing for protection, accordion drain noted to left lower abdominal quadrant. no s/sx of infection. The TN stated she performed the wound care and entered the orders into the Electronic Medical Record (EMR). Resident 1's care plans were reviewed and the TN stated she was unable to locate care plans addressing the nephrostomy tubes or drain site. The TN stated a care plan should have been entered on admission and updated when new orders were received. The TN stated care plans were important to address resident problems, identify the treatment goals and to put interventions in place to meet those goals. The TN stated that when a new resident was admitted with dressings, the admission nurse should assess the resident, check the transfer orders for wound care and contact the physician to review the information and receive new orders. The TN stated there was no wound care, site care or drain care ordered from admission on [DATE] until saw Resident 1 on 3/26/26. The TN stated Resident 1's dressings should have been changed at least twice since admission if the orders had been received sooner. The TN stated Resident 1's accordion drain was from an abscess site, making her at high risk of infection. The TN stated it was very important to have orders to monitor the drain and nephrostomy sites to assess changes to catch any issues quickly.During a concurrent interview and record review on 4/13/26 at 1:12 p.m. with the Director of Staff Development (DSD), the DSD stated Resident 1 was admitted to the facility from 3/20/26 to 3/27/36. Resident 1's Order Summary Report (OSR), undated, was reviewed and indicated . Nephrostomy: Assess STOMA site for s/sx [signs and symptoms] of infection (i.e. redness, swelling, tenderness, drainage, warm to touch) QS [every shift] & notify MD if any. 3/26/26. NEPHROSTOMY: Cleanse nephrostomy stoma site with NS and pat dry, apply dry dressing to Left and Right nephrostomy site QOD [every other day] and PRN [as needed]. 3/26/26. TREATMENT: ACOORDION DRAIN-Cleanse stoma site with NS, pat dry, apply dry dressing QOD and as needed if soiled or dislodged. 3/26/26. The DSD stated Resident 1 had bilateral nephrostomy tubes and a drain site on admission 3/20/26, but the care orders were not received until 3/26/26. The DSD stated the admission nurse should have documented the nephrostomy tubes and drain and called the physician for new orders. The DSD reviewed Resident 1's care plans but was unable to locate any care plans addressing the nephrostomy tubes and drain site. The DSD stated care plans were important to identify Resident 1's nephrostomy tubes and drain site, what the goals of treatment were, and care interventions needed to meet those goals. The DSD stated the nurses failed to identify the tubes and drain on admission and did not enter a care plan for their treatment. The DSD stated Resident 1 was placed at risk for drain and tube site infection from the delay in treatment. During an interview on 4/13/26 at 2:01 p.m. with the Director of Nursing (DON), the DON stated Resident 1 was admitted to the facility with nephrostomy tubes and a drain site, but they were not documented on admission. The DON stated the normal process for a new admission was for the Interdisciplinary Team (IDT- team from different healthcare disciplines who work together to provide comprehensive patient care) to meet, review the residents Electronic Medical Record (EMR) for the history and physical, hospital records, admission assessment for any needed treatments, consents or wound care to ensure the residents needs had been addressed in the plan of care. The DON stated Resident 1's IDT meeting was delayed, so the LN's failure to document the nephrostomy tubes and drain site and request physician orders was not found timely and resulted in the resident not receiving site care for 6 days. The DON stated normally the IDT would have met and followed up with the physician for new orders. The DON stated it was her expectation for the admission nurse to note the nephrostomy tubes and drain site in the admission assessment, skin assessment and be communicated to the floor staff. The DON stated the physician should have been notified and asked for orders to care for the sites such as dressing, monitoring the site for signs of infection or dislodgement. The DON stated monitoring was very important because any changes in the nephrostomy tubes and drain sites would need to be noted and reported to the physician immediately to prevent complications such as an infection. The DON stated care plans were important to have all problems addressed because they direct the care provided to the residents. During a review of the facility's policy and procedure (P&P) titled admission Assessment and Follow Up: Role of the Nurse, dated 9/2012, the P&P indicated, . purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan, and completing required assessment. Conduct an admission assessment (history and physical), including. summary of the individual's recent medical history, including hospitalizations, acute illnesses and overall status. Relevant medical, social, and family history. A list of active medical diagnoses and patient problems. especially those most related to reasons for admission to the facility. Conduct a physical assessment, including the following systems. genitourinary. skin. Contact the Attending Physician to communicate and review the findings of the initial assessment and any other pertinent information. Documentation. following information should be recorded in the resident's medical record. All relevant assessment data. Orders obtained from the physician. Report other information in accordance with facility policy and professional standards of practice.During a review of the facility's policy and procedures (P&P) titled Nephrostomy Tube, Care of, dated 10/2010, the P&P indicated, . purpose of this procedure is to provide guidelines for the care of the resident with a percutaneous nephrostomy tube. Assess the resident for indications of bleeding in the flank area . every 8 hours. Check placement of the tubing and integrity of the tape during assessments. Drainage should be below the level of the kidneys. no kinks in the tubing. if the tubing is dislodged, cover stoma with sterile 4X4 and notify the Attending Physician immediately. Empty drainage bag once per shift and as needed. Change drainage bag monthly, or as needed. Measure output as follows. Every 8 hours. Measure output from the right and left kidneys separately. Change dressings every 1-3 days, or as ordered. Reporting. Report any of the following signs or symptoms to the physician. Redness, inflammation, reports of pain, or other signs of infection at the insertion stie. Reduced output or output below established parameters. Inability to irrigate tube or signs of obstruction of the tube. Signs of skin breakdown. or If the tube becomes dislodged. During a review of the facility's documents titled Job Description: Licensed Nurse/Medication/Treatment Nurse, undated, the job description indicated, .Complete and file required recordkeeping forms/charts upon the resident's admission. Chart nurses' notes in an informative, descriptive and legible manner that reflects the care provided to the resident. Nursing Care Functions. Provide direct nursing care as necessary. Care Plan and Assessment Functions. Participate in the development of written preliminary and comprehensive assessments of the nursing needs of each resident. Participate in the development of a written care plan. that identifies the problems/needs of the resident, indicates the care to be given, goals to be accomplished . Review resident care plans for appropriate resident goals, problems, approaches, and revisions based on nursing needs. Ensure that all personnel involved in providing care to the resident are aware of the resident/s care plan. Ensure that nursing personnel refer to the resident's care plan prior to administering daily care to the resident. Review nurses' notes to determine if the care plan is being followed.During a review of a professional reference retrieved from https://www.ncbi.nlm.nih.gov/books/NBK242385/ titled Nephrostomy and Biliary Tube Management: A Review of the Clinical Evidence and Guidelines, dated 2014, the reference indicated, . General recommendations for patients and health care providers caring for nephrostomy tubes include routinely checking nephrostomy tube patency and monitoring for pain, leakage or bleeding, as well as fever. Patient instruction to inspect their nephrostomy tube daily, looking for skin breakdown, soiled dressings, kinks in the tubing, and evidence of blockage. An absence of urine, presence of blood in the collection bag, or flank pain may indicate that the tube is blocked. Recommendation for the frequency of changing drainage bags ranged from three times weekly to every 7 days. recommended frequency of dressing changes also varied from every other day to twice weekly; however, there was generally agreement across references that the dressing should be changed if it becomes visibly soiled.

Based on interview and record review, the facility failed to ensure Licensed Nurses received competency skills on the assessment and care of nephrostomies when three of three sampled Licensed Nursing staff (Registered Nurse [RN] 1, Licensed Vocational Nurse (LVN) 2 and the Treatment Nurse [TN]) did not receive competency training and skill set evaluate in assessing and providing nephrostomy (thin, flexible tube placed through the skin of a person's back into the kidney to drain urine into an outside bag) care.This failure had the potential to place residents with nephrostomies at risk for care to not be provided in a safe and competent manner.During an interview on 4/13/26 at 10:17 a.m. with LVN 2, LVN 2 stated there were residents at the facility with nephrostomy tubes. LVN 2 stated the facility tested skill competencies annually but could not remember if nephrostomy tubes were covered.During an interview on 4/13/26 at 11:38 a.m. with the Treatment Nurse (TN), the TN stated the facility held annual competencies for the nursing staff, which included genitourinary system (organs involved in producing urine and reproduction) such as catheters (thin, flexible tube inserted through the urethra into the bladder to drain urine into a collection bag) and suprapubic catheters (tube inserted through a small, permeant opening in the lower abdomen to drain urine), but was unsure if she had received training and competency regarding nephrostomy tubes.During a concurrent interview and record review on 4/13/26 at 1:12 p.m. with the Director of Staff Development (DSD), the DSD stated the facility provided the nurses with an annual training and competency skills check. The facility's document titled Licensed Nurse Competency Checklist, updated 7/5/2023, was reviewed and indicated, . Catheters. Urethral Catheterization. Female. Male. Insertion. Removal. Supra Pubic Catheter Daily Care. Insertion. Removal. Genitourinary Assessment. The DSD stated the template did not include competency for nephrostomy care, so the nurses had not been evaluated for their skill competency during the annual check. The DSD stated if it was not on the template, it was not done. The DSD stated there were residents in the facility with nephrostomy tubes, and it was important for all the nurses to be competent in providing care. The DSD stated he would reach out to the facility consultant to train the nursing staff for nephrostomies.During an interview on 4/13/26 at 1:53 p.m. with Registered Nurse (RN) 1, RN 1 stated the facility held in-services and annual competency checks, including the urinary system but was unsure if nephrostomies were covered.During an interview on 4/13/26 at 2:01 p.m. with the Director of Nursing (DON), the DON stated the annual competency skills check should cover procedures performed in the facility and nephrostomy care should be added to the checklist. The DON stated it was important to make sure the nurses were competent prior to providing nephrostomy care to ensure the care was adequate and would not bring harm to the resident. The DON stated ideally all nurses should have competencies checked before accepting a resident with an issue not covered by the competency check list. The DON stated there were residents in the building with nephrostomies and staff providing care needed to be competent.During a review of the facility's policy and procedures (P&P) titled Staffing, Sufficient and Competent Nursing, dated 8/2022, the P&P indicated, . Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. Licensed nurses. provide competent resident care services including. attaining or maintaining the highest practicable physical, mental and psychosocial well-being of each resident. assessing, evaluating, planning and implementing resident care plans. Competency is a measurable pattern of knowledge, skills, abilities, behaviors and other characteristics that an individual needs to perform work roles. All nursing staff must meet the specific competency requirements of their respective licensure and certification. Staff must demonstrate the skills and techniques necessary to care of resident needs including. Person centered care. Basic nursing skills. Skin and wound care. Infection control. Licensed nurses . are trained and must demonstrate competency in identifying, documenting and reporting resident changes of condition consistent with their scope of practice and responsibilities. Competency requirements and training for nursing staff are established and monitored by nursing leadership. programming for staff training results in nursing competency. gaps in education are identified and addressed. education topics and skills needed are determined based on the resident population. training includes critical thinking skills and managing care in a complex environment.

Based on interview and record review, the facility failed to ensure a comprehensive, person-centered care plan was developed and implemented to meet the identified needs for one of three sampled residents (Resident 1) when Resident 1 did not have a care plan for bilateral (both sides of the body) nephrostomy tubes (thin, flexible tube placed through the skin of a person's back into the kidney to drain urine into an outside bag) and abdominal accordion drain (a small tube placed into an abscess [pocket of pus/infection] to drain fluid using a collapsible plastic bulb that creates gentle suction) site.This failure had the potential for Resident 1's care needs to go unmet and resulted in a delay in care for dressing changes to the nephrostomy tubes and drain sites, placing the resident at risk for infection and dislodgement of the tubing. (Cross reference F684)During a review of Resident 1's admission Record, undated, the admission record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included psoas muscle (hip flexor muscle) abscess, malignant neoplasm of bladder (bladder cancer), encounter for surgical aftercare following surgery on the genitourinary system (the body's urinary and reproductive system), and artificial openings of urinary tract system (surgical procedure that creates a stoma [artificial opening] to drain urine when the bladder is no longer able to do so).During a review of Residents 1's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 1's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 14 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1 was not cognitively impaired.During a concurrent interview and record review on 4/13/26 at 11:38 a.m. with the Treatment Nurse (TN), the TN stated a CNA had paged her to Resident 1's room on 3/26/26 because the resident's family was requesting her dressings be changed to the nephrostomy tubes and drain site. The TN stated she was unaware Resident 1 had nephrostomy tubes or drain site dressings because they were not identified or documented on admission. The TN stated when she checked Resident 1, she discovered bilateral nephrostomy tubes from the residents back, each had a split gauze over the tube exit site and was secured with tape, and the resident also had an accordion drain in the lower abdomen. Resident 1's admission Assessment, dated 3/21/26 was reviewed and indicated, . Catheter/Ostomy. ileostomy/Urostomy [not checked] . Nephrostomy/urostomy [not checked] . Other Relevant Dx[diagnosis]/Concerns [left blank] . Additional nurses notes . voiding well and using bedpan . Resident 1's Skin Assessment, dated 3/20/26, indicated, . Special Equipment. Other. If other, specify [left blank] . Type of skin problem. Surgical site. Other. If other, specify [left blank] . The TN stated the nephrostomy tubes and drain were not documented on the admission assessment or skin assessment. The TN stated she had reviewed Resident 1's orders and was unable to find any dressing changes or site monitoring orders. The TN stated she contacted Resident 1's physician and received new orders to change the dressings every other day and to monitor the sites for signs and symptoms of infection. The TN stated she performed the wound care and entered the orders into the Electronic Medical Record (EMR). Resident 1's care plans were reviewed and the TN stated she was unable to locate care plans addressing the nephrostomy tubes or drain site. The TN stated a care plan should have been entered on admission and updated when new orders were received. The TN stated care plans were important to address resident problems, identify the treatment goals and to put interventions in place to meet those goals.During a concurrent interview and record review on 4/13/26 at 1:12 p.m. with the Director of Staff Development (DSD), the DSD stated Resident 1 was admitted to the facility from 3/20/26 to 3/27/36. Resident 1's Order Summary Report (OSR), undated, was reviewed and indicated . Nephrostomy: Assess STOMA site for s/sx [signs and symptoms] of infection (i.e. redness, swelling, tenderness, drainage, warm to touch) QS [every shift] & notify MD if any. 3/26/26. NEPHROSTOMY: Cleanse nephrostomy stoma site with NS and pat dry, apply dry dressing to Left and Right nephrostomy site QOD [every other day] and PRN [as needed]. 3/26/26. TREATMENT: ACOORDION DRAIN-Cleanse stoma site with NS, pat dry, apply dry dressing QOD and as needed if soiled or dislodged. 3/26/26. The DSD stated Resident 1 had bilateral nephrostomy tubes and a drain site on admission 3/20/26, but the care orders were not received until 3/26/26. The DSD stated the admission nurse should have documented the nephrostomy tubes and drain and called the physician for new orders. The DSD reviewed Resident 1's care plans but was unable to locate any care plans addressing the nephrostomy tubes and drain site. The DSD stated care plans were important to identify Resident 1's nephrostomy tubes and drain site, what the goals of treatment were, and care interventions needed to meet those goals. The DSD stated the nurses failed to identify the tubes and drain on admission and did not enter a care plan for their treatment. The DSD stated Resident 1 was placed at risk for drain and tube site infection from the delay in treatment.During an interview on 4/13/26 at 2:01 p.m. with the Director of Nursing (DON), the DON stated Resident 1 was admitted to the facility with nephrostomy tubes and a drain site, but they were not documented on admission. The DON stated it was her expectation for the admission nurse to note the nephrostomy tubes and drain site in the admission assessment, skin assessment and be communicated to the physician and floor staff. The DON stated the physician should have been notified and asked for orders to care for the nephrostomy tubes and drain site, such as dressing changes and monitoring the site for signs of infection or dislodgement (move out of place or fall out). The DON stated monitoring was very important because any changes in the nephrostomy tube and drain sites would need to be noted and reported to the physician immediately to prevent complications such as an infection. The DON reviewed Resident 1's care plans and stated the nephrostomy tubes and drain site were not documented in the plan of care. The DON stated care plans were important to have all problems addressed because they direct the care provided to the residents. During a review of the facility's policy and procedure (P&P) titled Care Plans-Baseline, dated 3/2022, the P&P indicated, . baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including. Initial goals based on admission orders. Physician orders. baseline care plan is used until the staff can conduct the comprehensive assessment and develop and interdisciplinary person-centered comprehensive care plan. base line care plan is updated as needed to meet the resident's needs until the comprehensive care plan is developed. resident and/or representative are provided a written summary of the baseline care plan. that includes. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.During a review of the facility's documents titled Job Description: Licensed Nurse/Medication/Treatment Nurse, undated, the job description indicated, . primary purpose of your job is to provide direct nursing care to the residents including medication management and skin care treatments. Ensure that the Nursing Services . reflects the day-to-day nursing procedures performed in this facility. Ensure that all nursing service personnel comply with the procedures set forth in the Nursing Service Procedures. Complete and file required recordkeeping forms/charts upon the resident's admission. Chart nurses' notes in an informative, descriptive and legible manner that reflects the care provided to the resident. Care Plan and Assessment Functions. Participate in the development of written preliminary and comprehensive assessments of the nursing needs of each resident. Participate in the development of a written care plan. that identifies the problems/needs of the resident, indicates the care to be given, goals to be accomplished . Review resident care plans for appropriate resident goals, problems, approaches, and revisions based on nursing needs. Ensure that all personnel involved in providing care to the resident are aware of the resident/s care plan. Ensure that nursing personnel refer to the resident's care plan prior to administering daily care to the resident. Review nurses' notes to determine if the care plan is being followed.

Based on observation, interview, and record review the facility failed to ensure the ice machine was in safe operating condition when the ice machine malfunctioned and the facility did not provide the residents with ice for two days, 3/21/26 and 3/22/26.This failure had the potential for the residents to decrease the amount of fluid they consumed risking dehydration (condition when body loses more fluids than it takes in) and urinary tract infections (UTI-infection caused by bacteria entering the urinary system [bladder, urethra, or kidneys] leading to painful urination).During a concurrent observation and interview on 3/23/26 at 10:51 a.m. with Resident 6, Resident 6 was lying in bed, there was an indwelling catheter bag hanging at her bedside. Resident 6 pointed to her cup on the overbed table and stated she had not received any ice since Friday 3/20/26. Resident 6's cup was empty and she stated she preferred her drinks to be ice cold and did not consume as much fluid as she normally would because there was no ice available. Resident 6 stated she was at high risk for UTIs because she had an indwelling catheter (thin flexible tube inserted into the bladder to drain urine).During a review of Resident 1's admission Record, undated, the admission record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses which included neuromuscular dysfunction of bladder (condition where the nerves to hold urine are damaged causing the bladder and muscles to work poorly), pressure ulcer left hip (skin wound or injury caused by long-lasting pressure on the skin over bony areas), protein-calorie malnutrition (state of inadequate intake of food) and paraplegia (form of paralysis [loss of ability to move one or more muscles in the body] that affects the lower half of the body).During a review of Residents 6's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 6's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 15 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 6 was not cognitively impaired.During a concurrent observation and interview on 3/23/26 at 10:59 a.m. with Resident 5, Resident 6's roommate, Resident 5 stated there was no ice to drink over the weekend. A Certified Nursing Assistant (CNA) entered the residents' room with a pitcher of ice and added ice to Resident 5's and 6's cups. The CNA stated the facility's ice machine stopped working on Friday. The CNA stated but the kitchen brought some ice to the floor this morning, so she was delivering ice to her residents. Resident 5 stated she had a urinary tract infection recently and needed to drink fluids to help prevent another infection. Resident 5 stated she preferred to have ice in her drinks and asked the CNA to bring her a soda with ice. During a review of Resident 5's admission Record, undated, the admission record indicated, Resident 5 was admitted to the facility on [DATE] with diagnoses that included cerebral palsy (a group of conditions that affect movement and posture caused by brain damage that occurs most often before birth), malignant neoplasm of the breast (breast cancer) and bipolar disorder mental health condition that causes extreme mood swings).During a review of Residents 5's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 5's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 14 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 5 was not cognitively impaired.During an interview on 3/23/26 at 11:26 a.m. with CNA 1, CNA 1 stated there was no ice available over the weekend. CNA 1 stated the kitchen staff brought ice late this morning for the residents. CNA 1 stated the facility's process was to bring out ice chests with ice to keep at the nurses' station and change it for clean ice once a shift. CNA 1 stated it was important to have ice available to provide ice water for the residents. CNA 1 stated it was important to have ice to make sure the residents drink enough water and fluids to stay hydrated because some residents did not like to drink water at room temperature water.During an interview on 3/23/26 at 12:13 p.m. with CNA 2, CNA 2 stated she had worked on 3/22/26 and the residents were complaining about not having ice for water or drinks. CNA 2 stated ice was important because some residents preferred to have ice in their drinks which improved the amount of fluid they drank.During an interview on 3/23/26 at 12:28 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the ice machine has broken down on occasion in the past. LVN 1 stated there was no ice on Saturday 3/21/26 when she passed medications. LVN 1 stated it was important to have ice available because some residents would not drink as much fluid if it were not cold.During a concurrent observation and interview on 3/23/26 at 1:16 p.m. with the Certified Dietary Manager (CDM), in the kitchen, the CDM stated she arrived at work and the ice chests which were normally out on the floor were sitting empty in the room next to the kitchen. The CDM stated she checked the ice machine, and the plastic dispenser was broken so the machine was not dispensing ice. The CDM stated she checked freezers for ice and realized there was no ice in the kitchen. The CDM stated she notified the Director of Maintenance (DOM) that the ice machine was not working, and he was able to fix it midmorning. The CDM stated it was an issue for the residents not to have ice because it would place them at risk for dehydration if they did not drink enough water. The CDM stated she did not receive any phone calls over the weekend notifying her the ice machine was not working.During a concurrent interview on 3/23/26 at 1:22 p.m. with [NAME] (CK) 1 and CK 2, CK 1 stated she had worked over the weekend and there was no ice available because the ice machine was not working. CK 2 stated she had worked on Saturday evening and the nursing supervisor was aware there was no ice and they were still waiting on ice when she left Saturday night. CK 2 stated she was told the administrator (ADM) had been notified there was no ice at the facility.During an interview on 3/23/26 at 1:44 p.m. with the DOM, the DOM stated on Thursday 3/19/26 he was notified by the CDM that the ice machine not working correctly so he checked it and found that the dispenser was misaligned and he was able to fix it on Thursday. The DOM stated he received a text message on Friday 3/20/26 that the ice machine was not working again. The DOM stated he was off work and did not hear any further communication, so he had thought the matter had been resolved. The DOM stated the dispenser gets off track if it is pushed too hard or too aggressively and will not dispense the ice. The DOM stated he came in to work earlier today and was told there was no ice over the weekend because the machine had not been dispensing the ice. The DOM stated when he checked the machine the plastic part was off track and hanging there. The DOM stated the ice machine was an old piece of equipment and has acted up off and on. The DOM stated he had not been called over the weekend, so he assumed the ice machine was working. During an interview on 3/23/26 at 2:49 p.m. with the Administrator (ADM), the ADM stated he had not been notified over the weekend that the ice machine was not working, and the residents did not have ice. The ADM stated he was disappointed there was no follow up because the staff could have bought ice to get through the weekend. The ADM stated if residents preferred ice cold drinks they may not drink as much if that was their preference. The ADM stated the department heads rotated working on the weekend, and the Minimum Data Set Coordinator (MDSC) was in the facility on Saturday and Payroll (PAY) was in the facility on Sunday.During an interview on 3/23/26 at 2:55 p.m. with the PAY, the PAY stated she was at the facility for most of the day on Sunday and she was not notified there was no ice for the residents.During an interview on 3/23/26 at 3:55 p.m. with the Director of Nursing (DON), the DON stated she was not notified the ice machine was not working over the weekend. The DON stated her expectation would be for the weekend staff to notify the DOM and ADM. The DON stated the residents not having ice available had the potential risk for dehydration and UTIs from not intaking enough fluid.During a telephone interview on 3/24/26 at 11:30 a.m. with the MDSC, the MDSC stated she was the department head on call and came to the facility on Saturday 3/21/26 from 8:00 am to 4:30 p.m. The MDSC stated she was not notified there was no ice until around 2:30 or 3:00 p.m. The MDSC stated a charge nurse notified her there was no ice and she asked the nurse if she notified other staff members. The MDSC stated the charge nurse sent it in a group chat which included the ADM, DON, herself and other department heads. The MDSC stated she checked the chat and had received the message. The MDSC stated she did not follow up further because the message was also sent to the ADM and she figured there was no further follow up needed from her. The MDSC stated if residents preferred ice in their drinks and did not have it available, they may not drink enough water which had the potential for dehydration.During a review of the facility's document titled Instructions, dated 3/23/2026, the document indicated, . Ice Machines. 3/19[2026] . Ice chute had fallen off track, likely due to pushing too hard on lever.During a review of the ice machine manufacturer guidelines titled Installation, Operation and Maintenance Manual, dated 3/9/23, the guidelines indicated, . Safety Notices. Proper installation, care and maintenance are essential for maximum performance and trouble-free operation of your equipment. Do not operate equipment that has been misused, abused, neglected, damaged. from that of original manufactured specifications. Ice Delivery. ice falls from the paddle wheel to the ice chute opening of the dispenser bin.During a review of the facility's policy and procedure titled Ice Machines and Ice Storage Chests, dated 1/2012, . Ice machines and ice storage/distribution containers will be used and maintained to assure a safe and sanitary supply of ice.

Based on interview and record review, the facility failed to ensure a complete and accurately documented medical record in accordance with acceptable professional standards of practice and the facility policy and procedure for three of seven sampled residents (Residents 1, 2, and 3) when the Social Services Director (SSD) did not document her attempts to schedule physician ordered consultations and diagnostic testing or contact and follow up with the responsible parties (RP) in the residents' electronic medical record (EMR). These failures had potential for Residents 1, 2, and 3 care needs to go unmet due to inaccurate documentation. (cross reference F745)During a concurrent interview and record review on 2/23/26 at 12:28 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 2's physician's order dated 10/9/26, was reviewed. The order indicated, . 10/9/3025. Modified Barium Swallow to R/O [rule out] Silent Aspiration. Resident 2's Nurses Notes, dated 10/9/25, indicated, . [name of physician] made rounds and examined resident with new order for Modified Barium Swallow to R/o Silent Aspiration [name of SSD] Social Service notified. LVN 1 stated it was important to schedule Resident 2's MBS to rule out swallowing issues and have a high risk of choking on food and drink and could aspirate. LVN 1 stated the note indicated the SSD was notified and should have scheduled the MBS according to the physician's order and documented in the EMR. Resident 3's physician's order dated 7/22/25, indicated, . for Barium Swallow Consult. Resident 3's Nurses notes, dated 7/22/25, indicated, . [name of physician] made rounds examined resident with New order for Barium Swallow Consult [name of Social Services Assistant (SSA)] Social Worker notified. LVN 1 stated Resident 3 had swallowing issues so he had the G-tube and an order for nothing by mouth. LVN 1 stated the SSA or SSD should have scheduled the appointment and documented follow-up in the residents EMR. Resident 1's physician's orders, dated 12/10/25 was reviewed and indicated, . EENT Consult to assist Vocal Cord Mobility. Modified Barium Swallow to r/o Silent aspiration to help determine if PO [by mouth] diet placement is possible. LVN stated Resident 1 was her resident while at the facility but had been discharged . LVN 1 stated Resident 1 had a G-tube when he was admitted to the facility and had graduated to an oral diet while admitted . LVN 1 stated the MDS was ordered to see if he could tolerate oral food and drink safely. LVN 1 stated it was important for Resident 1 to have the test done to rule out choking or aspiration with oral intake. LVN 1 was unable to locate documentation the SSD had scheduled appointment or followed up. LVN 1 stated the SSD was responsible for scheduling the appointments and documenting follow-up.During a concurrent interview and record review on 3/23/26 at 3:00 p.m., with the SSD, the SSD stated the referral process for consultations or outside testing was for a physician order to be placed, then nursing would send her a copy of the order. The SSD stated she would then start the process for scheduling the appointments. The SSD stated she did not document attempts to schedule appointments or follow-up notes in the EMR but kept papers in a folder with the orders and her notes on them. The SSD declined to answer if her folder was part of the Resident's medical record. The SSD stated that when she scheduled appointments, she would place a communication note in the facility's EMR program, but those notes were deleted after a set amount of time, it was not a part of the resident's medical record. Resident 3's order for an MBS on 7/22/25 was reviewed, the SSD stated she had contacted Resident 3's sister when she had called to schedule the appointment and the hospital indicated an RP needed to attend Resident 3's appointment to sign consents. The SSD stated she called the RP several times but did not document any of the attempts to schedule the MBS or contact the sister in the EMR. The SSD stated if something was not documented it was considered not done. The SSD stated Resident 2 had refused to have the MBS, so she had contacted his RP. The SSD stated she did not document a note in the resident's medical record that the resident and RP refused the appointment. The SSD stated Resident 1 had been scheduled for an inhouse ENT consultation on 2/23/26 but had been discharged prior to the appointment. The SSD stated she did not document the appointment in the EMR. The SSD stated she did not document any information in Resident 1's medical record regarding the appointments or follow-up phone calls. The SSD declined to answer if the Resident's medical records were accurate without her documentation and stated she kept notes in a folder in her office. The SSD stated she should have documented in the EMR so her attempts to schedule the appointments and follow-up phone calls were a part of the medical record.During an interview on 3/23/26 at 3:55 p.m. with the Director of Nursing, the DON stated the process for consultations and outpatient diagnostic testing were for the Interdisciplinary team (IDT- team from different healthcare disciplines who work together to provide comprehensive patient care) to review new orders during their daily meeting. The DON stated the IDT would discuss the orders as a group, where to schedule the appointments and then the SSD was responsible for scheduling the appointments. The DON stated the facility did not have a good system in place to verify appointments were made and followed up on and they were in the process of putting a new system in place. The DON stated she was unaware of Resident 1, 2, and 3's appointments were never completed. The DON stated she was not aware the SSD was keeping paper notes and stated it was not a wise choice. The DON stated the information needed to be documented in the Resident's EMR so everyone could track the appointment and follow up as needed. The DON stated the SSD should document all follow up phone calls in a progress note in the EMR. During a telephone interview on 3/24/26 at 4:16 p.m. with the Administrator, the ADM stated the IDT was made aware of the referral issues recently. The ADM stated his expectations were for the physician's orders to be followed and for the SSD to schedule the appointments as ordered. The ADM stated the SSD told him she was documenting on paper which was kept in her office and was not part of the EMR. The ADM stated he instructed the SSD her work needed to be documented in the Residents medical records because papers could be lost. The ADM stated the SSD notified him the MBS required the RP to be present at the appointment which was an issue. The ADM stated they were working with the RPs to have them attend an appointment. The ADM stated the facility was responsible for carrying out the physician orders. The ADM stated he was the SSDs direct supervisor, but he was not aware she was not documenting in the EMR. The SSD stated the notes needed to be a part of the medical record. The ADM stated he reviewed the EMR with the SSD and she showed him where she was entering appointments after they were made in the communication section of the EMR program. The ADM stated the communication board was automatically cleared within 3 days and was not part of the permanent medical record.During a review of the facility's P&P titled Charting and Documentation, July 2017, the P&P indicated, . All services provided to the resident, progress toward the care plan goals, or changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. Documentation of procedures and treatments will include care-specific details, including. notification of family, physician or other staff.During a review of the facility's P&P titled Referrals, Social Services, dated 12/2008, . Social services personnel shall coordinate most resident referrals with outside agencies. Social services shall coordinate most resident referrals. Social services will collaborate with the nursing staff or other pertinent disciplines to arrange for services that have been ordered by the physician. Social services will document the referral in the resident's medical record.During a review of the facility's Job Description: Director of Social Service, undated, the job description indicated, . primary purpose of your job position is to assist in planning, developing, organizing, implementing evaluating, and directing social service programs in accordance with current federal, state, and local standards, guidelines, and facility policies and procedures [P&P], to assure that the medically related emotional and social needs of the resident are met/maintained on an individual basis. As Social Services Director you are delegated the administrative authority, responsibility and accountability necessary for carrying out your assigned duties. Record and maintain regular Social Service progress notes indicating response to the treatment plan and/or adjustment to institutional life. Perform other charting duties as necessary. Assist in making appointments for the resident/family as requested or appropriate. Assist in arranging transportation. Assist in obtaining resources from community social, health and welfare agencies to meet the needs of the resident.

Based on interview and record review, the facility's Administrator (ADM) failed to provide effective oversight and necessary resources to ensure resident care services were met to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident for four of seven sampled residents (Residents 1, 2, and 3) when the Administrator did not provide oversight and supervision of the Social Services Director (SSD) and Residents 1, 2, and 3's physician ordered consultations and testing as outside entities were not scheduled timely and there was no documentation of a follow up or reason in the electronic medical record (EMR). This failure had the potential for residents' needs to go unmet. (cross reference F745 and F842)During a review of Resident 1's admission Record, undated, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (severe paralysis affecting one side of the body) and hemiparesis (weakness, numbness or reduced movement on one side of the body) following cerebral infarction (type of stroke caused by a blockage in the blood vessels sullying the brain resulting in tissue death), dysphagia (difficulty swallowing), aphasia (communication disorder caused by brain damage impairing a person's ability to process, speak, write or understand language), and gastrostomy (G-tube- medical device inserted through the abdomen directly into the stomach to deliver nutrition).During an observation on 3/23/26 at 11:15 a.m. with Resident 3, Resident 3 was lying in bed. Resident 3 had an enteral feeding pump (medical device that delivers liquid nutrition directly into the patient's stomach) at bedside not hooked up to his gastrostomy tube. Resident 3 was verbally nonresponsive.During a review of Resident 3's admission Record, undated, the admission record indicated, Resident 3 was admitted to the facility on [DATE] with diagnoses that included seizures (sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank states and loss of consciousness), dystonia (movement disorder that causes the muscles to contract), history of traumatic brain injury (form of acquired brain damage caused by a sudden external force) and gastrostomy.During a concurrent observation and interview on 3/23/26 at 11:18 a.m. with Resident 2, Resident 2 was groomed, dressed and lying in bed. Resident 2 stated he was unsure if he had any outside testing or consultations ordered.During a review of Resident 2's admission Record, undated, the admission record indicated, Resident 2 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), dysphagia, and altered mental status.During a concurrent interview and record review on 2/23/26 at 12:28 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 2's physician's order dated 10/9/26, was reviewed. The order indicated, . 10/9/3025. Modified Barium Swallow [MBS- real-time X-ray procedure used to evaluate swallowing function, identify aspiration (food/liquid entering the lungs), and determine safe food textures] to R/O [rule out] Silent Aspiration. Resident 2's Nurses Notes, dated 10/9/25, indicated, . [name of physician] made rounds and examined resident with new order for Modified Barium Swallow to R/o Silent Aspiration [name of SSD] Social Service notified. LVN 1 stated the note indicated the SSD was notified and should have scheduled the MBS according to the physician's order. Resident 3's physician's order dated 7/22/25, indicated, . for Barium Swallow Consult. Resident 3's Nurses Notes, dated 7/22/25, indicated, . [name of physician] made rounds examined resident with New order for Barium Swallow Consult [name of Social Services Assistant (SSA)] Social Worker notified. LVN 1 stated the SSA or SSD should have scheduled the appointment and documented any follow-up in the residents EMR. Resident 1's physician's orders, dated 12/10/25 was reviewed and indicated, . EENT [Ear, Nose and Throat] Consult to assist Vocal Cord Mobility [normal movement of the vocal cords required for breathing, swallowing, and producing sound]. Modified Barium Swallow to r/o Silent aspiration to help determine if PO [by mouth] diet placement is possible. LVN 1 stated the MBS was ordered to see if he could tolerate oral food and drink safely. LVN 1 was unable to locate documentation the SSD had scheduled appointment or followed up. LVN 1 stated the process for scheduling consultations and outside appointments such as the MBS was for the physician to enter the order, then the nurse would document in the nurse's note they received the order and then send it to the SSD who would schedule the appointments.During a concurrent interview and record review on 3/23/26 at 3:00 p.m., with the SSD, the SSD stated the referral process for consultations or outside testing was for a physician order to be placed, then nursing would send her a copy of the order. The SSD stated if she was not at the facility, the nursing staff would place the order under the door of her office. The SSD stated she would then start the process for scheduling the appointments. The SSD stated she did not document attempts to schedule appointments or follow-up notes in the EMR but kept papers in a folder with the orders and her notes on them. The SSD declined to answer if her folder was part of the Resident's medical record. The SSD stated she was told by the ST she was going to have a physician order placed, but she did not receive an order and did not follow up. The SSD stated that when she scheduled appointments, she would place a communication note in the facility's EMR program, but those notes were deleted after a set amount of time, it was not a part of the resident's medical record. Resident 3's order for an MBS on 7/22/25 was reviewed, the SSD stated she had contacted Resident 3's sister when she had called to schedule the appointment and the hospital indicated an RP needed to attend Resident 3's appointment to sign consents. The SSD stated she called the RP several times but did not document any of the attempts to schedule the MBS or contact the sister in the EMR. The SSD stated if something was not documented it was considered not done. The SSD stated she did not follow up with the ST after she was unable to schedule the test. The SSD stated Resident 2 had refused to have the MBS, so she had contacted his RP. The SSD stated she did not document a note in the resident's medical record that the resident and RP refused the appointment. Resident 1's order for the MBS and ENT consultation from 12/20/25 was reviewed and the SSD stated Resident 1 had been scheduled for an in-house ENT consultation on 2/23/26 but had discharged prior to the appointment. The SSD stated she did not document the appointment in the EMR. The SSD stated Resident 1's MBS had not been scheduled because they were waiting for the ENT consultation. The SSD stated she was working with Resident 1's insurance to have the MBS approved but had not received authorization prior to the residents' discharge. The SSD was unable to state if the ST or primary physician had been notified of the delay in the MBS appointment and had not documented any notification or follow up in the EMR. The SSD stated the ST usually notified her of recommended tests and consultations, but the SSD did not follow up unless she received the physician order. The SSD was unable to answer if the residents' needs had been met without the ordered tests and follow-up. The SSD stated she should have documented in the EMR so her attempts to schedule the appointments and follow-up phone calls were a part of the medical record.During a telephone interview on 3/24/26 at 4:16 p.m. with the Administrator (ADM), the ADM stated the IDT was made aware of the referral issues recently. The ADM stated his expectations were for the physician's orders to be followed and for the SSD to schedule the appointments as ordered. The ADM stated the SSD told him she was documenting on paper which was kept in her office and was not part of the EMR. The ADM stated he instructed the SSD her work needed to be documented in the Residents medical records because papers could be lost. The ADM stated the SSD notified him the hospital required the RP to be present at the MBS appointment which was an issue. The ADM stated they were working with the RPs to have them attend an appointment. The ADM stated advancing diet was in the ST's scope of practice and it sounds doubtful they [the MBS'] are necessary. But I'm not a clinician. The ADM stated the facility was responsible for carrying out the physician orders. The ADM stated he was the SSDs direct supervisor, but he was not aware she had not scheduled the appointments or documented in the EMR. The ADM stated the appointment scheduling and follow-up notes needed to be a part of the medical record. The ADM stated he reviewed the EMR with the SSD and she showed him where she was entering appointments after they were made in the communication section of the EMR program. The ADM stated the communication board was automatically cleared within 3 days and was not part of the permanent medical record.During a review of the facility's Job Description: Administrator, undated, the job description indicated, . primary purpose of your job position is to direct the day-to-day nursing functions of the facility in accordance with current federal, state, and local standards. and in accordance with the policies and procedures specified for the operation of the facility to assure that the highest degree of quality care can be provided to all patients/residents at all times. Develop and maintain written policies and procedures and professional standards of practice that govern the operation of the facility. Make routine inspections of the facility to assure that established policies and procedures are being implemented. Consult with department directors concerning the operation of their departments to assist in eliminating/correcting problem areas, and/or improvement of services. Review and check competence of work force and make necessary adjustments/corrections as required.During a review of the facility's policy and procedure (P&P) titled Referrals, Social Services, dated 12/2008, the P&P indicated, . Social Services personnel shall coordinate most resident referrals with outside agencies. Referrals for medical services must be based on physician evaluation of resident need. Social services will collaborate with the nursing staff or other pertinent disciplines to arrange for services that have been ordered by the physician. Social Services will document the referral in the resident's medical record.

Based on interview and record review, the facility failed to provide medically related social service needs for three of seven sampled residents (Residents 1, 2, and 3) when the Social Services Director (SSD) did not schedule physician ordered consultations and diagnostic testing from outside entities and failed to document any attempts to schedule the appointments or contact with the responsible parties (RP) in the electronic medical record (EMR). These failures caused a delay in care and had the potential for the residents' needs to go unmet. (cross reference F842)During a review of Resident 1's admission Record, undated, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (severe paralysis affecting one side of the body) and hemiparesis (weakness, numbness or reduced movement on one side of the body) following cerebral infarction (type of stroke caused by a blockage in the blood vessels sullying the brain resulting in tissue death), dysphagia (difficulty swallowing), aphasia (communication disorder caused by brain damage impairing a person's ability to process, speak, write or understand language), and gastrostomy (G-tube- medical device inserted through the abdomen directly into the stomach to deliver nutrition).During an observation on 3/23/26 at 11:15 a.m. with Resident 3, Resident 3 was lying in bed. Resident 3 had an enteral feeding pump (medical device that delivers liquid nutrition directly into the patient's stomach) at bedside not hooked up to his gastrostomy tube. Resident 3 was verbally nonresponsive.During a review of Resident 3's admission Record, undated, the admission record indicated, Resident 3 was admitted to the facility on [DATE] with diagnoses that included seizures (sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank states and loss of consciousness), dystonia (movement disorder that causes the muscles to contract), history of traumatic brain injury (form of acquired brain damage caused by a sudden external force) and gastrostomy.During a concurrent observation and interview on 3/23/26 at 11:18 a.m. with Resident 2, Resident 2 was groomed, dressed and lying in bed. Resident 2 stated he was unsure if he had any outside testing or consultations ordered.During a review of Resident 2's admission Record, undated, the admission record indicated, Resident 2 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), dysphagia, and altered mental status.During an interview on 3/23/26 at 11:26 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was assigned to Residents 2 and 3. CNA 1 stated Resident 2 was receiving a modified diet (altered food consistency to assist with swallowing difficulties), mechanical soft (foods that are soft, moist, chopped, ground or pureed to require minimal chewing) with nectar thick liquids (mildly thick liquids designed for residents with difficulty swallowing). CNA 2 stated Resident 3 had a G-tube feeding and he did not eat orally for as long as she had known him.During a concurrent interview and record review on 2/23/26 at 12:28 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was assigned to Residents 2 and 3. Resident 2's physician's order dated 10/9/26, was reviewed. The order indicated, . 10/9/3025. Modified Barium Swallow [MBS- real-time X-ray procedure used to evaluate swallowing function, identify aspiration (food/liquid entering the lungs), and determine safe food textures] to R/O [rule out] Silent Aspiration. Resident 2's Nurses Notes, dated 10/9/25, indicated, . [name of physician] made rounds and examined resident with new order for Modified Barium Swallow to R/o Silent Aspiration [name of SSD] Social Service notified. LVN 1 stated it was important to schedule Resident 2's MBS to rule out swallowing issues because he had a high risk of choking on food and drink and could aspirate. LVN 1 stated the staff were aware Resident 2 was at high risk of aspiration and would watch him carefully while he ate and made sure his liquids were the correct thickened consistency. LVN 1 stated the note indicated the SSD was notified and should have scheduled the MBS according to the physician's order. Resident 3's physician's order dated 7/22/25, indicated, . for Barium Swallow Consult. Resident 3's Nurses Notes, dated 7/22/25, indicated, . [name of physician] made rounds examined resident with New order for Barium Swallow Consult [name of Social Services Assistant (SSA)] Social Worker notified. LVN 1 stated Resident 3 had swallowing issues so he had the G-tube for nutrition and medication because he was not safe to eat or drink by mouth. LVN 1 stated the SSA or SSD should have scheduled the appointment and documented any follow-up in the residents EMR. Resident 1's physician's orders, dated 12/10/25 was reviewed and indicated, . EENT [Ear, Nose and Throat] Consult to assist Vocal Cord Mobility [normal movement of the vocal cords required for breathing, swallowing, and producing sound]. Modified Barium Swallow to r/o Silent aspiration to help determine if PO [by mouth] diet placement is possible. LVN 1 stated Resident 1 was her resident while he was at the facility but had been discharged . LVN 1 stated Resident 1 had a G-tube when he was admitted to the facility and had graduated to an oral diet while admitted . LVN 1 stated the MBS was ordered to see if he could tolerate oral food and drink safely. LVN 1 stated it was important for Resident 1 to have the test done to rule out choking or aspiration with oral intake. LVN 1 was unable to locate documentation the SSD had scheduled appointment or followed up. LVN 1 stated the process for scheduling consultations and outside appointments such as the MBS was for the physician to enter the order, then the nurse would document in the nurse's note they received the order and then send it to the SSD who would schedule the appointments. LVN 1 stated she would print the order and give a copy to the SSD for follow up. LVN 1 stated after the SSD has the order, the nurses do not normally follow up because the SSD was responsible for scheduling the appointments.During a concurrent interview and record review on 3/23/26 at 1:57 p.m. with the Speech Therapist (ST), the ST stated Residents 1, 2, and 3 had MBS' ordered and the SSD did not schedule the appointments. The ST stated she was treating Resident 1 while he was in the facility, the resident was dependent on a G-tube feeding and needed an MBS to be sure he could tolerate an oral diet without aspirating. The ST stated Resident 1 was also supposed to have an ENT consultation for his vocal cords to help with his communication. The ST stated Resident 2 needed an MBS to rule out if he was aspirating while eating to prevent any respiratory infections and to assess if he could tolerate advancing his diet. The ST stated Resident 3 was dependent on a G-tube feeding and had an order for an MBS on 7/22/25 to assess if he would be able to tolerate an oral diet. The ST stated she would discuss needed consultations with the SSD after the physician placed an order and the resident or responsible party had agreed to the testing and/or consultation. The ST stated she had been told by the SSD that it would take three months for the tests and consultations to be scheduled. The ST stated she had discussed Resident 3's MBS and had followed up with the SSD three months later and was told the SSD was still working on scheduling the test. The ST stated the SSD stated Resident 2 had refused the MBS, but she had already discussed the test with Resident 2 and his RP and they agreed with the testing. The ST stated the process if she determined a resident needed a consultation or MBS was to discuss it with the patient and RP, if okay request an order from the physician either directly or through the charge nurse, then the order was to be sent by nursing to the SSD for scheduling.During a concurrent interview and record review on 3/23/26 at 3:00 p.m., with the SSD, the SSD stated the referral process for consultations or outside testing was for a physician order to be placed, then nursing would send her a copy of the order. The SSD stated if she was not at the facility, the nursing staff would place the order under the door of her office. The SSD stated she would then start the process for scheduling the appointments. The SSD stated she did not document attempts to schedule appointments or follow-up notes in the EMR but kept papers in a folder with the orders and her notes on them. The SSD declined to answer if her folder was part of the Resident's medical record. The SSD stated that when she scheduled appointments, she would place a communication note in the facility's EMR program, but those notes were deleted after a set amount of time, it was not a part of the resident's medical record. Resident 3's order for an MBS on 7/22/25 was reviewed, the SSD stated she had contacted Resident 3's sister when she had called to schedule the appointment and the hospital indicated an RP needed to attend Resident 3's appointment to sign consents. The SSD stated she called the RP several times but did not document any of the attempts to schedule the MBS or contact the sister in the EMR. The SSD stated if something was not documented it was considered not done. The SSD stated she did not follow up with the ST after she was unable to schedule the test. The SSD stated Resident 2 had refused to have the MBS, so she had contacted his RP. The SSD stated she did not document a note in the resident's medical record that the resident and RP refused the appointment. Resident 1's order for the MBS and ENT consultation from 12/20/25 was reviewed and the SSD stated Resident 1 had been scheduled for an in-house ENT consultation on 2/23/26 but had discharged prior to the appointment. The SSD stated she did not document the appointment in the EMR. The SSD stated Resident 1's MBS had not been scheduled because they were waiting for the ENT consultation. The SSD stated she was working with Resident 1's insurance to have the MBS approved but had not received authorization prior to the residents' discharge. The SSD was unable to state if the ST or primary physician had been notified of the delay in the MBS appointment and had not documented any notification or follow up in the EMR. The SSD stated the ST usually notified her of recommended tests and consultations, but the SSD did not follow up unless she received the physician order. The SSD was unable to answer if the residents' needs had been met without the ordered tests and follow-up. The SSD stated she should have documented in the EMR so her attempts to schedule the appointments and follow-up phone calls were a part of the medical record.During an interview on 3/23/26 at 3:55 p.m. with the Director of Nursing, the DON stated the process for consultations and outpatient diagnostic testing were for the Interdisciplinary team (IDT- team from different healthcare disciplines who work together to provide comprehensive patient care) to review new orders during their daily meeting. The DON stated the IDT would discuss the orders as a group, where to schedule the appointments and then the SSD was responsible for scheduling the appointments. The DON stated the facility did not have a good system in place to verify appointments were made and followed up on and they were in the process of putting a new system in place. The DON stated she was unaware of Resident 1, 2, and 3's appointments were never completed. The DON stated she was not aware the SSD was keeping paper notes and stated it was not a wise choice. The DON stated the information needed to be documented in the Resident's EMR so everyone could track the appointment and follow up as needed. The DON stated the SSD should document all follow up phone calls in a progress note in the EMR. The DON stated it was important for the physician ordered ENT consultations and MBS' to be scheduled as ordered for quality and continuity of care.During a telephone interview on 3/24/26 at 4:16 p.m. with the Administrator (ADM), the ADM stated the IDT was made aware of the referral issues recently. The ADM stated his expectations were for the physician's orders to be followed and for the SSD to schedule the appointments as ordered. The ADM stated the SSD told him she was documenting on paper which was kept in her office and was not part of the EMR. The ADM stated he instructed the SSD her work needed to be documented in the Residents medical records because papers could be lost. The ADM stated the SSD notified him the hospital required the RP to be present at the MBS appointment which was an issue. The ADM stated they were working with the RPs to have them attend an appointment. The ADM stated advancing diet was in the ST's scope of practice and it sounds doubtful they [the MBS'] are necessary. But I'm not a clinician. The ADM stated the facility was responsible for carrying out the physician orders. The ADM stated he was the SSDs direct supervisor, but he was not aware she had not scheduled the appointments or documented in the EMR. The ADM stated the appointment scheduling and follow-up notes needed to be a part of the medical record. The ADM stated he reviewed the EMR with the SSD and she showed him where she was entering appointments after they were made in the communication section of the EMR program. The ADM stated the communication board was automatically cleared within 3 days and was not part of the permanent medical record. During a review of the facility's Job Description: Director of Social Service, undated, the job description indicated, . primary purpose of your job position is to assist in planning, developing, organizing, implementing evaluating, and directing social service programs in accordance with current federal, state, and local standards, guidelines, and facility policies and procedures [P&P], to assure that the medically related emotional and social needs of the resident are met/maintained on an individual basis. As Social Services Director you are delegated the administrative authority, responsibility and accountability necessary for carrying out your assigned duties. Record and maintain regular Social Service progress notes indicating response to the treatment plan and/or adjustment to institutional life. Perform other charting duties as necessary. Assist in making appointments for the resident/family as requested or appropriate. Assist in arranging transportation. Assist in obtaining resources from community social, health and welfare agencies to meet the needs of the resident.During a review of the facility's policy and procedure (P&P) titled Referrals, Social Services, dated 12/2008, the P&P indicated, . Social Services personnel shall coordinate most resident referrals with outside agencies. Referrals for medical services must be based on physician evaluation of resident need. Social services will collaborate with the nursing staff or other pertinent disciplines to arrange for services that have been ordered by the physician. Social Services will document the referral in the resident's medical record.

Based on observation, interview and record review the facility failed to ensure the facility employed an infection preventionist (professionals who works to stop the spread of infections within a healthcare facility) to meet the facility's infection control needs when the facility did not have a trained and certified infection preventionist for over two weeks and the staff failed to follow proper infection control procedures including failing to follow the facility's infection control policy and procedure for performing fingerstick blood glucose, one of three CNA's did not perform hand hygiene when entering and exiting a resident room after touching the residents environment and enhanced barrier precaution signs were not hung by the PPE carts for two rooms.These failures had the potential to have an outbreak of infectious disease throughout the facility. (Cross reference F880)During a concurrent interview on 11/25/25 at 10:30 a.m. with the Administrator (ADM) and the Assistant Director of Nurses (ADON), the ADM stated the facility did not have an Infection Preventionist (IP) because the IP was terminated two weeks prior. The ADM stated there were multiple people covering the IP role including the ADON, DON and DSD. The ADON stated he had been off work for a month and returned today. The ADON was unable to answer how he had performed the IP duties while he was not working.During an interview on 11/25/25 at 10:56 a.m. with CNA 1, CNA 1 stated she had not seen the IP for a month and there were no recent infection prevention in-services provided recently.During an interview on 11/25/25 at 11:12 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated the facility had an IP but we have not seen her for a few weeks. LVN 2 stated the IP was employed for a short period of time. LVN 2 stated an IP was important to the facility because they were responsible for staff education and to make sure infection control procedures were followed.During a concurrent observation and interview on 11/25/25 at 11:31 a.m. with CNA 3, CNA 3 was observed entering room [ROOM NUMBER], touching the resident's environment and exiting the room without performing hand hygiene. CNA 3 stated she could not remember when the last infection prevention training was provided for the staff. CNA 3 stated she did not know who the IP was now and stated, I don't think we have one.During an interview on 11/25/25 at 11:35 a.m. with LVN 1, LVN 1 stated the facility had not had an IP for a while, but she was not sure of the exact timeframe.During an interview on 11/25/25 at 1:07 p.m. with the DSD, the DSD stated she started working at the facility on 11/3/25. The DSD stated she never met the IP and was told she worked from home. The DSD stated she had been making rounds and had identified infection control issues which she was scheduling in-services for the staff. The DSD stated she did not have an IP certification and had not attended the IP classes. The DSD stated she was not certified to perform the IP duties.During an interview on 11/25/25 at 1:27 p.m. with the ADON, the ADON stated he was IP certified but had been off for about a month. The ADON stated the IP was no longer employed by the facility, but he was not sure when her last day was.During an interview on 11/25/25 at 1:44 p.m. with the DON, the DON stated she was not IP certified. The DON stated there had been no certified IP meeting the facility's infection preventionist duties. The DON stated it was necessary to have an IP employed to meet the regulations and facility's needs. The DON stated she last saw the IP onsite the week of 9/30/25 which was when she had started working at the facility. The DON stated she had not seen the IP onsite for the past three weeks.During a review of an e-mail dated 12/1/25, from the Administrator (ADM), the e-mail indicated the IP's resignation date from the facility was 11/14/25. The ADM indicated the IP's last day onsite at the facility was 10/31/25.During a review of the facility's Job Description: Infection Control Coordinator, undated, the job description indicated, . primary purpose of your job is to plan, organized, develop, coordinate, and direct our infection control program and its activities in accordance with current federal, state, and local standards, guideline, and regulations. Coordinate the development and monitoring of our facility's established infection prevention and control policies and practices. Plan, develop, organize, implement, evaluate, and director our infection control program. Monitor infection control practices and procedures to ensure that all personnel are implementing our standard operating procedures. Make rounds to nursing units for the purpose of case findings, review of environmental sanitation procedures, and supervision of isolation precautions/practices. Orient new employees to the importance of infection control policies and procedures. Ensure that all nursing service personnel follow established isolation precautions and aseptic technique to include universal precautions . Make rounds. Monitor medication passes and treatments to ensure that appropriate hand washing techniques are being followed in the handling and administering of drugs, medications, and treatments. Develop and participate in the planning, conducting, and scheduling of timely in-service training classes and educational programs that provide instructions on how to do the job.During a professional reference review titled State Operations Manual [SOM], Appendix PP, dated 7/23/25, the SOM, indicated, . Infection preventionist . The facility must designate one or more individual(s) as the infection preventionist(s) (IP)(s) who are responsible for the facility's IPCP [infection prevention and control plan]. The IP must . Be qualified by education, training, experience or certification . Work at least part-time at the facility . Have completed specialized training in infection prevention and control. The IP must physically work onsite in the facility. He/she cannot be an off-site consultant or perform the IP work at a separate location .An IP must have obtained specialized IPC [infection prevention and control] training beyond initial professional training or education prior to assuming the role.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections when:1. Two out of three Licensed Vocational Nurses (LVN 1 and 3), did not follow infection control measures while checking fingerstick (pricking a fingertip with a small needle to obtain a sample of blood) blood glucose (measures the level of sugar in the blood) on residents 4, 5 and 7. This failure had the potential to spread germs from the residents environment to other residents and expose residents to other resident's blood. 2. One of three Certified Nursing Assistants (CNA) failed to perform hand hygiene before and after providing resident care and contact with the resident's environment. This failure had the potential to spread infections between residents.3. Two rooms on enhanced barrier precautions (EBP-infection control measures for nursing homes that involve wearing a gown and gloves during high-contact activities with residents who are colonized or infected with multidrug-resistant organisms [MDROs-germs resistant to many antibiotics] or have wounds or indwelling medical devices [a medical device which provides a direct pathway for pathogens in the environment to enter the body and cause infection]) did not have signage to notify staff of necessary precautions prior to entering rooms [ROOM NUMBERS]. This failure had the potential for staff to not don (put on) the correct personal protective equipment (PPE-equipment [such as gloves, gowns, masks and eye protection] worn by staff to minimize exposure to infectious materials) when coming in contact with the residents and potentially spreading infection to susceptible residents.1. During a concurrent observation and interview on 11/25/25 at 11:35 a.m. with LVN 1, in front of Resident 4's room, LVN 1 prepared items to check Resident 4's blood glucose. LVN 1 took a glucometer (a small, portable device used to measure the amount of glucose in a small drop of blood), testing strip, a lancet (a sharp instrument to make small punctures in the skin) and alcohol swab from the medication cart and walked into Resident 4's room. LVN 1 placed the glucometer directly onto Resident 4's overbed table. LVN 1 checked Resident 4's blood glucose grabbed the glucometer pulled the strip out and walked back to the medication cart placing the soiled glucometer on top of the cart without a barrier. LVN 1 then took off her soiled gloves, did hand hygiene and donned new gloves. LVN 1 took a disinfecting wipe (premoistened towelette saturated with an antimicrobial solution designed to kill bacteria [germs that can cause infection] and viruses [germ that have the potential to infect a person]) and wiped down the glucometer. LVN 1 stated the disinfecting wipes had a 2-minute contact time (the amount of time a disinfectant must remain wet on a surface to effectively kill germs) and stated the contact time was the amount of time you allow the equipment to dry to kill germs. LVN 1 she was not aware the 2-minute contact time meant the equipment needed to be wet for 2-minutes to disinfect the equipment.During a concurrent observation and interview on 11/25/25 at 11:45 a.m. with LVN 1 in front of Resident 5's room, LVN 1 took the glucometer with a strip inserted, lancet and alcohol swab into the resident's room and placed all items directly on the resident's bed, on top of the blanket. LVN 1 checked the resident's blood glucose then took the glucometer out and laid it directly on top of the medication cart. LVN 1 stated, I should not have laid it [the glucometer] directly on the bed. LVN 1 stated the glucometer could spread germs to other residents if it were not properly handled and cleaned. LVN 1 stated the glucometer could spread germs from the resident's environment to the top of the medication cart. LVN 1 stated she should have placed a barrier such as a paper towel under the glucometer on the residents table and the med cart.During a concurrent observation and interview on 11/25/25 at 12:07 p.m. with LVN 3 in front of Resident 7's room, LVN 3 placed a drape on top of the medication cart, then placed the glucometer on top. LVN 3 donned a gown and gloves and stated Resident 7 was on EBPs. LVN 3 placed a paper towel on the overbed table and placed the glucometer, strip, lancet and alcohol swab on top. LVN 3 checked Resident 7's blood glucose then doffed (to take off) his gown, took the strip out of the glucometer, pulled off his gloves and placed the soiled glucometer directly on top of the medication cart. LVN 3 stated he should not have placed the soiled glucometer on top of the medication cart without a barrier because it contaminated the top of the medication cart.During an interview on 11/25/25 at 1:07 p.m. with the Director of Staff Development (DSD), the DSD stated she had done rounds the previous day and noticed the nurses needed an in-service to review the nurse's glucometer infection prevention methods because they needed to improve.During an interview on 11/25/25 at 1:44 p.m. with the Director of Nursing (DON), the DON stated the nurses needed to clean and disinfect the glucometer thoroughly between residents. The DON stated the disinfecting wipes used by the facility had a 2-minute contact time and should be kept wet for 2 minutes to disinfect the glucometer correctly. The DON stated the glucometer should be placed on a barrier such as a paper towel or tissue on top of a flat surface. The DON stated the glucometer needed to be disinfected prior to moving to another resident and a clean barrier should be placed on top of the medication cart prior to placing a soiled glucometer on it. The DON stated the resident's overbed tables could have blood, body fluids or leftover food from meals. The DON stated if the glucometer were moved from the resident's environment to the top of the medication cart without a barrier down, it could transmit germs for all residents receiving medication from the same medication cart.During a review of the facility's P&P titled Blood Sampling-Capillary (Finger Sticks), dated 9/2014, the P&P indicated, . purpose of this procedure is to guide the safe handling of capillary-blood sampling devices to prevent transmission of bloodborne diseases to residents and employees . Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses . Steps in the Procedure . Wash hands . [NAME] gloves . Place blood glucose monitoring device on clean field [physical barrier to reduce the number of overall germs] . Obtain the blood sample . Following the manufacturer's instructions, clean and disinfect reusable equipment . after each use .During a review of the blood glucose monitor manufacturer guidelines, the guidelines indicated, . The meter should be cleaned and disinfected after use on each patient . cleaning procedure is needed to clean dirt, blood and other bodily fluids off exterior of the meter before performing the disinfecting procedure . disinfecting procedure is needed to prevent the transmission of bloodborne pathogens . each time the cleaning and disinfecting procedure is performed two wipes are needed. One wipe to clean the meter and a second wipe to disinfect the meter . an LTC [long term care] facility establish a program for infection control and identify a key individual responsible for the overall program oversight . program should include addressing the cleaning and disinfecting of blood glucose meters along with other equipment and environmental surfaces .During a review of the facility's policy and procedure (P&P) titled Policies and Practices-Infection Control, dated 10/2023, the P&P indicated, . This facility's infection control policies and practices apply equally to all personnel . objectives of our infection control policies and practices are to . prevent, detect, investigate, and control infections in the facility . establish guidelines for implementing isolation precautions, including standard and transmission-based precautions . maintain records of incidents and corrective actions related to infections . 2. During an interview on 11/25/25 at 10:56 a.m. with CNA 1, CNA 1 stated hand hygiene should be done every time a staff member enters or exits a resident's room and before and after contact with the resident or their belongings. CNA 1 stated hand hygiene prevents the spread of disease to other residents.During a concurrent observation and interview on 11/25/25 at 11:31 a.m. with CNA 3, CNA 3 was observed entering room [ROOM NUMBER] without performing hand hygiene and assisted the resident with her bed, touching the resident's environment and left the room without performing hand hygiene. There was an Enhanced Barrier Precautions, sign hanging above the door outside room [ROOM NUMBER], the sign indicated . Everyone must. Clean their hands including before entering and when leaving the room . CNA 3 stated she should have used hand sanitizer prior to entering and exiting the room. CNA 3 stated poor hand hygiene (cleaning hands to prevent the spread of germs by either washing them or using an alcohol-based hand sanitizer) could spread germs to other residents.During an interview on 11/25/25 at 1:07 p.m. with the DSD, the DSD stated the hand hygiene expectations were for staff to use hand sanitizer gel or wash hands, prior to and upon leaving the resident rooms. The DSD stated hand hygiene was important to prevent the spread of disease to the residents and staff.During an interview on 11/25/25 at 1:44 p.m. with the DON, the DON stated hand hygiene was to be performed when entering and exiting resident rooms, prior to moving from resident to resident and before and after administering medication. The DON stated if hand hygiene was not performed correctly, it could transmit infection from resident to resident or from resident to staff.During a review of the facility's P&P titled Handwashing/Hand Hygiene, dated 8/2019, the P&P indicated, . facility considers hand hygiene the primary means to prevent the spread of infections . All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . Use an alcohol-based hand rub containing at least 62% alcohol . or, alternatively, soap . and water for the following situations . before and after coming on duty . Before and after direct contact with residents . After contact with a residents' intact skin . After contact with objects in the immediate vicinity of the resident . Before and after entering isolation precaution settings .3. During an observation on 11/25/25 at 10:50 a.m., rooms [ROOM NUMBERS] had Personal Protective Equipment (PPE) carts in front of the room with no signage indicating the reason for the PPE cart or instructions for use of PPE for the necessary precautions.During an interview on 11/25/25 at 10:56 a.m. with CNA 1, CNA 1 stated she was assigned to rooms [ROOM NUMBERS]. CNA 1 stated the PPE carts were in front of the rooms but there were no signs because the residents in those rooms were not on any precautions. CNA 1 stated she had asked the nurses previously and was told the residents in the rooms did not need PPE for precautions. CNA 1 stated EBPs were a type of isolation when the residents had a wound or urinary catheter. CNA 1 stated EBP signage notifies the staff to wear gloves and a gown any time they provide care to the residents.During an observation on 11/25/25 at 11:03 a.m. in front of rooms [ROOM NUMBERS], Enhanced Barrier Precautions signs were hanging above the PPE carts indicating . Everyone must. Clean their hands including before entering and when leaving the room . Wear gloves and a gown for the following High-Contact Resident Care Activities . Dressing. Bathing . transferring . providing hygiene. assisting with toileting . Device care or use. Wound care .During an interview on 11/25/25 at 11:55 a.m. in the hallway in front of rooms 5 & 6, the Director of Staff Development came down the hallway and stated she hung the EBP signs above the PPE carts in front of rooms [ROOM NUMBERS] this morning. The DSD stated the signs were missing and should have been on the wall above the PPE carts, so staff were aware of what precautions to take and what PPE to wear.During an interview on 11/25/25 at 11:10 a.m. with the Assistant Director of Nursing (ADON), the ADON stated isolation or precaution signs should hang above the PPE cart to notify staff what type of PPE is needed and the necessary precautions to take when providing care for the residents.During an interview on 11/25/25 at 1:44 p.m. with the Director of Nursing (DON), the DON stated there needed to be a sign hanging above the PPE carts when residents are on any type of isolation or EBP. The DON stated staff and visitors needed to know what types of precautions to use to keep the residents safe and limit the transmission of infectious disease.During a review of the facility's P&P titled Enhanced Barrier Precautions, dated 8/2022, the P&P indicated, . Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents . used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MRDOs) to residents . EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise [NAME] . Examples of high-contact resident care activities . dressing bathing/showering . transferring . providing hygiene . changing linens . changing briefs or assisting with toileting . device care or use . wound care . Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required . PPE is available outside of the resident rooms .During a review of a professional reference retrieved from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html titled Definition and scope of Enhanced Barrier Precautions, dated 6/28/24, the reference indicated, . Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multi-drug resistant organisms (MDROs) in nursing homes . Enhanced Barrier Precautions expand the use of gown and gloves beyond anticipated blood and body fluid exposures . use of gown and gloves during high-contact resident care activities that have been demonstrated to result in the transfer of MDROs to hands and clothing of healthcare personnel . Signs are intended to signal to individuals entering the room the specific actions they should take to protect themselves and the resident. To do this effectively, the sign must contain information about the type of Precautions and the recommended PPE to be worn when caring for the resident.

Based on observation, interview, and record review the facility failed to provide foot care and treatment, in accordance with professional standards of practice for two of four sampled residents (Resident 1 and Resident 4) when Resident 1 and Resident 4 had long, overgrown toenails. This failure had the potential to result in Resident 1 and Resident 4 cutting their skin with their long toenails, leading to poor wound healing, infection, and hospitalization. Findings:During a concurrent observation and interview on 9/10/25 at 11:26 a.m. with Certified Nursing Assistant (CNA) 1 in the hallway outside Resident (R) 4's room, R 4 was non-verbal and observed wearing a gown, laying in a geriatric chair (Geri-chair - a semi-specialized seating for older adults that achieves a reclined position and elevated leg rest) in the hallway with his left foot uncovered. R 4's left foot toenails were observed to be long, yellow, thick and jagged with dark crusted substance under his left big toenail. CNA 1 stated if a resident was not diabetic (when the blood sugar levels in the body are too high), the nurses trimmed the resident's nails. CNA 1 stated the CNAs filled out the resident's shower sheet, which indicated areas of concern for the nurse to review, and marked if the resident's toenails needed to be trimmed. CNA 1 stated R 4's toenails needed to be trimmed.During a review of R 4's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information, dated 9/10/25, the AR indicated R 4 was admitted to the facility from an acute care hospital on [DATE] with diagnoses of traumatic brain injury (a brain dysfunction caused by an outside force, usually a violent blow to the head), seizure (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness), dysphagia (difficulty swallowing), dystonia (a movement disorder that causes the muscles to contract), acquired absence of right leg above the knee, and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities).During a review of R 4's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 6/30/25, the MDS indicated R 4 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of 00 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated R 4 was severely cognitively impaired.During a concurrent observation and interview on 9/10/25 at 11:40 a.m. with Resident (R) 1 in the hallway outside R 1's room. R 1 was observed at the end of the hallway in a Geri-chair covered with a sheet, wearing a gown with both hands contracted (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff). R 1 was observed moving his left leg and kicked off his sheet. R 1's fingernails and toenails were observed to be long with jagged edges. R 1 stated the podiatrist trimmed his nails and he had his nails trimmed last week. R 1 stated the nurse trimmed his fingernails and the podiatrist trimmed his fingernails.During a review of R 1's AR, dated 9/10/25, the AR indicated R 1 was admitted to the facility from a nursing home on 3/25/22 with diagnoses of schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), pain, muscle weakness, anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and depression (persistent feelings of sadness, despair, loss of energy, and difficulty dealing with normal daily life).During a review of R 1's MDS, dated [DATE], the MDS section C indicated R 1 had a BIMS score of 15, which suggested R 1 was cognitively intact.During a concurrent observation and interview on 9/10/25 at 12:07 p.m. with Licensed Vocational Nurse (LVN) 1 in the hallway near R 1's room, R 1 was observed at the end of his hallway in a Geri-chair wearing a gown, covered with a sheet with his feet uncovered exposing R 1's toenails. LVN 1 stated she had been at the facility for two years and was familiar with R 1. LVN 1 stated the nurses trimmed the residents' nails. LVN 1 stated the CNAs reported if the resident's nails were long. LVN 1 stated the podiatrist came out when called, otherwise LVN 1 thought he came to the facility once a month. LVN 1 stated R 1's nails needed to be trimmed.During a concurrent interview and record review on 9/10/25 at 12:25 p.m. with the Director of Staff Development (DSD), Resident 1's Skin Monitoring: Comprehensive CNA Shower Review (SS), dated 9/9/25 was reviewed. The SS indicated, . does the resident need his/her toenails cut? . No . Resident 1's SS, dated 9/5/25 was reviewed. The SS indicated, . does the resident need his/her toenails cut? . Yes . Resident 1's SS, dated 9/2/25 was reviewed. The SS indicated, . does the resident need his/her toenails cut? . Yes. Resident 4's SS, dated 9/2/25 was reviewed. The SS indicated, date 9/2/25. does the resident need his/her toenails cut? . Yes. Resident 4's SS, dated 9/5/25 was reviewed. The SS indicated, . does the resident need his/her toenails cut? . Yes. Resident 4's SS, dated 9/9/25 was reviewed. The SS indicated, . does the resident need his/her toenails cut? . No. The DSD stated if the CNAs felt a resident's nails were long, the CNA would have informed the nurse, and the nurse would have logged the resident's name in a binder for the Social Services Director (SSD) to review and schedule a podiatrist appointment for the resident. The SSD binder was reviewed, which indicated the last log for a resident was on 2/24/25. The DSD stated R 1 and R 4 were not listed on the log for the SSD to schedule a podiatry visit. Pictures of R 1's and R 4's toenails dated 9/10/25 were reviewed. The DSD stated R 1 and R 4 needed their toenails trimmed. The DSD stated R 1 and R 4 should have had nail care marked yes on their 9/9/25 shower sheets (SS) and should have been put on the list for nail care. The DSD stated there were no refusals for care from R 4 this month in system.During an interview on 9/10/25 at 12:35 p.m. with the Infection Preventionist (IP), the IP stated proper nail care was important for the residents' comfort and to prevent the residents from scratching themselves. The IP stated the facility's resident population was at a higher risk of infection due to the residents had a low immune system. The IP stated bacteria can stay under the resident's nails and be a risk for infection for the resident. During a concurrent interview and record review on 9/10/25 at 4:20 p.m. with Registered Nurse (RN) 1, Resident 1 and Resident 4's pictures of their nails were reviewed. RN 1 stated if a resident was diabetic, the licensed nurse only trimmed the resident's fingernails. RN 1 stated if there was too much nail or disease, or if the resident was a diabetic, the resident needed to see the podiatrist for nail care. RN 1 stated the nurse filled out a form and gave it to the SSD to give to the podiatrist. RN 1 stated the charge nurse signed the resident's shower sheet and filled out the SSD form or gave the form to the DSD to notify the SSD of nail care needed. RN 1 stated the nurse followed up with the shower log to trim resident's nails if marked. RN 1 stated if the form was marked on a Wednesday, then on Friday if the resident's nails were not trimmed the Charge Nurse should have asked why it had not been completed. RN 1 stated R 1 and R 4's nail care should have been completed right away once the nurse was notified. RN 1 stated R 1 and R 4's nail care should have been documented in the nurses' tasks or nurses' notes that a resident requiring nail care was reported to the social worker or noted on the resident's shower sheet. RN 1 stated R 1 and R 4's nails should have been addressed. RN 1 stated if a resident refused care, staff had to respect the resident's rights, and should have notified the RP and physician, and initiate a care plan for the residents' refusal of nail care.During an interview on 9/10/25 at 4:28 p.m. with the Interim Director of Nursing (IDON), the IDON stated her expectation was for the resident's shower sheets to be completed correctly and for the nurse to follow up on the marked areas to be reviewed. The IDON stated it was not acceptable to mark the shower sheets dated 9/9/25 no nail care was needed for R 1 and R 4. The IDON stated the charge nurse signed off on the shower sheets and the IDON's expectation was for the nurse to immediately do something about the concern that same day. The IDON stated if a resident did not have their nails trimmed, it was an infection risk for the resident.During a review of the facility P&P titled, Fingernails/Toenails, Care of, dated 2/2018 indicated, . the purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections .nail care includes daily cleaning and regular trimming .proper nail care can aid in the prevention of skin problems around the nail bed . trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin .watch for and report any changes in the color of the skin around the nail bed . cracking of the skin between the toes . stop and report to the nurse supervisor if there is evidence of ingrown nails, infections, pain, or if nails are too hard or too thick to cut with ease .documentation . any difficulties in cutting the resident's nails . if the resident refused the treatment, the reasons why and the intervention taken .notify the supervisor if the resident refuses the care .

Based on observation, interview and record review, the facility failed to meet professional standards of practice for two of five sampled residents (Resident 1 and Resident 4) when the physician and Resident Responsible Party (RP) were not notified of Resident 1 and Resident 4's refusal of care with having their nails trimmed. Findings:During a concurrent observation and interview on 9/10/25 at 11:26 a.m. with Certified Nursing Assistant (CNA) 1 in the hallway outside Resident (R) 4's room, R 4 was non-verbal and observed wearing a gown, laying in a geriatric chair (Geri-chair - a semi-specialized seating for older adults that achieves a reclined position and elevated leg rest) in the hallway with his left foot uncovered. R 4's left foot toenails were observed to be long, yellow, thick and jagged with dark crusted substance under his left big toenail. CNA 1 stated if a resident was not diabetic (when the blood sugar levels in the body are too high), the nurses trimmed the resident's nails. CNA 1 stated the CNAs filled out the resident's shower sheet, which indicated areas of concern for the nurse to review, and marked if the resident's toenails needed to be trimmed. CNA 1 stated if a resident refused a shower staff encouraged the resident, and if the resident still refused, staff left the resident and went back after a while and asked the resident again. CNA 1 stated if residents refused a bath or care, the charge nurse was informed, and she asked the residents the reason for the refusal. CNA 1 stated R 4's toenails needed to be trimmed.During a review of R 4's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information, dated 9/10/25, the AR indicated R 4 was admitted to the facility from an acute care hospital on [DATE] with diagnoses of traumatic brain injury (a brain dysfunction caused by an outside force, usually a violent blow to the head), seizure (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness), dysphagia (difficulty swallowing), dystonia (a movement disorder that causes the muscles to contract), acquired absence of right leg above the knee, and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities).During a review of R 4's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 6/30/25, the MDS indicated R 4 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of 00 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated R 4 was severely cognitively impaired.During a concurrent interview and record review on 9/10/25 at 12:25 p.m. with the Director of Staff Development (DSD), pictures of R 4's toenails dated 9/10/25 were reviewed. The DSD stated R 4 needed his toenails trimmed. The DSD stated R 4 should have had nail care marked yes on his 9/9/25 shower sheet (SS) and should have been put on the list for nail care. The DSD stated there were no refusals for care from R 4 this month in system.During an interview on 9/10/25 at 12:35 p.m. with the Infection Preventionist (IP), the IP stated proper nail care was important for the residents' comfort and to prevent the residents from scratching themselves. The IP stated the facility's resident population was at a higher risk of infection due to the residents had a low immune system. The IP stated bacteria can stay under the resident's nails and be a risk for infection for the resident. During a concurrent interview and record review on 9/10/25 at 12:43 a.m. with the Social Services Director (SSD), R 4's record was reviewed. The SSD stated on 4/14/25 R 4 refused nail care, so the podiatrist would not have seen him for six months. The SSD stated R 4 was also not diabetic, so nursing should have provided nail care. The SSD stated if a resident was refusing care, nursing should have let her know and she would have sent out a request to the podiatrist office if it was urgent. The SSD reviewed R 4's picture of his toenails dated 9/10/25 and the SSD stated she felt R 4's left toenail looked like it needed urgent care. During a concurrent interview and record review on 9/10/25 at 4:20 p.m. with Registered Nurse (RN) 1, Resident 4's picture of his toenails was reviewed. RN 1 stated R 4's nail care should have been completed right away once the nurse was notified. RN 1 stated R 4's nail care should have been documented in the nurses' tasks or nurses' notes that a resident requiring nail care was reported to the social worker or noted on the resident's shower sheet. RN 1 stated R 4's nails should have been addressed. RN 1 stated if a resident refused care, staff had to respect the resident's rights, and should have notified the RP and physician, and initiate a care plan for the residents' refusal of nail care.During an interview on 9/12/25 at 11:30 a.m. with the Interim Director of Nursing (IDON), the IDON stated R 4 was non-communicative. The IDON stated R 4 had a care plan initiated on 9/10/25 for non-compliance with care. The IDON stated R 4 should have had a care plan initiated for non-compliance when he first refused care. The IDON stated there was no documentation that R 4's RP or the physician was notified of R 4's refusal of care. The IDON stated there was no documentation for notification, and no nursing documentation for any change of conditions (COC) in R 4's record. The IDON stated staff should have called R 4's RP and the physician of R 4's refusal of care and the refusal of care and notifications should have been documented in R 4's record. The IDON stated it was important to notify R 4's RP to help staff see why R 4 was refusing care and the RP might have been able to convince R 4 to allow care. The IDON stated it was important staff notified the physician to see if R 4 needed to be treated and to receive an order to treat. The IDON stated if the RP and physician were not notified of R 4's refusal of treatment, it was a risk for R 4 to obtain an infection or break down of his toes.During a concurrent observation and interview on 9/10/25 at 11:40 a.m. with Resident (R) 1 in the hallway outside R 1's room. R 1 was observed at the end of the hallway in a Geri-chair covered with a sheet, wearing a gown with both hands contracted (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff). R 1 was observed moving his left leg and kicked off his sheet. R 1's fingernails and toenails were observed to be long with jagged edges. R 1 stated the podiatrist trimmed his nails and he had his nails trimmed last week. R 1 stated the nurse trimmed his fingernails and the podiatrist trimmed his fingernails.During a review of R 1's AR, dated 9/10/25, the AR indicated R 1 was admitted to the facility from a nursing home on 3/25/22 with diagnoses of schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), pain, muscle weakness, anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and depression (persistent feelings of sadness, despair, loss of energy, and difficulty dealing with normal daily life).During a review of R 1's MDS, dated [DATE], the MDS section C indicated R 1 had a BIMS score of 15, which suggested R 1 was cognitively intact.During a concurrent interview and record review on 9/10/25 at 12:12 p.m. with Licensed Vocational Nurse (LVN) 1, R 1's Care Plan (CP), undated was reviewed. The CP indicated, . (Resident 1 Name) is non-compliant with care manifested by (m/b) refusing fingernail trimming, check and change medication, Activities of Daily Living (ADL) care, as manifested by refusal of the following . date initiated; 3/10/2025 . interventions . notify physician (MD) of their non-compliance . date initiated: 3/10/25 . notify resident representative . date initiated 3/10/2025 . LVN 1 stated R 1 had a lot of refusals of care and the nurse had notified R 1's physician and R 1's Responsible Party (RP) of incidents. LVN 1 was unable to find documentation of notification of RP or physician notification of Resident 1's refusal of nail care.During an interview on 9/10/25 at 4:20 p.m. with RN 1, RN 1 stated if a resident was diabetic, the licensed nurse only trimmed the resident's fingernails. RN 1 stated if there was too much nail or disease, or if the resident was a diabetic, the resident needed to see the podiatrist for nail care. RN 1 stated R 1's nails should have been addressed. RN 1 stated if a resident refused care, staff had to respect the resident's rights, and should have notified the RP and physician, and initiate a care plan for the residents' refusal of nail care.During an interview on 9/12/25 at 11:35 a.m. with the IDON, the IDON stated R 1 had a CP entered on 3/10/25 for non-compliance, with interventions for RP notification and physician notification. The IDON stated the only documented RP notification attempt was on 3/25/22, and no documentation was found for physician notification. The IDON stated there was no current documentation of attempts to call R 1's RP or physician for refusal of care. The IDON stated R 1's refusals and RP and physician notifications should have been documented and followed up on. The IDON stated if it was not documented, then it was not done. The IDON stated if a resident was refusing care, nurses should have called the RP if they had time. The IDON stated if the refusal was not emergent, the nurse should have called the next morning. The IDON stated if the RP and physician were not notified of R 1's refusal of treatment, it was a risk for R 1 to obtain an infection or break down of his toes.During a review of professional reference titled, Improving Communication Among Attending Physicians, Long-Term Care Facilities, Residents, and Residents' Families, dated March-April, 2024, obtained from https://www.jamda.com/article/S1525-8610(04)70066-3/abstract, indicated, . effective bidirectional communication between attending physicians and long-term care facilities is of critical importance to ensure timely, appropriate, and high-quality care that is responsive to resident's needs, values, and preferences . ongoing communication with residents and resident's families is essential to the establishment of mutual trust and respect .

Based on observation, interview and record review, the facility failed to ensure a comprehensive person-centered care plan (CP - a detailed approach to care customized to an individual resident's needs) was developed and implemented for two of five residents (Resident 1 and Resident 4) when:1. Resident 1's care plan was not implemented for refusal of care and notification of Resident 1's Responsible Party (RP) and physician.2. Resident 4's care plan was not developed and implemented for refusal of care.These failures had the potential to result in Resident 1 and Resident 4 receiving inadequate person-centered care and put Resident 1 and Resident 4 at risk of not having their needs met.Findings:1. During a concurrent observation and interview on 9/10/25 at 11:40 a.m. with Resident (R) 1 in the hallway outside Resident 1's room. R 1 was observed at the end of the hallway in a geriatric chair (Geri-chair - a semi-specialized seating for older adults that achieves a reclined position and elevated leg rest) covered with a sheet, wearing a gown with both hands contracted (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff). R 1 was observed moving his left leg and kicked off his sheet. R 1's fingernails and toenails were observed to be long with jagged edges. R 1 stated the podiatrist trimmed his nails and he had his nails trimmed last week. R 1 stated the nurse trimmed his fingernails and the podiatrist trimmed his fingernails.During a review of R 1's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 9/10/25, the AR indicated R 1 was admitted to the facility from a nursing home on 3/25/22 with diagnoses of schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), pain, muscle weakness, anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and depression (persistent feelings of sadness, despair, loss of energy, and difficulty dealing with normal daily life).During a review of R 1's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 7/25/2, the MDS section C indicated R 1 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested R 1 was cognitively intact.During a concurrent interview and record review on 9/10/25 at 12:12 p.m. with Licensed Vocational Nurse (LVN) 1, R 1's Care Plan (CP), undated was reviewed. The CP indicated, . (Resident 1 Name) is non-compliant with care manifested by (m/b) refusing fingernail trimming, check and change medication, Activities of Daily Living (ADL) care, as manifested by refusal of the following . date initiated; 3/10/2025 . interventions . notify physician (MD) of their non-compliance . date initiated: 3/10/25 . notify resident representative . date initiated 3/10/2025 . LVN 1 stated R 1 had a lot of refusals of care and the nurse had notified R 1's physician and R 1's Responsible Party (RP) of incidents. LVN 1 was unable to find documentation of notification of RP or physician notification of Resident 1's refusal of nail care.During an interview on 9/10/25 at 4:20 p.m. with Registered Nurse (RN) 1, RN 1 stated if a resident was diabetic (when the blood sugar levels in the body are too high), the licensed nurse only trimmed the resident's fingernails. RN 1 stated if there was too much nail or disease, or if the resident was a diabetic, the resident needed to see the podiatrist for nail care. RN 1 stated R 1's nails should have been addressed. RN 1 stated if a resident refused care, staff had to respect the resident's rights, and should have notified the RP and physician, and initiate a care plan for the residents' refusal of nail care.During an interview on 9/12/25 at 11:30 with the Interim Director of Nursing (IDON), the IDON stated R 1 had a CP entered on 3/10/25 for non-compliance with interventions for RP notification and physician notification. The IDON stated the only documented RP notification attempt was on 3/25/22, and there was no documentation of physician notification. The IDON stated there was no current documentation of attempts to call R 1's RP or physician for refusal of care. The IDON stated R 1's refusals and RP and physician notifications should have been documented and followed up on. The IDON stated if it was not documented, then it was not done. The IDON stated if a resident was refusing care, nurses should have called the RP if they had time. The IDON stated if the refusal was not emergent, the nurse should have called the next morning.2. During a concurrent observation and interview on 9/10/25 at 11:26 a.m. with Certified Nursing Assistant (CNA) 1 in the hallway outside R 4's room, Resident 4 was non-verbal and observed wearing a gown, laying in a Geri-chair in the hallway with his feet uncovered. Resident 4's left foot toenails were observed to be long, yellow, thick and jagged with dark crusted substance under his left big toenail. CNA 1 stated if a resident was not diabetic, the nurses trimmed the resident's nails. CNA 1 stated the CNAs filled out the resident's shower sheet (SS), which indicated areas of concern for the nurse to review, and marked if the resident's toenails needed to be trimmed. CNA 1 stated R 4's toenails needed to be trimmed.During a review of Resident 4's AR dated 9/10/25, the AR indicated Resident 4 was admitted to the facility from an acute care hospital on [DATE] with diagnoses of traumatic brain injury (a brain dysfunction caused by an outside force, usually a violent blow to the head), seizure (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness), dysphagia (difficulty swallowing), dystonia (a movement disorder that causes the muscles to contract), acquired absence of right leg above the knee, and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities).During a review of Resident 4's MDS, dated 6/30/25, the MDS indicated Resident 4 had a BIMS score of 00, which indicated Resident 4 was severely cognitively impaired.During an interview on 9/10/25 at 4:20 p.m. with RN 1, RN 1 stated if a resident was diabetic, the licensed nurse only trimmed the resident's fingernails. RN 1 stated if there was too much nail or disease, or if the resident was a diabetic, the resident needed to see the podiatrist for nail care. RN 1 stated R 4's nails should have been addressed. RN 1 stated if a resident refused care, staff had to respect the resident's rights, and should have notified the RP and physician, and initiate a care plan for the residents' refusal of nail care.During an interview on 9/12/25 at 11:35 a.m. with the IDON, the IDON stated R 4 had a CP initiated on 9/10/25 for non-compliance with care. The IDON stated R 4 should have had a CP for non-compliance when he first refused care. The IDON stated a CP was important so everyone understood what R 4's behavior was and would have been able to communicate with each other about R 4's behavior. The IDON stated the CP indicated what actions and interventions to try to provide the best interventions for the residents. The IDON stated the CP allowed staff to see what worked and what didn't work, so the interventions could have been revised. The IDON stated she expected staff to follow resident care plans and interventions. The IDON stated if staff did not follow the CPs, there was a risk the staff would not have provided patient centered care, which included what the resident wanted and allowed family to be involved in the resident's care.During a review of the facility policy and procedure titled, Care Plans, Comprehensive Person-Centered, dated3/2022, 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 . the comprehensive, person-centered care plan . describes the services that are to be furnished . care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making . assessments of residents are ongoing and care plans are revised as information about the residents and residents' conditions change . the resident has the right to refuse . medical and nursing treatments. Such refusals are documented in the resident's clinical record in accordance with established policies .

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the safety and well-being for 1 (Resident #37) of 1 sampled resident reviewed for smoking. Specifically, the facility failed to failed to implement further interventions to ensure the safety of the resident and others when the resident continued to smoke after there was indication that the resident agreed to smoking cessation and failed to implement interventions when the resident refused to turn in their lighter. It was determined the provider's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment or death to residents. The Immediate Jeopardy was related to State Operations Manual, Appendix PP, 483.25 (d) Accidents, at a scope and severity of J. On 03/12/2025 at 4:38 P.M. the Administrator and the Director of Nursing (DON) were informed of the Immediate Jeopardy situation. Findings included: A facility policy titled, Smoking Policy- Residents, revised 08/2022, revealed, This facility has established and maintains safe resident smoking practices. Policy Interpretation and Implementation 1. Prior to, and upon admission, residents are informed of the facility smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences. 2. Smoking is only permitted in designated resident smoking areas, which are located outside of the building. The policy specified, 6. Resident smoking status is evaluated upon admission. If a smoker, the evaluation includes: a. current level of tobacco consumption; b. method of tobacco consumption (traditional cigarettes; electronic cigarettes; pipe, etc. [et cetera, and other similar things]); c. desire to quit smoking; and d. ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation). 7. The staff consults with the attending physician and the director of nursing services (DNS) to determine if safety restrictions need to be placed on a resident's smoking privileges based on the Safe Smoking Evaluation. 8. A resident's ability to smoke safely is re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by staff. 9. Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) are noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. 10. The facility may impose smoking restrictions on a resident at any time if it is determined that the resident cannot smoke safely with the available levels of support and supervision. 11. Any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. 12. Residents who have independent smoking privileges are permitted to keep cigarettes, electronic-cigarettes, pipes, tobacco, and other smoking items in their possession. Only disposable safety lighters are permitted. All other forms of lighters, including matches, are prohibited. 13. Residents are not permitted to give smoking items to other residents. 14. Residents without independent smoking privileges may not have or keep any smoking items, including cigarettes, tobacco, etc., except under direct supervision. An Admission Record revealed the facility admitted Resident #37 on 12/12/2024. According to the Admission Record, the resident had a medical history that included diagnoses of dementia, delirium due to known physiological condition, and nicotine dependence. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/19/2024, revealed Resident #37 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. An Admission Nursing Assessment, dated 12/12/2024, revealed Resident #37 was a current smoker and the assessment directed staff to complete a smoking assessment. Resident #37's Care Plan Report included a focus area initiated 12/13/2024, that indicated the resident had a heightened safety risk related to confusion and a personal desire to smoke. Interventions directed staff to apply protective non-flammable apron or cover/barrier during smoking activity (initiated 12/13/2024), keep the resident's cigarettes (initiated 12/13/2024), and keep the resident's lighter(s) (initiated 12/13/2024). Further review of the Care Plan Report included a focus area initiated 01/31/2025, that indicated the resident was noted to smoke used cigarettes found on the ground. Interventions directed staff to post cigarette times in the resident's room (initiated 01/31/2025); explain the risks and benefits to the resident, including the risk of infection (initiated 01/31/2025); and indicated that the resident refused to give staff their lighter (initiated 02/10/2025). Resident #37's Medical Professional Note, dated 12/13/2024, indicated for the resident's diagnosis of tobacco abuse, the resident was counseled and advised to quit and the impact of smoking cessation was discussed in detail. Per the Medical Professional Note, several options, to include patches and gums, medication management, relaxation techniques, and to avoid the company of other smokers were discussed with resident. Resident #37's Smoking - Initial Assessment, dated 01/31/2025, indicated the resident was a smoker with cognitive loss, who smoked two to five times per day. Per the Smoking - Initial Assessment, the resident required a smoking apron and supervision. The Smoking - Initial Assessment indicated the facility stored the resident's smoking materials and a plan of care was used to ensure the resident was safe while smoking. During an interview on 03/14/2025 at 1:09 PM, the MDS Coordinator stated she completed the initial smoking assessment for Resident #37 on 01/31/2025 and verbally communicated with the staff about the care plan interventions on that day, but the communication was not documented anywhere. During an interview on 03/11/2025 at 8:52 AM, the DON stated residents had an initial assessment completed, a smoking safety assessment, an evaluation of whether the resident smoked or not, and a care plan would be completed if the resident smoked. She stated the assessments were completed by the charge nurse The DON stated from what she remembered, Resident #37 was not a smoker initially. She stated that around January 2025, staff observed the resident gathering cigarette butts and trying to smoke them and that was when staff realized the resident smoked, so staff assessed the resident as a smoker at that time. Resident #37's Activities-Progress Notes, dated 03/03/2025 at 10:30 AM, revealed activities staff witnessed Resident #37 smoking on the back patio during a non-smoking time. The note indicated the resident had a lighter, and the activities staff member notified the resident of the designated smoking times and asked the resident to turn in their lighter. The note indicated the resident refused to turn their lighter in to the activities staff member. Resident #37's Activities-Progress Notes, dated 03/04/2025 at 11:30 AM, revealed an activities staff member spoke with Resident #37 and notified them of the facility's smoking policy. According to the note, the resident refused to sign a copy of the smoking policy that was discussed with them. Resident #37's Administrator Notes, dated 03/04/2025 at 4:11 PM, revealed the Administrator contacted the Ombudsman regarding Resident #37's noncompliance with care and smoking. The note indicated the facility received verbal consent to the facility's admission agreement, which included the smoking policy, from Resident #37's family. According to the note, the Administrator informed the resident if they wanted to smoke, they must follow the facility's smoking policy. The note indicated the Administrator informed the resident that if they desired unlimited smoking freedom, then a discharge to another location may be best for the resident. According to the note, the Administrator informed the Ombudsman that Resident #37 was a potential risk to themself or other residents if their noncompliance continued. Per the note, at the recommendation of the Ombudsman, the Administrator agreed to seek discharge for the resident. Resident #37's Activities-Progress Notes, dated 03/05/2025 at 10:36 AM, revealed an activities staff member witnessed Resident #37 smoking outside of the door which led to the back patio. The note indicated the staff member advised the resident they could not smoke outside of the designated times and asked the resident to extinguish their cigarette, but the resident refused and continued smoking until the resident was finished. Resident #37's Activities Progress Note, dated 03/10/2025 at 6:33 PM, indicated the Activity Supervisor was outside sweeping the designated smoking area when Resident #37 came outside looking for cigarette butts. According to the note, the Activity Supervisor explained the facility's smoking policy to the resident and informed the resident they could not pick up cigarette butts from the ground. The note indicated Resident #37 became agitated and attempted to swing at the staff member, then cursed and walked back into the building. Per the note, the Administrator and DON were notified. During a concurrent observation and interview on 03/10/2025 at 3:27 PM, Resident #37 removed a butane cigarette lighter out of their jacket. Resident #37 stated they went outside to smoke by their self whenever they wanted to. During a concurrent observation and interview on 03/10/2025 at 3:43 PM, the surveyor noted Resident #37 wore a gray hospital gown that had multiple brown holes visible through the fabric. There were two small holes near the mid chest area on the left side, one small hole on the left upper chest area, and one dime size hole near the resident's right leg. Resident #37 stated the holes in their gown was from cigarette ashes but was unable to remember when the holes occurred. The resident stated they did not use a smoking apron. During an interview on 03/10/2025 at 3:53 PM, Certified Nursing Assistant (CNA) #5 stated Resident #37 was independent and refused care. CNA #5 stated the resident went outside with activities staff when they wanted to smoke. She stated that she believed staff knew that the resident smoked, but the resident wandered around and went by their self. During an interview on 03/10/2025 at 4:17 PM, Licensed Vocational Nurse (LVN) #6 stated she had no idea how the resident got the burn holes on their gown. LVN #6 stated she was unsure if the resident smoked. During an interview on 03/11/2025 at 2:24 PM, Activity Staff (AS) #1 stated she witnessed Resident #37 go smoke a couple of times and she tried to get them to sign a smoking policy, but the resident refused. She stated she told the resident that smoking could not be done outside of designated smoking times. AS #1 stated the resident had their own lighter, and the cigarettes were obtained from the ash tray or off the ground on the back patio, where everyone smoked. She stated the resident refused to give her their lighter and then she reported it to the Administrator. She stated that the incident occurred at the end of February 2025 or the beginning of March 2025 and that she had not seen the resident smoke prior to that incident. During an interview on 03/11/2025 at 8:52 AM, the DON stated that once a resident was identified as a smoker, the resident was not to have their cigarettes or lighter because it was a safety issue. She stated if they were found with a cigarette or a lighter, then it would be removed, and education provided. The DON stated if a resident refused to follow the policy, then a discharge notice would be provided to the resident. During an interview on 03/15/2025 at 1:36 PM, the DON stated there should have been additional interventions implemented at the time Resident #6 had a lighter on 02/10/2025, to include removal of the lighter, education to the resident, and supervision of the resident. During an interview on 03/11/2025 at 9:13 AM, the Administrator stated residents were assessed by nursing staff at admission to determine their desire to smoke. He stated there was a smoking area with designated times, and the activities staff took the residents who smoked to the designated area. The Administrator stated he was not aware that Resident #37 had burn areas on their gown. The Administrator stated the Ombudsman was contacted regarding the resident's smoking. During an interview on 03/13/2025 at 4:06 PM, the Administrator stated a discharge notice had not been issued to Resident #37 yet, as a safe placement had to be identified before the resident could be discharged . During an interview on 03/14/2025 at 8:58 AM, the Administrator stated that prior to Monday, 03/10/2025, the interventions staff implemented was that a smoking assessment was completed for Resident #6, monitoring was completed by nursing staff each shift, the facility attempted to get the resident to sign the smoking agreement a few times, and discharge had been discussed with the Ombudsman in February 2025 and on 03/04/2025. On 03/14/2025 at 10:08 AM, a Removal Plan was submitted by the facility and accepted by the State Agency. It read as follows: 1. Immediate Smoking Assessments: a. As of 03/12/2025, all five identified residents who smoke were immediately assessed for safety risks, including cognitive impairment and ability to handle smoking materials safely. Residents were identified based on their current desire to smoke. The resident smoking assessment titled, Resident Smoking Initial Assessment, was completed by the Director of Nursing on 03/12/2025 for the five residents identified. The assessments were completed, and the residents' care plans were updated accordingly on 03/12/2025 by the Director of Nursing. b. The active smoker list was updated on 03/12/2025 to included Resident #37. c. All residents were previously assessed on admission for a desire to smoke. All new residents will be assessed on admission if they have a desire to smoke. This will be completed by admitting nurse. d. All five identified residents were re-educated by the Director of Nursing on the risk vs benefit of following the smoking policy on 3/12/25. e. All other necessary interventions including supervised smoking, appropriate storage of smoking materials, smoking in designated areas, and offering of aprons were implemented immediately on 3/12/25. 2. Immediate Supervision Implementation: a. The smoking program was reviewed on 03/12/2025 for resident safety by the interdisciplinary team including the Administrator, Activities Director, Director of Nursing, Medical Records Director, Director of Staff Development, Social Services, and the Medical Director. b. Staff were educated on 03/12/2025 by the Director of Staff Development. Staff education included nurses, nurse assistants, activity assistants, department heads, dietary, administration, and housekeeping. Education included how to ensure smoking activities occur in designated, supervised areas to prevent unsupervised smoking and reduce fire hazards. Additionally, staff were trained on the importance of supervision and monitoring of smoking residents, including the prevention of unsafe practices. Education will be ongoing with an expected completion of all staff by 03/14/2025. Education will be conducted by the Director of Staff Development or designee. Any additional staff or new staff will be given a one on one education prior to start of shift. c. Training on the importance of supervision and monitoring of smoking residents, including the prevention of unsafe practices will be provided for all new hires by Director of Staff Development as part of the orientation process. 3. Restriction of Smoking Materials: a. Any potentially dangerous items, including lighters or cigarettes, have been removed from residents' rooms. This was completed on 03/12/25 by Activity Director b. A lighter was removed from Resident #37's room on 03/10/2025 at 5 :00 PM by CNA. c. On 03/12/2025, all rooms were visually inspected, and residents were asked for any smoking paraphernalia. There was no additional smoking paraphernalia. This was completed on 3/12/25 by Activity Director d. The Activities Director will conduct a monthly sweep visually inspecting all resident rooms and asking for smoking paraphernalia. The Activity Director was educated to this responsibility on 03/13/2025 by the Administrator and Director of Nursing e. All Staff including nurses, nurse assistants, activity assistants, department heads, dietary, administration, and housekeeping educated by the Director of Staff Development on 03/13/2025 that staff who identify smoking paraphernalia should report it to Administrator or designee. All staff off site were educated via phone by department heads, administrator or designee on 3/13/25 and 3/14/25. 4. Revised Smoking Policy and Agreement Enforcement: a. A smoking agreement has been reintroduced and enforced for all residents who smoke, with clear guidelines about safe smoking practices, supervision, and the need to follow all facility policies. The smoking agreement was revised to better match the facility's smoking policy and procedure. A revision was made indicating that aprons are offered and strongly encouraged based on assessment, instead of requiring an apron to be eligible for the smoking program. b. Residents have the right to refuse smoking apron. Staff will continue to offer and encourage the apron. In the event of a refusal, the resident will be educated on the risk vs. benefit of the apron use. The resident will be provided supervision during smoking by Activity aide or designee during smoke break. Fire blanket and fire extinguisher are available in smoking area. c. Staff assisting residents who refuse to wear apron will notify the Activity Director or designee. Activity aides were trained on 3/13/25 by Activity Director. The Activity Director or designee will bring this to the attention to the interdisciplinary team during the interdisciplinary team meeting. This will then be care planned by nursing during the interdisciplinary team meeting. d. Residents who refuse to sign the agreement will have their smoking materials stored securely and will only be allowed to smoke under direct supervision. Residents who refuse to sign will be asked to turn in any smoking paraphernalia. If resident refuses to voluntarily give up paraphernalia the interdisciplinary team including the administrator, director of nursing, activity director, medical record director, director of staff development, infection preventionist, social services or other designee, will confiscate smoking materials as per our policy or discharge the resident. e. Residents who refuse to sign will be placed on every shift visual monitoring for smoking paraphernalia. Monitoring will be done by licensed nurses. Licensed nurses were trained by Director of Staff Development and Director of Nursing on 3/13/25. 5. Staff Education and Training: a. On 03/12/2025, facility staff, including nurses, nurse assistants, activity assistants, department heads, dietary, administration and housekeeping, have been immediately educated on the updated smoking policy, the importance of smoking assessments, and how to ensure that all smoking activities are managed safely. The education was conducted by the Director of Staff Development. 6. Environmental Safety Measures: a. Fire safety training was given on 12/11/2024 and 02/20/2025 by fire training vendor. b. Additionally, fire safety training was done by the Director of Staff Development on 03/14/2025. Staff educated included nurses, nurse assistants, activity assistants, department heads, dietary, administration and housekeeping. Training was completed, and additional fire safety measures, such as fire extinguishers and fire blankets near designated smoking areas, have been implemented. Staff not currently in facility were called and educated by the Director of Staff Development via phone on 3/13/25 and 3/14/25. c. Safe smoking area training was done for the Activities Director and activity assistants on 03/11/2025. Training was done by the Director of Staff Development and Administrator. d. Activities and or designee will do a check after each smoke break to ensure that smoking areas are safe and free from hazards such as loose smoke buds. Aides will verify receptacle is in working order, fire extinguisher is in place and fire blanket is in present. Activity aides were trained on 3/11/25 by activity director and administrator on 3/11/25. e. Activity aides will supervise that all cigarettes will be extinguished and disposed in proper receptacle of after each smoking break. Activity aides were trained by activity director and administrator on 3/11/25. f. A weekly scheduled audit conducted by the Medical Records Director or designee to review and monitor compliance with safety procedures. g. Compliance of audits conducted by the Medical Records Director will be monitored for three months and will be added to the Medical Record Director's portion (or designee) for our [quality assurance performance improvement] QAPI meeting, quarterly thereafter. Corrective Action Completion Date: The Immediate Jeopardy removal actions have been completed as of 03/14/2025, and the facility will continue to monitor compliance on an ongoing basis. X. All corrections were completed on 3/14/25. X. The immediacy of the IJ was removed on 3/14/25. Onsite Verification: The IJ was removed on 03/14/2025 at 3:40 PM after the survey team verified the implementation of the facility's Removal Plan as follows: 1. The survey team reviewed and verified the facility completed smoking assessments for the five residents who smoked in the facility, their care plans were updated, and verified the Active Smokers list had been updated to include Resident #37. The survey team also reviewed and verified the facility reviewed the smoking policy with the five residents. Interviews on 03/14/2025 with the five residents verified facility staff discussed the smoking policy and procedures with the residents. 2. The survey team conducted interviews with the Administrator, the Activity Supervisor, the DON, the Medical Records Staff, the Director of Staff Development, Social Services Supervisor, and the Medical Director to discuss their understanding of the facility's smoking program. The survey team reviewed and verified the facility provided staff training on 03/13/2025 at 4:00 PM through a review of a facility document titled, [the facility's name] Lesson Plan. Per the document, the training was related to smoke breaks, observing smoke breaks, ensuring smoking occurred in designated areas, smoking assessments, fire safety, providing a smoking apron, reporting finding smoking paraphernalia to the Administrator or designated supervisor, and understanding how to extinguish residents in case of an emergency. The team conducted interviews with staff, including CNAs, LVNs, registered nurses (RNs), housekeeping staff, and activities staff to verify training was provided. 3. The survey team reviewed a facility document titled, Secure Smoking Paraphernalia, that indicated that each of the five smoker's rooms were inspected on 03/10/2025. The document indicated that a lighter was confiscated from Resident #37's room on 03/10/2025. The documented indicated that the remainder of the rooms were inspected on 03/12/2025. The survey team confirmed with the Activity Supervisor that room inspections would be continued on a monthly basis and confirmed that a lighter was removed from Resident #37's room. During an interview on 03/11/2025 at 1:34 PM, Resident #37 stated that someone took their lighter on 03/10/2025. 4. The survey team reviewed an undated facility policy titled, Smoking Policy that indicated that the smoking policy would be reviewed with the residents or their legal representative and a signed copy of acknowledgement would be maintained in the resident's health record. The policy indicated that residents would not be able to keep smoking items in their possession, and indicated the smoking aprons would be offered and encouraged to all residents based on assessment. The policy included lines where the resident or their representative as well as a witness could sign. The survey team confirmed through interviews with staff what to do if residents refused to sign the smoking agreement, if they refused to wear a smoking apron, or if they refused to turn in their smoking paraphernalia. An observation of a smoke break on 03/14/2025 at 1:56 PM revealed multiple smoking aprons hung in the area. Two residents were offered a smoking apron and both residents refused. The Activity Supervisor witnessed the refusals. 5. The survey team reviewed and verified the facility provided staff training on 03/13/2025 at 4:00 PM through a review of a facility document titled, [the facility's name] Lesson Plan. Per the document, the training was related to smoke breaks, observing smoke breaks, ensuring smoking occurred in designated areas, smoking assessments, fire safety, providing a smoking apron, reporting finding smoking paraphernalia to the Administrator or designated supervisor, and understanding how to extinguish residents in case of an emergency. The team conducted interviews with staff, including CNAs, LVNs, RNs, housekeeping staff, and activities staff to verify training was provided. 6. The survey team reviewed facility documents titled, Fire Drill Report dated 12/11/2024 and 02/20/2025 that indicated fire drills were conducted on those days. An observation of a smoke break on 03/14/2025 at 1:56 PM revealed a fire blanket and fire extinguisher on the exterior wall of the facility in the area. A facility document titled, Safe smoking Activity Assistant Training log indicated that AS #1, AS #9, and AS #10 were trained related to a safe smoking area. The survey team reviewed a facility document titled, Smoking Area Safety Check, that indicated staff checked the smoke areas five times per day. The survey team reviewed a facility document titled, Performance Improvement Project (PIP) Guide, dated 03/12/2025, that indicated the facility initiated a PIP related to smoking practices at the facility. The survey team conducted interviews with activities staff, the Medical Records Staff, and the Administrator to confirm training was provided and a system to monitor for compliance was established.

Based on interview and record review, the facility failed to ensure services provided met professional standards of quality for one of 15 sampled residents' (Resident 8) when Resident 8's Albuterol Sulfate inhaler (medication for shortness of breath or wheezing) was not accounted for as active medication and kept by Resident 8 on her overbed table from 3/17/25 to 4/10/25. This failure had the potential to result in Resident 8 to use the inhaler without proper staff supervision and placed Resident 8 at an increased risk for adverse side effects, such as nervousness, shakiness, fast or irregular heart rate, chest pain, headache, and throat irritation. Findings: During a review of Resident 8's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 4/10/25, the AR indicated, Resident 8 was admitted from an acute care hospital on 3/17/25 to the facility, with diagnoses that included Fracture of Left Tibia (the large bone in the lower leg), Hypertension (high blood pressure), Congestive Heart Failure (CHF- weakness in the heart where fluid accumulates in the lungs), Coronary Artery Bypass Graft (CABG- a surgical procedure used to improve blood flow to the heart), Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and Anxiety Disorder (a mental health illness characterized by a sudden feeling of panic and fear, restlessness, and uneasiness). During a review of Resident 8's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 8's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 15 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 8 had no cognitive impairment. During a concurrent observation and interview on 4/10/25 at 1:54 p.m., with Resident 8, inside Resident 8's room, a canister (container, containing the medication) with actuator (a plastic piece that releases the medication) of Albuterol Sulfate inhaler was observed inside a plastic cup on Resident 8's overbed table. Resident 8 stated she uses the Albuterol inhaler daily for her shortness of breath. Resident 8 stated her Albuterol inhaler was always on her overbed table and no staff told her that she cannot keep and use her inhaler from home. During a concurrent observation and interview on 4/10/25 at 1:56 p.m., with Registered Nurse Supervisor (RNS), inside Resident 8's room. RNS looked at Resident 8's overbed table and stated a partially used Albuterol inhaler was inside a clear plastic cup. RNS stated Resident 8's albuterol inhaler was not prescribed by the facility's attending physician and no record of monitoring for potential side effects. RNS stated self-administration of medications requires a physician order and a nursing care plan, and it was not done. During an interview on 4/10/25 at 5:04 p.m., with the Director of Nursing (DON), the DON stated her expectation was for the licensed nurses to query alert Residents about their current medications during admission and to check Residents' room for home medications brought to the facility. The DON stated Resident 8's use of Albuterol inhaler without the facility's knowledge could result to a negative outcome, including drug interactions with her current medications. The DON stated other residents could potentially access and use Resident 8's Albuterol inhaler. During a review of the facility's Policy and Procedure (P&P) titled, Medication and Treatment Orders, dated 7/16, the P&P indicated, . Orders for medications and treatments will be consistent with principles of safe and effective order writing . 1. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications . During a review of the facility's document titled, Job Description: Licensed Vocational Nurse, undated, the document indicated, . Duties and Responsibilities . Conducts initial and ongoing assessments of residents' health status . Administers medications as prescribed by the healthcare provider . Ensures accurate dosage, proper route, and timely administration . Monitors and records resident's responses to medications . During a review of the facility's document titled, Job Description: Registered Nurse (RN), undated, the document indicated, . Supervises and coordinates the efforts of nursing staff and provides total nursing care for residents . Specific Duties . Monitors nursing care for residents throughout the shift . Obtains medications, supplies, and medical records needed to provide safe, efficient, and therapeutic care to residents on a continuing basis . During a review of a professional reference Food and Drug Administration (FDA), dated 6/2016, the manufacturer's instructions for Albuterol Sulfate indicated, . Indications and Usage . Treatment or prevention of bronchospasm (narrowing of airways, causing wheezing, coughing, and difficulty breathing) . Excessive use may be fatal . Most common adverse reactions . headache, tachycardia (fast heartbeat), pain, dizziness .

Based on interview and record review, the facility failed to ensure services provided met professional standards of quality for one of 15 sampled residents' (Resident 8) when Resident 8's Albuterol Sulfate inhaler (medication for shortness of breath or wheezing) was not accounted for as active medication and kept by Resident 8 on her overbed table from 3/17/25 to 4/10/25. This failure had the potential to result in Resident 8 to use the inhaler without proper staff supervision and placed Resident 8 at an increased risk for adverse side effects, such as nervousness, shakiness, fast or irregular heart rate, chest pain, headache, and throat irritation. Findings: During a review of Resident 8's Admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 4/10/25, the AR indicated, Resident 8 was admitted from an acute care hospital on 3/17/25 to the facility, with diagnoses that included Fracture of Left Tibia (the large bone in the lower leg), Hypertension (high blood pressure), Congestive Heart Failure (CHF- weakness in the heart where fluid accumulates in the lungs), Coronary Artery Bypass Graft (CABG- a surgical procedure used to improve blood flow to the heart), Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and Anxiety Disorder (a mental health illness characterized by a sudden feeling of panic and fear, restlessness, and uneasiness). During a review of Resident 8's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 8's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 15 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 8 had no cognitive impairment. During a concurrent observation and interview on 4/10/25 at 1:54 p.m., with Resident 8, inside Resident 8's room, a canister (container, containing the medication) with actuator (a plastic piece that releases the medication) of Albuterol Sulfate inhaler was observed inside a plastic cup on Resident 8's overbed table. Resident 8 stated she uses the Albuterol inhaler daily for her shortness of breath. Resident 8 stated her Albuterol inhaler was always on her overbed table and no staff told her that she cannot keep and use her inhaler from home. During a concurrent observation and interview on 4/10/25 at 1:56 p.m., with Registered Nurse Supervisor (RNS), inside Resident 8's room. RNS looked at Resident 8's overbed table and stated a partially used Albuterol inhaler was inside a clear plastic cup. RNS stated Resident 8's albuterol inhaler was not prescribed by the facility's attending physician and no record of monitoring for potential side effects. RNS stated self-administration of medications requires a physician order and a nursing care plan, and it was not done. During an interview on 4/10/25 at 5:04 p.m., with the Director of Nursing (DON), the DON stated her expectation was for the licensed nurses to query alert Residents about their current medications during admission and to check Residents' room for home medications brought to the facility. The DON stated Resident 8's use of Albuterol inhaler without the facility's knowledge could result to a negative outcome, including drug interactions with her current medications. The DON stated other residents could potentially access and use Resident 8's Albuterol inhaler. During a review of the facility's Policy and Procedure (P&P) titled, Medication and Treatment Orders, dated 7/16, the P&P indicated, . Orders for medications and treatments will be consistent with principles of safe and effective order writing . 1. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications . During a review of the facility's document titled, Job Description: Licensed Vocational Nurse, undated, the document indicated, . Duties and Responsibilities . Conducts initial and ongoing assessments of residents' health status . Administers medications as prescribed by the healthcare provider . Ensures accurate dosage, proper route, and timely administration . Monitors and records resident's responses to medications . During a review of the facility's document titled, Job Description: Registered Nurse (RN), undated, the document indicated, . Supervises and coordinates the efforts of nursing staff and provides total nursing care for residents . Specific Duties . Monitors nursing care for residents throughout the shift . Obtains medications, supplies, and medical records needed to provide safe, efficient, and therapeutic care to residents on a continuing basis . During a review of a professional reference Food and Drug Administration (FDA), dated 6/2016, the manufacturer's instructions for Albuterol Sulfate indicated, . Indications and Usage . Treatment or prevention of bronchospasm (narrowing of airways, causing wheezing, coughing, and difficulty breathing) . Excessive use may be fatal . Most common adverse reactions . headache, tachycardia (fast heartbeat), pain, dizziness .

Based on interview, record review, and facility policy review, the facility failed to ensure a resident's care plan reflected the resident's refusal to sign the smoking policy and interventions for staff to obtain a cigarette lighter from the resident for 1 (Resident #37) of 1 sampled resident reviewed for smoking. Findings included: A facility policy titled, Care Plans, Comprehensive Person-Centered, revised 03/2022, 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. The policy specified, 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS [Minimum Data Set] assessment. A facility policy titled, Smoking Policy- Residents, revised 08/2022, revealed, 9. Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) are noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. An Admission Record revealed the facility admitted Resident #37 on 12/12/2024. According to the Admission Record, the resident had a medical history that included diagnoses of dementia, delirium due to known physiological condition, and nicotine dependence. An Admission Nursing Assessment, dated 12/12/2024, revealed Resident #37 was a current smoker and the assessment directed staff to complete a smoking assessment. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/19/2024, revealed Resident #37 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. Resident #37's Care Plan Report included a focus area initiated 12/13/2024, that indicated the resident had a heightened safety risk related to confusion and a personal desire to smoke. Interventions directed staff to apply protective non-flammable apron or cover/barrier during smoking activity (initiated 12/13/2024), keep the resident's cigarettes (initiated 12/13/2024), and keep the resident's lighter(s) (initiated 12/13/2024). Further review of the Care Plan Report included a focus area initiated 01/31/2025, that indicated the resident was noted to smoke used cigarettes found on the ground. Interventions directed staff to post cigarette times in the resident's room (initiated 01/31/2025); explain the risks and benefits to the resident, including the risk of infection (initiated 01/31/2025); and indicated that the resident refused to give staff their lighter (initiated 02/10/2025). Resident #37's Activities-Progress Notes, dated 03/04/2025 at 11:30 AM, revealed an activities staff member spoke with Resident #37 and notified them of the facility's smoking policy. According to the note, the resident refused to sign a copy of the smoking policy that was discussed with them. During an interview on 03/11/2025 at 8:52 AM, the Director of Nursing stated Resident #37 refused to sign the facility's smoking policy. During an interview on 03/11/2025 at 9:13 AM, the Administrator stated he was aware of Resident #37's desire to smoke but not sign the policy. He stated residents were required to sign the smoking policy at admission, but if they refused, a meeting was held with the resident, and they were told that they were not allowed to have a cigarette lighter or cigarettes in their possession. He stated if a resident refused to sign the policy, the information was documented on the smoking policy and the resident's care plan. During an interview on 03/14/2025 at 1:09 PM, the MDS Coordinator stated she had never personally seen Resident #37 with a lighter. She stated interventions should have been added to the care plan to address how staff could obtain the resident's cigarette lighter from the resident. She stated how staff could do that would have been determined by the interdisciplinary team (IDT), which consisted of social services staff, nursing, MDS staff, dietary staff, activities staff, and sometimes administration. She stated that she did not know why there were not additional revisions made to the care plan once it was discovered that the resident had a cigarette lighter.

Based on interview, record review, and facility policy review, the facility failed to ensure a new level I preadmission screening and resident review (PASARR) was completed for 2 (Resident #53 and Resident #75) of 2 sampled residents reviewed for PASARR, who remained in the facility after 30 days. Findings included: A facility policy, titled, Admission Criteria, revised 03/2019, indicated, 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-Admission Screening and Resident Review (PASARR) process. 1. An Admission Record indicated the facility admitted Resident #53 on 09/12/2024. According to the Admission Record, the resident had a medical history that included diagnoses of borderline personality disorder and bipolar disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/04/2025, revealed Resident #53 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. Resident #53's Care Plan Report, included a focus area initiated 01/21/2025, that indicated the resident used psychotropic medications related to anxiety. A typed document from the California Department of Health Care Services dated 09/10/2024, revealed Resident #53's level I screening indicated a level II mental health evaluation was not required. The document indicated, If the Individual [Resident #53] remains in the NF [nursing facility] longer than 30 days, the facility must submit a new Level I Screening as a Resident Review on the 31st day. During an interview on 03/14/2025 at 4:09 PM, the MDS Coordinator stated Resident #53 was a 30-day hospital exempt resident but had been in the facility for more than 30 days. Per the MDS Coordinator, another level I PASARR should have been completed prior to the resident being in the facility for a month, but it was an oversight on her part because it was not done. During an interview on 03/15/2025 at 9:38 AM, the Director of Nursing (DON) stated if a resident was going to be in the facility longer than 30 days, the facility needed to do another level I PASARR. The DON stated Resident #53 should have had a second level I PASARR completed because they were in the facility longer than 30 days. During an interview on 03/15/2025 at 9:54 AM, the Administrator stated he was not really involved in the PASARR process, was not sure of the process, and deferred to nursing. 51749 2. An Admission Record revealed the facility admitted Resident #75 on 08/15/2024. According to the Admission Record, the resident had a medical history that included diagnoses of post-traumatic stress disorder, bipolar disorder, and anxiety disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/20/2025, revealed Resident #75 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. Resident #75's Care Plan Report, included a focus area initiated 09/11/2024, that indicated the resident used psychotropic medications related to diagnoses of depression and bipolar disorder. A typed document from the California Department of Health Care Services dated 08/15/2024, revealed Resident #75's level I screening indicated a level II mental health evaluation was not required. The document indicated, If the Individual [Resident #53] remains in the NF [nursing facility] longer than 30 days, the facility must submit a new Level I Screening as a Resident Review on the 31st day. During an interview on 03/13/2025 at 2:49 PM, the MDS Coordinator stated another level I screening should have been done for Resident #75 on the resident's 31st day of admission to the facility. During a follow-up interview on 03/13/2025 at 3:50 PM, the MDS Coordinator stated another level I screening for Resident #75 was not done on the 31st day of the resident's admission to the facility as it was an oversight. During an interview on 03/15/2025 at 9:38 AM, the Director of Nursing (DON) stated if a resident was going to be in the facility longer than 30 days, the facility needed to do another level I PASARR. The DON stated Resident #53 should have had a second level I PASARR completed because they were in the facility longer than 30 days. During an interview on 03/15/2025 at 9:54 AM, the Administrator stated he was not really involved in the PASARR process, was not sure of the process, and deferred to nursing.

Based on interview and record review, the facility failed to notify the physician that 1 (Resident #6) of 1 sampled resident reviewed for dialysis did not receive their ordered medications when they were out of the facility at dialysis three days each week. Findings included: An Admission Record revealed the facility admitted Resident #6 on 04/06/2024. According to the Admission Record, the resident had a medical history to include diagnoses of acute pulmonary embolism, dependence of renal dialysis, major depressive disorder, hypotension, chronic embolism and thrombosis of left lower extremity, and chronic kidney disease. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/30/2024, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #6's Care Plan Report included a focus area initiated 12/29/2023, that indicated the resident needed dialysis related to a diagnosis of end stage renal disease. Interventions indicated the resident's dialysis days were Mondays, Wednesdays, and Fridays, with a chair time of 6:30 AM on each day. Resident #6's Medication Administration Record [MAR] for the timeframe 03/01/2025 - 03/31/2025, revealed the transcription of the following orders: - an order with a start date of 06/30/2024 and a discontinue date of 03/13/2025, for fluoxetine hydrochloride (HCL) (an antidepressant medication) oral capsule 10 milligram (mg), give one capsule by mouth one time a day for crying spells and irritability. - an order with a start date of 04/07/2024 and a discontinue date of 03/13/2025, for Lasix (a diuretic medication) oral tablet 20 mg, give one tablet by mouth one time a day for pulmonary edema. - an order with a start date of 04/06/2024, for Eliquis (an anticoagulant medication) oral tablet 5 mg, give 5 mg by mouth two times a day for chronic embolism. - an order with a start date of 06/20/2024 and a discontinue date of 03/13/2025, for metoprolol tartrate (a blood pressure medication) oral tablet 25 mg, give one tablet by mouth every 12 hours and hold for a systolic blood pressure of less than 100 millimeters of mercury a heart rate less than 60 beats per minute. According to the MAR, there was no evidence to indicate fluoxetine HCL, Lasix, Eliquis, or metoprolol tartrate were administered to the resident on 03/03/2025 (Monday), 03/05/2025 (Wednesday), 03/07/2025 (Friday), 03/10/2025 (Monday), and 03/12/2025 (Wednesday). During an interview on 03/13/2025 at 2:15 PM, Licensed Vocational Nurse (LVN) #7 reviewed Resident #6's MAR for the timeframe 03/01/2025 - 03/31/2025 and stated the resident did not receive those medications (fluoxetine, Lasix, Eliquis, and metoprolol) because the resident was at dialysis. According to LVN #7, this was something the physician should have been notified of. During an interview on 03/13/2025 at 3:52 PM, LVN #2 reviewed Resident #6's MAR for the timeframe 03/01/2025 - 03/31/2025 and stated she notified the physician of the resident missing those medications ((fluoxetine, Lasix, Eliquis, and metoprolol) three times each week, but could not find any documentation to show evidence the physician had been notified. During an interview on 03/14/2025 at 4:00 PM, Medical Doctor #3 stated he would like to be notified when the resident missed medications three times each week. During an interview on 03/14/2025 at 4:14 PM, the Assistant Director of Nursing stated it would be expected of the staff to notify the physician if medications were not administered as ordered. During an interview on 03/15/2025 at 9:45 AM, the Director of Nursing (DON) stated the expectation was that staff notify the physician when a resident missed their medications. Per the DON, the staff should have notified the physician when Resident #6 missed their medications three times each week. During an interview on 03/15/2025 at 9:56 AM, the Administrator stated he deferred all questions related to notification of the physician to nursing. During a follow-up interview on 03/15/2025 at 1:57 PM, the DON stated she was unable to find a policy related to notification of the physician.

Based on observation, interview, record review, and facility policy review, the facility failed to maintain a medication error rate of 5 percent (%) or less. There were 2 errors out of 26 opportunities, which resulted in a medication error rate of 7.69% for 1 (Resident #12) of 8 residents observed for medication administration. Findings included: A facility policy, titled, Administering Medications, revised 04/2019, indicated, 4. Medications are administered in accordance with prescriber orders, including any required time frame. An Admission Record indicated the facility admitted Resident #12 on 11/19/2024. According to the Admission Record, the resident had a medical history that included diagnoses of muscle weakness and age-related osteoporosis. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/05/2025, revealed Resident #12 had a Brief Interview for Mental Status (BIMS) of 9, which indicated the resident had moderate cognitive impairment. Resident #12's Order Summary Report for active orders as of 03/13/2025, revealed an order dated 11/19/2024, for calcium 600 +D plus minerals oral tablet 600-400 milligrams (mg), give one tablet by mouth two times a day for supplement and an order dated 11/19/2024, for cranberry oral capsule, give 425 mg by mouth one time a day for preventive for urinary tract infection. During medication administration observation on 03/12/2025 at 7:17 AM, Licensed Vocational (LVN) #2 administered medications to Resident #12 to include one cranberry 450 mg tablet and one Oyster Shell Calcium 500 mg tablet. During an interview on 03/13/2025 at 10:05 AM, LVN #2 stated she been trained and was expected to administer the right medication to the residents. According to LVN #2, if the facility did not have the correct medication, she would notify the physician to see if they wanted to change, hold, or provide an alternative medication. LVN #2 stated the Oyster Shell Calcium 500 mg tablet and the cranberry 450 mg tablets were the only ones the facility had in-house as stock medications. During an interview on 03/13/2025 at 10:18 AM, the Director of Nursing (DON) stated staff were trained and expected to administer medications based upon the resident medication rights. The DON stated if a medication was not available, then the physician would be notified, and a follow-up with pharmacy would occur. During an interview on 03/13/2025 at 10:27 AM, the Administrator stated he expected staff to administer medications correctly.

Based on interview and record review, the facility failed to develop and implement a person-centered care plan that included interventions for one of four sampled residents (Resident 1) to prevent choking. There was no care plan developed or implemented for Resident 1's known behavior of rapidly stuffing food in her mouth. On [DATE], Resident 1 had a choking incident and was hospitalized . This failure resulted in an avoidable second choking incident resulting in Resident 1 expiring on [DATE]. Findings: During a review of Resident 1's admission Face Sheet (FS), dated [DATE], the document indicated Resident 1 had diagnoses of bipolar disorder (shifts in a person's mood, energy, activity levels, and concentration), and anxiety (worry or nervousness) disorder. During a review of Resident 1's Acute Care Final Report document, dated [DATE] at 3:28 p.m., indicated Resident 1 was first admitted to the hospital for a history of cerebral vascular accident (CVA- an interruption in the flow of blood to cells in the brain), failed multiple swallow evaluations (test determining swallowing abilities), and aphasia (inability to speak). The report indicated Resident 1 needs assistance with meals . initial [swallow evaluation] . indicated aphasia present. MD (medical doctor) and PT (physical therapy)/OT (occupational therapy) notes indicate . impulsivity with need for sitter . During a review of Resident 1's Acute Care Discharge Summary dated [DATE] at 12:50 p.m., indicated .CVA w/[with]R[right] residual weakness, dysphagia (difficulty swallowing) . Patient presents on [DATE] complaining of choking on food. Per notes, patient was eating a chicken sandwich when she choked on a piece of chicken. They were able to remove some of the chicken from her mouth, but she became hypoxic [decreased oxygen] and with respiratory distress prompted her to come to the ED [Emergency Department] . [Resident 1 was] . high risk for aspiration as she is supposed to be on a[n] aspiration safe diet . During a review of Progress Notes (PN), dated [DATE] at 3:39 p.m., the PN indicated At approximately 1245 this CN [charge nurse] was notified by CNA [Certified Nursing Assistant] that pt [patient] had stuffed food into her mouth and would not open her mouth, upon observation of pt she was sitting in her wheelchair pointing to her mouth, this CN immediately started performing the Heimlich maneuver (a procedure to force food out of someone throat). Two CNAs also attempted the Heimlich maneuver unsuccessfully. Alternate nurse called 911 for AMR [ambulance] support Pt was assisted back into her bed to try and obtain VS [vital signs heart pulse rate, temperature, respiration rate, and blood pressure], no reading obtained from BP [blood pressure] cuff, no pulse, no chest rise. AMR arrived at approximately 1310. TOD [time of death] pronounced by paramedics x2 from AMR @ 1314. Pt DNR [Do Not Resuscitate], comfort measures. This CN asked CNA what occurred, she stated that she placed meal tray on patients table, was attempting to set up her tray when pt grabbed a handful of food and stuffed it into her mouth and would not open her mouth despite several attempts of CNA asking her to open her mouth, pt then started choking . During an interview on [DATE] at 2:17 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 tended to eat her food quickly. LVN 1 stated Resident 1 had an episode of aspiration a month before she died due to eating her food too fast. During an interview [DATE] at 10:19 a.m., with CNA 1, CNA 1 stated Resident 1 would grab whatever food was presented in front of her and Resident 1 would eat very fast and overstuff her mouth. CNA 1 stated Resident 1 had a history of eating fast and overfilling her mouth and staff were aware of these eating behaviors. CNA 1 stated Resident 1 was sent out to the hospital in the past because she choked. CNA 1 stated she did not receive specific instructions on how to monitor Resident 1 during meals. CNA 1 stated Resident 1 could have been considered a choking risk due to her behaviors. CNA 1 stated Resident 1 ate this way from the time of her admission, [DATE]. During an interview on [DATE] at 10:57 a.m., with the registered dietician (RD), the RD stated she was aware Resident 1 was sent out in the past for aspiration, based on reviewing previous hospitalization documents. The RD stated she was not aware of any feeding behaviors Resident 1 had because she never saw her eat and no one communicated any resident eating concerns to her. The RD stated if she knew about Resident 1's eating behaviors she would have put in a referral for Resident 1 to be seen by the speech pathologist to assess for a possible choking risk. The RD stated she was unaware if Resident 1 was ever seen by a speech pathologist. During an interview on [DATE] at 11:08 a.m., with CNA 2, CNA 2 stated [Resident 1] would grab the trays and shove the food in her mouth, she likes to stuff her mouth. CNA 2 stated Resident 1 would eat very fast and insert large amounts of food into her mouth and staff was aware of her eating behaviors since admission. CNA 2 stated, I thought she would eventually choke one day . CNA 2 stated Resident 1 was a high risk for choking due to her behaviors and being sent out to the hospital for a previous choking incident. CNA 2 stated no specific orders or directions were ever communicated to staff on how to monitor Resident 1's feeding behaviors. CNA 2 stated staff were alerted on Resident 1's eating behavior but the only intervention present was to ensure Resident 1 received the right tray. During an interview on [DATE] at 12:11 p.m., with the director of staff development (DSD), the DSD stated staff did not communicate with her regarding Resident 1's eating behavior. The DSD stated if she had knowledge of these behaviors, she would have created specific training for Resident 1's meals. The DSD stated, I would definitely do a lot of in-service and be hands on with my staff if this was brought to my attention. The DSD stated training would have been important to prevent any incidents of choking. During a concurrent interview and record review on [DATE] at 12:48 p.m., with LVN 1, LVN 1 stated, the choking incident could have been anticipated and avoided. LVN 1 stated Resident 1 went out to the hospital for choking in the past due to eating behaviors. LVN 1 stated Resident 1's eating behaviors were known by the staff. LVN 1 stated due to Resident 1's eating behavior she could have benefited from having a feeder (a staff member who helps resident with all meals) or have had someone monitor her while she ate. LVN 1 stated after Resident 1 returned from the hospital, she had a diagnosis of dysphagia. LVN 1 stated this diagnosis put her at high risk for choking. LVN 1 stated Resident 1 had no interventions in place to deal with her eating behavior. LVN 1 stated all staff knew about Resident 1's eating behavior. LVN 1 stated she would have considered Resident 1 a high risk for choking due to the way she ate, and her past hospitalization related to choking. LVN 1 concurred there was no documented evidence of a care plan to address her behavior and no interventions in place to deal with her eating behavior. During an interview on [DATE] at 2:13 p.m., with LVN 2, LVN 2 stated before Resident 1 died , she had a previous choking incident in which she was transferred to the acute hospital. LVN 2 stated Resident 1 ate very quickly and fit large portions of food into her mouth. LVN 2 stated staff knew about these eating behaviors because Resident 1 did them every day. LVN 2 stated she was not surprised Resident 1 expired due to choking because she had a previous incident where she choked and was sent out to the hospital. LVN 2 stated Resident 1's dysphagia put her at risk for choking and aspiration. LVN 2 stated a diagnosis of dysphagia means staff should closely monitor consumption of liquids and food. During an interview on [DATE] at 3:30 p.m., with the director of nurses (DON), the DON stated the facility did not think Resident 1's death from choking was an unusual occurrence. The DON stated due to Resident 1's history of CVA and dysphagia the Interdisciplinary Team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of their residents) and the administrator (ADM) did not consider the incident an unusual occurrence due to Resident 1's known behaviors of trying to consume foods too quickly. The DON stated staff not familiar with Resident 1's behavior would not be aware of her risk for choking. The DON stated there was no choking assessment done and no care plan detailing her risk for choking or aspiration for Resident 1. The DON stated Resident 1 needed a care plan in place regarding aspiration and choking. The DON agreed Resident 1 needed a care plan. The DON stated a care plan is important to make all nurses aware of Resident 1's behaviors. The DON stated Resident 1 was at a high risk for aspiration and a speech therapist should have been involved in her care. The DON stated no speech therapist assessed Resident 1 in the facility. The DON stated the Registered Dietician (RD) was not aware of Resident 1's eating behaviors and since she was not aware, it could have led to negative outcomes for Resident 1. The DON stated staff should have informed the RD about Resident 1's eating behavior if they were aware of it. During an interview on [DATE] at 4:20 p.m., with the ADM, the ADM stated Resident 1's death was not reported because they did not think it was an unusual occurrence. The ADM stated it was not uncommon to have residents die in facilities. During a review of Resident 1's Order Details dated [DATE] at 4:12 p.m., the document indicated Resident 1 had an order for a swallow evaluation with a speech therapist. During a review of Resident 1's Order Details dated [DATE] at 9:03 a.m., the document indicated Resident 1 had a speech therapy evaluation ordered due to swallowing difficulties. During an interview on [DATE] at 10:41 a.m., with the speech pathologist (SP), the SP stated she did not receive any communication regarding Resident 1. The SP stated Resident 1 should have been seen by a speech pathologist. The SP stated there was a failure to communicate regarding Resident 1's speech pathology order which is why it was missed. The SP stated a resident assessment normally occurred within 48 hours of an order. The SP stated Resident 1's first speech therapy consult was ordered on [DATE]. The SP stated if she had been aware of Resident 1's required speech therapy assessment, the SP would have done it. During a concurrent interview and record review, on [DATE] at 4:52 p.m., with the social services director (SSD), the SSD stated she attended IDT meetings and did not recall Resident 1's eating behaviors being discussed. The SSD stated she heard Resident 1 would try to fit a lot of food in her mouth and Resident 1 once had her whole fist in her mouth to prevent staff from removing the food. The SSD stated a speech therapy evaluation was ordered for Resident 1, but she was unsure if it was done. The SSD stated staff may have forgotten about Resident 1's speech therapy appointment or staff may not have realized she had an appointment. The SD concurred there was no documented evidence of a speech evaluation completed. During an interview on [DATE] at 4:30 p.m., with a family member (FM), the FM stated Resident 1 had a diagnosis of bipolar disorder her whole life. The FM stated Resident 1 had trouble speaking and had right sided weakness due to a stroke. The FM stated Resident 1 had a feeding tube due to her inability to swallow at the hospital. The FM stated the facility staff said Resident 1 would receive a swallow evaluation by a speech therapist, but they never told him this was not done. The FM stated Resident 1 tended to eat quickly and he told her [Resident 1] she might choke again due to this behavior. The FM stated he visited Resident 1 regularly and did not observe a feeder or staff member monitoring her while she ate. During a concurrent interview and record review, on [DATE] at 12:48 p.m., with LVN 1, Resident 1's admission nursing assessment, dated [DATE] was reviewed. The readmission form indicated, Resident 1 was readmitted to the facility with a diagnosis of dysphagia. Resident 1 returned after being hospitalized for a choking incident at the facility. LVN 1 stated due to Resident 1's diagnosis and hospitalization , her death from choking could have been anticipated. LVN 1 stated Resident 1's diagnosis of dysphagia means Resident 1 had difficulty swallowing and speaking and the facility should have better monitored her to prevent any future choking incidents. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered , dated [DATE], the document indicated, . 11. Assessments of residents are ongoing and care plans are revisedas information about the residents and the residents' condition change. 12. The interdisciplinary team reviewsand updates the care plan: a. when there had been a significant change in the resident's condition . c. when the resident has been readmitted to the facility from a hospital stay . During a review of the facility's policy and procedure titled, Dysphagia -Clinical Protocol , dated [DATE], the document indicated, 1. the staff and physician will identify individuals with a history of swallowing or related diagnosis such as dysphagia, as well as individuals who currently have difficulty chewing or swallowing food . 2. Based on information collected and correlated by various disciplines, the staff and practitioner, in conjunction with the SLP, will define the situation carefully . and whether the situation needs additional evaluation and clarification . Cause Identification 1. It is important to clarify the symptoms and the history in detail to help identify causes, since symptoms related to chewing or swallowing may have modifiable causes . 4. medical and other causes of dysphagia can include the following . f. psychiatric disorders (anxiety, depression, and various personality disorders) . 5 . b (1) examples of situations in which speech therapy interventions may be helpful include individuals who have had a recent stroke with subsequent impaired chewing and swallowing During a review of Resident 1's Certification of Death dated [DATE], the Certification of Death indicated, . 107. CAUSE OF DEATH . (A) IMMEDIATE CAUSE . ACUTE RESPIRATORY FAILURE . sequentially, list conditions, if any, leading to cause . ENTER UNDERLYING CAUSE (disease or injury that initiated the events resulting in death) LAST . (B) ASPHYXIA (C) ASPIRATION (D) STROKE WITH DYSPHAGIA . 123. PLACE OF INJURY OTHER: NURSING HOME .124. DESCRIBE HOW INJURY OCCURRED: CHOKED ON FOOD BOLUS .

Based on interview and record review, the facility failed to develop and implement adequate supervision and assistive devices for the prevention of falls for one of three sampled residents (Resident 1) when Resident 1 was identified as a high fall risk (assessment of the likelihood of a resident falling) and experienced falls on [DATE], [DATE] and [DATE]. The facility did not implement interventions to keep Resident 1 safe and free from falls and injuries. These failures resulted in Resident 1 sustaining an avoidable fall on [DATE] and subsequently obtained a fracture (broken bone) to the right forearm experiencing pain and suffering. Findings: During a review of Resident 1's Admission Record, dated [DATE], indicated, Resident 1 was admitted to the facility on [DATE]. Resident 1 had a diagnosis of [CONDITION(S)] (disorder of the central nervous system that affects movement, often including tremors). During a review of Resident 1's Progress Note dated, [DATE], indicated, .Housekeeper called the LN [Licensed Nurse] and found resident sitting on the floor on his right side. Housekeeper stated that I saw resident walking out of his room and he loss [lost] his balance and end up sitting on the floor. Per housekeeper he did not hit his head. Upon further assessment from head to toe, no redness no bruising noted able to move all extremities without c/o [complaint] pain and discomfort. Assisted back to his wheelchair .V/S (vital signs clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure that indicates the state of a patient's essential body functions) 97.5 (F -Fahrenheit unit of temperature) 66 (bpm-beats per minute to indicate heart rate) 18 (rpm-respirations per minute indicating respiratory rate) ,d+[DATE] (mm hg- millimeter of mercury to indicate blood pressure). [DATE] Resident complained of pain to right forearm x'ray (type of [CONDITION(S)] called electromagnetic waves creating pictures of the inside of the body) done [DATE] Xray result received had hairline fracture with no dislocation. Resident was transferred to ER (emergency room ) for further evaluation and treatment . During a review of Residents 1's Diagnostic Laboratories and Radiology, dated [DATE], indicated, .Exam: Forearm AP (anteroposterior front to back) and LAT (lateral .There is acute hairline fracture (tiny crack in a bone caused by repetitive stress or force) involving right distal ulna (bone in the forearm) without displacement. The elbow and wrist joints are intact in alignment . During a concurrent interview and record review on [DATE], at 3:08 p.m., with the Director of Nursing (DON), the Progress Notes dated [DATE], [DATE], [DATE], and [DATE] were reviewed. The DON stated Resident 1 had four falls within the last two months from [DATE] to [DATE]. The DON stated Resident 1 was declining due to his diagnosis of [CONDITION(S)] and had been placed on hospice care on [DATE]. The DON stated Resident 1 would shuffle his feet when he would get up to walk to restroom and gait was getting worse the last two months of life. The DON stated Resident 1 expired on [DATE] from disease process of [CONDITION(S)] disesase. The DON stated the IDT (interdisciplinary team-group of healthcare professionals with various areas of expertise who work together toward the goals of their clients) would meet after every resident fall to add a different intervention to minimize the risk for the next fall. The DON stated she did not remember what intervention was put into place to address Resident 1's shuffling gait. The DON stated shuffling gait could have been reason for Resident 1's fall on [DATE]. During an interview on [DATE], at 9:30 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 was able to walk on his own but would have an unstable gait. LVN 1 stated when any resident would fall, the facility would implement interventions such as assessing residents with neurological checks (visual check for level of consciousness) for three days if a resident had an unwitnessed fall. LVN 1 stated the staff would monitor the residents every 15 minutes for the first two hours after the fall, have the call light within reach for the residents. During an interview on [DATE], at 12:05 p.m., with LVN 2, LVN 2 stated Resident had a history of falls. LVN 2 stated the housekeeper (HS), saw Resident 1 fall on [DATE]. LVN 2 stated Resident 1 had a diagnosis of [CONDITION(S)]. LVN 2 stated Resident 1 would have the tendency of getting up out of his wheelchair. LVN 2 stated Resident 1 would be noncompliant (failing to act in accordance with commands) with wheelchair use, and would stand up without asking for assistance with care. LVN 2 stated Resident 1 would walk but would not listen to staff to sit in his wheelchair for his safety. During an interview on [DATE], at 12:42 p.m., with the Housekeeper (HK), the HK stated on [DATE], she was at the nurse's station emptying out trash bins when she turned around and saw Resident 1 standing near the doorway of his room. The HK stated Resident 1 fell on his side. The HK stated Resident 1 appeared to have lost his balance and attempted to grab the handrail near the doorway, but could not keep himself up and fell to the floor. The HK stated there was no staff member near him when the fall occurred. During a concurrent interview and record review on [DATE], at 1:07 p.m., with the DON and Director of Staff Development (DSD), the DON, stated the same interventions for Resident 1 were continued for falls. Resident 1's Care Plan, dated [DATE], indicated, .offer fluids as tolerated: Date initiated: [DATE] .Be sure [Resident 1] call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Date initiated: [DATE] .Blue arm band applied to resident's wheel chair to signify he is at risk for falls and on the fall prevention program. Date initiated: [DATE] .Blue arm band: [Resident 1] REFUSED to wear, when staff attempted to place on resident to signify he is a FALL RISK and on the Fall prevention program (designed to implement interventions to reduce the risk for falls). Date initiated: [DATE] .Blue Non skid sock provided to [Resident 1] to wear to signify he is at risk for falls. Date initiated: [DATE] .Constant reminder not to get up from the wheelchair abruptly to prevent from losing his balance. Date initiated: [DATE] .Encourage resident to call for assistance when reaching for items in nightstand. Date initiated: [DATE] . The DON stated there was not a different intervention implemented for Resident 1's fall on [DATE] that lead to Resident 1 sustaining a fracture of the forearm. The DON stated the intervention for offering fluids was not an intervention used to prevent Resident 1 from falling. The DON and DSD stated the facility had implemented every intervention they could think of for Resident 1. The DON and DSD stated monitoring Resident 1's whereabouts was the only intervention that they could prevent Resident 1 from falling. Resident 1's Care Plan did not indicate a floor mat was implemented for falls. The DSD stated bed alarms (sensor alarm that allows a caregiver to monitor the activity of a resident in bed to reduce the risk for falls) were not implemented for Resident 1 as they were considered restraints (devices that limit a resident's movement) and Resident 1 had the right to fall. The DON stated there should have been a new intervention implemented for Resident 1's fall on [DATE] to prevent possible falls for Resident 1. During a concurrent interview and record review, on [DATE], at 2:05 p.m., with the DON, Resident 1's PT (Physical Therapy) Daily Treatment Note, dated [DATE], indicated, .Safety: Poor .Balance: Poor . The DON stated Resident 1 was assessed as having poor safety awareness and poor balance. During a concurrent interview and record review, on [DATE], at 2:05 p.m., with the DON, Resident 1's PN dated [DATE] was reviewed. The Resident 1's PN indicated, .Resident had an witnessed fall@ 0000 (midnight), outside (on the street), resident was being combative and confused, resident attempted to run outside of the building, resident stated that he is looking for his dog, and had an witnessed fall, on his left side, resident noted with some abrasions (skin that is scraped or rubbed off) to his left hip, resident able to move his upper/lower extremities (legs), without any discomfort, no head injuries noted, after the fall, resident was helped by the CNAs (Certified Nursing Assistant) to his wheelchair, and back to his bed, no altered mental status (group of clinical symptoms rather than a specific diagnosis, and includes cognitive disorders, attention disorders, arousal disorders, and decreased level of consciousness) noted, PERRLA (pupils, equal, round, and reactive to light and accommodation is a convenient description of pupillomotor function), no pain noted, resident vocal to the staff, alert and able to follow simple command. MD [medical doctor] aware @ 0010 (12:10 a.m.), and rp (responsible party) aware . The DON stated Resident 1 would be confused to the point of running out of building. The DON stated he needed to be assessed for wandering to ensure he did not fall. The DON stated the Resident 1's fall risk needed to be evaluated to minimize the risk for future falls. The DON stated she did not know at the time if interventions were put into place for behaviors of running out of building during midnight. During a concurrent interview and record review, on [DATE], at 2:05 p.m., with the DON, Resident 1's PN dated [DATE] was reviewed. The Resident 1's PN indicated, .Resident was in his wheel chair in the hall way stand up quickly and went out of balance and end up sitting on the floor witnessed by license nurse upon further assessment from head to toe no redness no bruising no swelling noted able to move all extremities without c/o (complaint of) pain or discomfort assisted resident back to his wheelchair with 3 person assist . The DON stated a Morse Fall Risk (rapid and simple method of assessing a resident's likelihood of falling) assessment was completed on [DATE] and indicated, Category: High Risk for Falling .Score 65 . The DON stated the score indicated Resident 1 was at high risk for falling. During a concurrent interview and record review, on [DATE], at 2:05 p.m., with the DON, Resident 1's PN dated [DATE] was reviewed. The Resident 1's PN indicated, .Resident was standing in front of nursing station, purposely let go off his hands and lean backward and let himself on the floor in front of nursing staffs. resident awake, alert and verbally responsive and laughing, no C/O (complaint of) pain or discomfort able to make all extremities well, no any bruises, no bump no skin tear, no redness noted . The DON stated a Morse Fall Risk assessment was completed on [DATE] and indicated, Category: High Risk for Falling .Score 65 . The DON stated the score indicated Resident 1 was at high risk for falling. The DON stated the falls sustained by Resident 1 from [DATE] to [DATE] were all related to Resident 1's gait and balance. The DON stated more visual monitoring needed to be done to ensure Resident 1 was safe from falling. The DON stated the interventions implemented for the four falls were not working because Resident 1 continued to fall and condition was declining. During a concurrent interview and record review on [DATE], at 2:05 p.m., with the DON, Resident 1's Morse Fall Scale (method of assessing a patient's likelihood of falling), dated [DATE] was reviewed. Resident 1's Morse Fall Scale indicated, .Category: High Risk for Falling .Score 75 .E. Gait Impaired difficulty rising from chair, uses chair arms to get up, bounces to rise .Weak stooped but able to lift head without losing balance steps are short, resident may shuffle .What type of gait does the resident exhibit? 1. Impaired .Morse Fall Scoring: High Risk 45 and higher . The DON stated there was an increase in fall risk for Resident 1. The DON stated the increase in Resident 1's fall risk should have prompted the facility to re evaluate Resident 1's safety awareness and balance to prevent future falls from occurring. During a review of Resident 1's IDT Note (Interdisciplinary Team), dated [DATE], indicated .IDT Recommendations .Resident had history of multiple intentional falls with no injury. Resident was placed under hospice care for End Stage [CONDITION(S)], Polyosteoarthritis (related to the process of aging, repetitive use of joints causes damage to cartilage, resulting in joint pain and swelling, and eventually cartilage will degenerate), Dementia (group of conditions characterized by impairment of at least two brain functions such as memory loss and judgment) with Behavior disturbance. IDT recommendation to continue present plan of care under Hospice services . The DON stated Resident 1's IDT note, did not indicate interventions to address Resident 1's poor safety awareness or poor balance. During a review of the facility policy and procedure titled, Falls, dated ,d+[DATE], indicated, .Treatment/Management 1. Based on preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences falling .4. If the individual continues to fall, the staff and physician will re evaluate the situation and consider other possible reasons for the resident's falling (besides those that have already been identified) and will re evaluate the continued relevance of current interventions .

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services on acquiring, receiving, dispensing, and administering of all drugs to meet the needs of each resident for 11 of 12 sampled residents (Resident 1, 2, 3, 4, 6, 7, 8, 9, 10, 11 and 12) when the contracted pharmacist for the facility did not deliver prescribed medications between 12/12/19 and 12/19/19. 1. Resident 1 was prescribed [MEDICATION NAME] (anti-coagulant medications to prevent normal blood clotting) on 12/16/19 to prevent [MEDICAL CONDITION] ([MEDICAL CONDITION]- blood clot) for [DIAGNOSES REDACTED]. The [MEDICATION NAME] was not delivered by pharmacy and not administered to Resident 1 on 12/17/19, 12/18/19 and 12/19/19. The [MEDICATION NAME] was not administered by licensed nurses because the facility did not have the medication to administer. 2. Resident 2 was prescribed [MEDICATION NAME] (medication use to treat migraine headaches-severe headaches often accompanied by vision difficulties and nausea) on 7/26/19 for migraine and was not delivered by pharmacy and not administered to Resident 2 on 12/12/19 to 12/19/19. Resident 2 was prescribed [MEDICATION NAME] propionate suspension 50 mcg per act (mcg means micrograms which is a measured weight; act means actuation or the metered dose for each spray; a nasal spray medication used to relieve stuffy or runny nose, itching and sneezing) on 7/26/19 for nasal allergies and was not delivered by pharmacy and not administered to Resident 2 from 12/7/19 to 12/18/19. The [MEDICATION NAME] and [MEDICATION NAME] propionate was not administered by licensed nurses because the facility did not have the medication to administer. 3. Resident 3 was prescribed [MEDICATION NAME] (a medication used to relieve nerve pain) on 11/19/19 for nerve pain and was not delivered by pharmacy and not administered to Resident 3 on 12/18/19. The [MEDICATION NAME] was not administered by licensed nurses because the facility did not have the medication to administer. 4. Resident 4 was prescribed levetiracetam (a medication used to treat [MEDICAL CONDITION]- a sudden, uncontrolled electrical disturbance in the brain) on 5/3/18 for [MEDICAL CONDITION] and was not delivered by pharmacy and not administered to Resident 4 on 12/17/19, 12/18/19 and 12/19/19. The levetiracetam was not administered by licensed nurses because the facility did not have the medication to administer. 5. Resident 6 was prescribed [MEDICATION NAME] (a psychiatric medication used to treat mental/mood disorder) on 11/26/19 to manage behaviors of increased agitation and aggression and was not delivered by pharmacy and not administered to Resident 6 on 12/17/19 and 12/18/19. The [MEDICATION NAME] was not administered by licensed nurses because the facility did not have the medication to administer. 6. Resident 7 was prescribed [MEDICATION NAME] (a psychiatric medication use to treat mental/mood disorder) on 9/19/19 to manage increased behaviors of agitation and was not delivered by pharmacy and not administered to Resident 7 on 12/17/19 and 12/18/19. The [MEDICATION NAME] was not administered by licensed nurses because the facility did not have the medication to administer. 7. Resident 8 was prescribed potassium chloride (a medication used to prevent or treat [DIAGNOSES REDACTED] (low blood levels of potassium) on 4/2/18 to treat [DIAGNOSES REDACTED] and was not delivered by pharmacy and not administered to Resident 8 on 12/18/19 and 12/19/19. The potassium chloride was not administered because the facility did not have the medication to administer. 8. Resident 9 was prescribed floucinonide (a medication used to treat variety of skin conditions such as rash) on 12/13/19 to treat rash and was not delivered by pharmacy and not administered to Resident 8 from 12/14/19 to 12/18/19. The floucinonide was not administered because the facility did not have the medication to administer. 9. Resident 10 was prescribed [MEDICATION NAME] (a medication used to treat manic episodes) to manage increased behaviors of agitation and duloxetine (a medication use to treat diabetic [MEDICAL CONDITION] (numbness and loss of sensation in the feet, legs or hands) on 2/4/19 and was not delivered by pharmacy not administered to Resident 10 on 12/18/19 and 12/19/19. The [MEDICATION NAME] and duloxetine was not administered because the facility did not have the medication to administer. 10. Resident 11 was prescribed losartan (a medication use to treat high blood pressure) and [MEDICATION NAME] (a medication use to treat behavior problem yelling/screaming manifested by paranoid [MEDICAL CONDITION] disorder) on 12/13/19 and was not delivered by pharmacy and not administered to Resident 11 on 12/18/19. The losartan and [MEDICATION NAME] was not administered because the facility did not have the medication to administer. 11. Resident 12 was prescribed umeclidinium vilanterol (a medication use to prevent [MEDICAL CONDITION] ([MEDICAL CONDITION] - a chronic [MEDICAL CONDITION] lung disease that causes obstructed airflow from the lungs) exacerbation (increased in severity) on 9/15/19 and was not delivered by pharmacy and not administered to Resident 12 on 12/18/19. The umeclidinium vilanterol was not administered because the facility did not have the medication to administer. These failures resulted in Resident 1 not being administered [MEDICATION NAME] (medication to treat and prevent [MEDICAL CONDITIONS] - a serious condition that occurs when a blood clot forms in a vein deep in the body and blood clots in your veins can break loose, travel through your bloodstream and lodge in your lungs, blocking blood flow) to prevent blood clots; Resident 2 suffered severe migraine headaches (migraines are a recurring type of headache. The migraine headaches caused moderate to severe pain that was described as throbbing or pulsing) and Resident 2 was not administered [MEDICATION NAME] (a medication helps to relieved headache, pain and other migraine symptoms), Resident 3 was not administered [MEDICATION NAME] (a medication used to relieved nerve pain), Resident 4 was not administered levetiracetam (a medication use to treat [MEDICAL CONDITION]- a sudden, uncontrolled electrical disturbance in the brain), Resident 6 was not administered [MEDICATION NAME] (a psychiatric medication use to treat mental/mood disorder) to manage behaviors of increased agitation and aggression, Resident 7 was not administered [MEDICATION NAME] (a psychiatric medication use to treat mental/mood disorder) to manage increased behaviors of agitation, Resident 8 was not administered potassium (a medication use to prevent or treat [DIAGNOSES REDACTED] (low blood levels of potassium), Resident 9 was not administered floucinonide (a medication use to treat variety of skin conditions such as rash), Resident 10 was not administered [MEDICATION NAME] (a medication use to treat manic episodes) to manage increased behaviors of agitation and duloxetine (a medication use to treat diabetic [MEDICAL CONDITION] (numbness and loss of sensation in the feet, legs or hands), Resident 11 was not administered losartan (a medication use to treat high blood pressure) and Resident 12 was not administered umeclidinium vilanterol (a medication use to prevent [MEDICAL CONDITION] ([MEDICAL CONDITION] - a chronic [MEDICAL CONDITION] lung disease that causes obstructed airflow from the lungs) exacerbation (increased in severity). Because of the serious potential harm related to not administering physician ordered medications to Residents 1, 2, 3, 4, 6, 7, 8, 9, 10, 11 and 12 diagnosed with [REDACTED]. The facility submitted an acceptable Action Plan (AP) that addressed the IJ situation. The AP included in-service education to the LNs on assessment, documentation and notification of the MD and pharmacy when a medication was unavailable. The AP also included Resident 1's transfer to the General Acute Care Hospital (GACH) for evaluation for a possible [MEDICAL CONDITION] and administration of [MEDICATION NAME]. Resident 2 received [MEDICATION NAME] and [MEDICATION NAME] on 12/19/19 and was assessed for signs and symptoms of migraine headaches and nasal congestion. Resident 3 received [MEDICATION NAME] on 12/19/19 and was assessed for signs and symptoms of pain. Resident 4 received levetiracetam on 12/20/19 and was assessed for signs and symptoms of [MEDICAL CONDITION] activity such as loss of consciousness and uncontrollable jerking movements of the arms and legs. Resident 6 received [MEDICATION NAME] on 12/19/19 and was assessed for signs and symptoms of increased behaviors of aggression. Resident 7 received [MEDICATION NAME] on 12/20/19 and was assessed for signs of increased behaviors of agitation and aggression. Resident 8 received potassium Extended Released (ER) on 12/19/19 and was assessed for signs and symptoms of [DIAGNOSES REDACTED] (low potassium) such as muscle weakness and heart palpitations. Resident 9 received [MEDICATION NAME] cream 12/19/19 and was assessed for signs and symptoms of worsening rash. Resident 10 received duloxetine and [MEDICATION NAME] sodium on 12/20/19 and was assessed for signs and symptoms of increased behaviors of agitation. Resident 11 received losartan potassium and [MEDICATION NAME] sodium (use to treat behavior problem yelling/screaming in the hallway manifested by paranoid [MEDICAL CONDITION] disorder) delayed released on 12/19/19 and was assessed for signs and symptoms of elevated blood pressure. Resident 12 received umeclidinium/vilanterol aerosol (used to relax the airway muscles to assist with breathing) on 12/19/19 and was assessed for signs and symptoms for [MEDICAL CONDITION] exacerbation such as shortness of breath and wheezing. The interventions to address the IJ situation on the AP were fully implemented and the IJ was removed on 12/23/19 at 4:52 p.m. Findings: 1. During an interview on 12/16/19, at 10:14 a.m., with the Administrator (ADM), the ADM stated he finalized the contract with (Name of New Pharmacy) on 12/12/19. The ADM stated the transition from the facility's previous pharmacy to the new pharmacy started on 12/16/19. The ADM stated (name of pharmacy) was located in (name of city) which was 310 miles away from the facility. The ADM stated Licensed Nurses (LNs) were not fully aware of the transition to their new pharmacy. The ADM stated, (LNs) were still ordering from the previous pharmacy. The ADM stated LNs should have been provided in-service training during the transition from the previous pharmacy to the new pharmacy to ensure all residents' medications were available. The ADM stated, We failed on that part to prepare the Licensed Nurses during the transition (from the previous pharmacy to the new pharmacy). The ADM stated LNs should have notified the Medical Director and the pharmacy when the medications were unavailable and they did not. The ADM stated LNs should have assessed Resident 1,2 ,3 ,4 6, 7, 8, 9, 10, 11 and 12 when their medications were unavailable and were not administered to ensure residents' health and safety. During a review of Pharmaceutical Services Agreement, dated 12/12/19, indicated, . This Pharmaceutical Services Agreement is hereby entered into by and between (Name of New Pharmacy), and Central Valley Post-Acute/Riverbank . Pharmacy shall sell and distribute pharmaceutical products . to facility and residents . In accordance with any applicable requirements of federal, state or local laws regulations . (name of pharmacy) will perform deliveries Monday through Sunday, all deliveries shall be performed in a timely manner as required . An emergency kit will be supplied by (name of pharmacy) to the facility containing backup medication doses that are allowed by law and the State of California Pharmacy Board for the use of, and the discretion of the facility for (name of pharmacy) patients only . During a review of the facility's document titled, Job Description of Administrator, undated, indicated, . The Administrator is responsible to plan, organize, develop and direct the overall operation of the skilled nursing services in accordance with current federal, state and local standards, guidelines, and regulations that govern our facility . to ensure that the highest degree of quality care is maintained at all times . Monitor quality and appropriateness of care provided . During a concurrent interview and record review, on 12/18/19, at 2:09 p.m., with Registered Nurse (RN) 3, the Medication administration audit report, dated 12/18/19 indicated, . (Resident 1) [MEDICATION NAME] sodium 40 mg/0.4 ml (milligrams per milliliter-unit of measure) subcutaneously (under the skin) one time a day for blood clot prevention for 30 days . RN 3 stated the [MEDICATION NAME] for Resident 1 was unavailable and was not administered by LNs. RN 3 stated the [MEDICATION NAME] should have been administered to Resident 1 as prescribed by the physician and pharmacy should have been notified of the unavailability of the [MEDICATION NAME] and it was not done. RN 3 stated the facility transitioned to a new pharmacy and pharmacy in-serviced was not provided to LNs on ordering and acquiring medications from the new pharmacy. During a concurrent interview and record review on, 12/19/19, at 9:58 a.m., with the ADON, Resident 1's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. see progress notes) in the box for Resident 1's [MEDICATION NAME] sodium 40 mg/0.4 ml. Resident 1's Progress Notes dated 12/18/19 and 12/19/19 was reviewed by the ADON which indicated Resident 1's [MEDICATION NAME] sodium was unavailable and was not administered to Resident 1 by LNs. The ADON stated LNs should have notified the pharmacy of the unavailability of the [MEDICATION NAME] sodium for Resident 1 and it was not done. During a record review on, 12/19/19, at 10:15 a.m., with the ADON, Resident 1's face sheet (a document containing personal and medical information) dated 12/16/19, indicated Resident 1 was admitted to the facility with [DIAGNOSES REDACTED]. Resident 1's physician's orders [REDACTED]. ( [MEDICATION NAME] sodium 40 mg/0.4 ml) inject 40 mg subcutaneously one time a day for blood clot prevention for 30 days . During an interview on, 12/19/19, at 10:35 a.m., with Licensed Vocational Nurse (LVN) 7, LVN 7 stated she was the LN on duty the morning of 12/19/19 and she had not administered Resident 1's [MEDICATION NAME] because it was unavailable and had not been delivered by the pharmacy. LVN 7 stated, The ([MEDICATION NAME]) dose is missing since 12/17/19 . the MD and the pharmacy should have been notified . and it was not done. During a concurrent observation and interview on, 12/19/19, at 10:45 a.m., with LVN 7 in nursing station two, medication cart 4, LVN 7 checked the medication cart 4 for Resident 1's [MEDICATION NAME] and was unable to find the medication. LVN 7 stated, It's ([MEDICATION NAME]) not here. LVN 7 stated the facility transitioned to a new pharmacy and pharmacy in-service training was not provided to LNs on ordering medications. During a telephone interview on, 12/19/19, at 2:12 p.m., with the Pharmacy Owner (PO), the PO stated, (Name of New Pharmacy) is still in transition with the facility. The PO stated the pharmacy contract agreement was finalized on 12/12/19 and started delivery of medications to the facility on [DATE]. The PO stated, If (LNs) notified and followed up with the pharmacy with urgency, the ([MEDICATION NAME] for Resident 1) would have been sent (stat)-as soon as possible within 4 hours. It would have been delivered and the medication would not be missed for 3 days . During a concurrent interview and record review on, 12/19/19, at 4:16 p.m., with LVN 5, LVN 5 stated he was the LN on duty on 12/18/19 and he had not administered Resident 1's [MEDICATION NAME] because it was unavailable and had not been delivered by pharmacy. LVN 5 stated, The ([MEDICATION NAME]) was not in the (medication cart) because there was a transition from the pharmacy. (Facility) used to have another pharmacy and there is a new pharmacy . LVN 5 stated the LN were not aware of the pharmacy transition and were still ordering from the previous pharmacy. LVN 5 stated the facility should have communicated and provided in-service education of the transition to the new pharmacy. LVN 5 stated the facility transitioned to a new pharmacy and pharmacy in-service education was not provided to LNs on ordering medications. During a telephone interview on, 12/19/19, 4:32 p.m., with the MD, the MD stated, I was not informed that ([MEDICATION NAME]) was not given on (12/17/19, 12/18/19, and 12/19/19) . the dose has to be given immediately . to prevent blood clot. It's a very important medication so it should not be missed . During a telephone interview on, 12/23/19, at 4:59 p.m., with RN 2, RN 2 stated she was the LN on duty on 12/17/19. RN 2 stated she had not administered the ([MEDICATION NAME]) on 12/17/19 because the medication was not available and was not delivered by the pharmacy. RN 2 stated, I was never trained (by the facility on medication administration) . I was just thrown in the (medication) cart . I don't know these residents . I should have called the pharmacy and the doctor and charted that I did not give ([MEDICATION NAME]) . (LNs) were never in-serviced or informed that the pharmacy was transitioning . RN 2 stated the facility should have communicated and provide in-service education to all LNs of the change to the new pharmacy to ensure all medications were available during the transition period. RN 2 stated Resident 1 had a history of [REDACTED]. RN 2 stated Resident 1 was prescribed [MEDICATION NAME] to prevent blood clots. During a review of Professional reference from https://orthoinfo.aaos.org/en/diseases--conditions/deep-vein-[MEDICAL CONDITION], titled, [MEDICAL CONDITION], dated 6/15, indicated, . [MEDICAL CONDITION], or [MEDICAL CONDITION], occurs when a blood clot forms in one of the deep veins of the body. This can happen if a vein becomes damaged or if the blood flow within a vein slows down or stops. While there are a number of risk factors for developing a [MEDICAL CONDITION], two of the most common are experiencing an injury to your lower body . that involves your hips or legs . A [MEDICAL CONDITION] can have serious consequences. If a blood clot breaks free, it may travel through the bloodstream and block blood flow to the lungs . this complication-called a [MEDICAL CONDITION] embolism-can be fatal. Even if a blood clot does not break free, it may cause permanent damage to the valves in the vein. This damage can lead to long-term problems in the leg such as pain, swelling, and leg sores . In many cases, [MEDICAL CONDITION] occurs without noticeable symptoms and is very difficult to detect. For this reason, doctors focus on preventing the development of [MEDICAL CONDITION] using different types of therapies, depending upon a patient's needs. Your doctor will take steps to prevent [MEDICAL CONDITION] if you have a major fracture .A broken hip or leg . on your hip, knee or lower leg can affect normal blood flow and clotting. In these orthopedic situations, three primary factors contribute to the formation of blood clots in veins: slow blood flow, hyper-coagulation (excessive blood clotting), and damage to the veins . Nonsurgical treatment usually consists of taking anticoagulants-blood thinning medications that will prevent further clotting and help dissolve existing clots . [MEDICATION NAME] (a medication to prevent and treat blood clot). treatment for [REDACTED]. Standard [MEDICATION NAME] is given intravenously (injection into a vein) while LMWH is given by subcutaneous injection under the skin. LMWH has a short half-life and is eliminated from the body in 12 hours . During a review of Professional reference from https://www.ncbi.nlm.nih.gov/books/NBK 7/, titled, Low Molecular Weight [MEDICATION NAME] (LMWH), dated 2/19, indicated, .Low-molecular-weight [MEDICATION NAME] (LMWHs), for example . ([MEDICATION NAME] Sodium), among others are anticoagulants (medication to prevent blood clots). These drugs are used in the [MEDICATION NAME] (action taken to prevent diseases) of venous [MEDICAL CONDITION] disease (VTE- is a condition in which a blood clot forms in a vein and then dislodges to travel in the blood) on acute or elective admission to hospital, and they are used in the treatment of [REDACTED]. 3. During an interview on, 12/18/19, at 11:05 a.m., with Resident 2, Resident 2 stated, I didn't have my medication for migraine since (12/12/19). I didn't even get my nasal spray because (the facility) does not have it. I had migraine attacks and I need that medication but since (the facility) does not have it, I had to wait. I even had stuffy and congested nose and not enough sleep. During a review of Resident 2's face sheet, dated 7/26/19, the face sheet indicated Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During a review of Resident 2's MDS assessment dated [DATE], the MDS assessment indicated Resident 2's Brief Interview for Mental Status (BIMS- assessment of cognitive status) score was 15 of 15 points which indicated Resident 2 had no cognitive impairment. During a review of Resident 2's physician's orders [REDACTED]. [MEDICATION NAME] Propionate suspension 50 mcg/act one spray in each nostrils every 12 hours for allergies . During a concurrent interview and record review on, 12/18/19, at 1:17 p.m., with LVN 1, Resident 2's MAR indicated [REDACTED]. LVN 1 stated Resident 2's [MEDICATION NAME] 50 mg and [MEDICATION NAME] 50 mcg/act was not available and should be readily available in the event Resident 2 experienced a migraine attack and nasal allergies. LVN 1 stated LNs should have notified the pharmacy of the unavailability of the medications for Resident 2. LVN 1 stated the facility transitioned to a new pharmacy and pharmacy in-serviced was not provided to LNs on ordering medications. During a concurrent interview and record review on, 12/18/19, at 2:09 p.m., with RN 3, the medication administration audit report dated 12/18/19 indicated, . (Resident 2) [MEDICATION NAME] propionate suspension 50 mcg/act 1 spray in each nostril every 12 hours for allergy . [MEDICATION NAME] 50 mg prn every 2 hours as needed for migraines . RN 3 stated the medications reviewed for Residents 2 was unavailable and was not administered by LNs to the residents. RN 3 stated all medications should be administered to the residents as prescribed by the physician. RN 3 stated LNs should have notified the pharmacy and MD and assess residents for serious medical complications. During a concurrent interview and record review on, 12/19/19, at 1:46 p.m., with RN 3, Resident 2's MAR indicated [REDACTED]. RN 3 stated she was the licensed nurse assigned to Resident 2 on 12/18/19 and 12/19/19. RN 2 stated Resident 2 experienced migraine attack on 12/18/19 and 12/19/19 and was not administered because the [MEDICATION NAME] was not available. RN 2 stated Resident 2's [MEDICATION NAME] and [MEDICATION NAME] was not available and should be readily available in the event Resident 2 experienced a migraine attack and nasal allergies. During a concurrent observation and interview on, 12/19/19, at 1:50 a.m., with RN 3, in nursing station 1, medication cart 1, RN 3 checked the medication cart 1 for Resident 2's [MEDICATION NAME] and [MEDICATION NAME] and was unable to find the medications. RN 3 stated the [MEDICATION NAME] and [MEDICATION NAME] were not available and pharmacy should have been notified. During an interview on, 12/19/19, at 2:02 p.m., with Resident 2, Resident 2 stated she experienced severe migraine headaches on 12/12/19, 12/18/19 and 12/19/19 and the migraine medication ([MEDICATION NAME]) was not available. Resident 2 stated, My migraine starts with a headache and blurry vision. I've had blurry vision all day the night before (12/18/19) and today (12/19/19). If I took the migraine medication, it (headache) would not get worst. I feel so congested in my sinus because I have not had my ([MEDICATION NAME]) inhaler. Resident 2 stated she also experienced severe migraine headaches on 12/12/19 and LNs informed her the medication was unavailable. During an interview on, 12/19/19, at 2: 19 p.m., with RN 3, RN stated she was the LN assigned to Resident 2 on 12/18/19 and 12/19/19. RN 3 stated, (Resident 2) asked for [MEDICATION NAME] yesterday (12/18/19) and today (12/19/19). (Resident 2) said she feels a migraine attack coming but I told her the medication ([MEDICATION NAME]) is not available. She always complained of migraine headaches and pain everyday but I don't know if it's actually real. RN 3 stated Resident 2's [MEDICATION NAME] should have been available and administered to Resident 2 to relieve migraine headaches. RN 3 stated Resident 2 complains of migraine headaches everyday so she needed her [MEDICATION NAME] medication. During a review of Professional reference from https://www.mayoclinic.org/diseases-conditions/migraine-headache/symptoms-causes/syc- 201, titled, Migraine dated, 12/19, indicated, .A migraine can cause severe throbbing pain or a pulsing sensation, usually on one side of the head. It's often accompanied by nausea, vomiting, and extreme sensitivity to light and sound. Migraine attacks can last for hours to days, and the pain can be so severe that it interferes with your daily activities . A migraine usually lasts from four to 72 hours if untreated. How often migraines occur varies from person to person . prescription drugs such as . ([MEDICATION NAME]) . are prescription drugs used for migraine because they block pain pathways in the brain. Taken as pills, shots or nasal sprays, they can relieve many symptoms of migraine . 4. During a concurrent interview and record review, on 12/18/19, at 2:09 p.m., with RN 3, the Medication administration audit report dated 12/18/19 indicated, . Resident 3 [MEDICATION NAME] 400 mg give 1 capsule by mouth three times a day for nerve pain . RN 3 stated the [MEDICATION NAME] for Residents 3 was unavailable and was not administered by LNs. RN 3 stated the [MEDICATION NAME] should have been administered to Resident 3 as prescribed by the physician and pharmacy should have been notified of the unavailability of the [MEDICATION NAME]. During a concurrent interview and record review on, 12/19/19, at 5:35 p.m., with the ADON, Resident 3's MAR, dated 12//18/19 was reviewed. The ADON stated Resident 3's [MEDICATION NAME] (a medication to relieve nerve pain) 400 mg was not administered on 12/18/19. The ADON stated LNs should have notified the MD and the pharmacy of the unavailability of the [MEDICATION NAME] and it was not done. During a review of Resident 3's face sheet, dated 9/20/19, the face sheet indicated Resident 3 was admitted in the facility with [DIAGNOSES REDACTED]. During a review of Resident 3's physician's orders [REDACTED]. During a review of Professional reference from https://www.healthline.com/health/[MEDICATION NAME]-oral-capsule#alternatives, titled, [MEDICATION NAME], Oral Capsule undated, indicated, .[MEDICATION NAME] oral capsule is used for short-term or long-term treatment. The length of treatment depends on what condition it's being used to treat. It comes with serious risks if you don't take it as prescribed . Your medication may not work as well or may stop working completely. In order for this drug to work well, a certain amount needs to be in your body at all times . 5. During a concurrent interview and record review on, 12/18/19, at 2:09 p.m., with RN 3, the Medication administration audit report dated 12/18/19 indicated, . (Resident 4) levetiracetam tablet 500 mg give 2 tablets by mouth in the morning for [MEDICAL CONDITION] . RN 3 stated the levetiracetam for Residents 4 was unavailable and was not administered by LNs. RN 3 stated the levetiracetam should have been administered to Resident 4 as prescribed by the physician and LNs should have notified the MD and pharmacy of the unavailability of levetiracetam and it was not done. During a concurrent interview and record review on, 12/19/19, at 5:45 p.m., with the ADON, Resident 4's physician's orders [REDACTED]. The physician's orders [REDACTED]. give 1 tablet by mouth in the evening for [MEDICAL CONDITION] . Levetiracetam tablet 500 mg . give 2 tablet by mouth in the morning for [MEDICAL CONDITION] . The ADON reviewed Resident 4's MAR, dated 12/19 and stated Resident 4's Levetiracetam 500 mg was unavailable and was not administered on 12/17/19, 12/18/19 and 12/19/19. The ADON stated LN should have notified the MD and pharmacy of the unavailability of levetiracetam on 12/17/19, 12/18/19 and 12/19/19 and it was not done. During a review of Resident 4's face sheet, dated 1/12/13, the face sheet indicated Resident 4 was admitted in the facility with a [DIAGNOSES REDACTED]. During a review of Resident 4's Care plan, dated 1/9/18, the care plan indicated, . (Resident 4) has a [MEDICAL CONDITION] disorder related to brain trauma (head injury) . Give [MEDICAL CONDITION] medication as ordered by doctor. Monitor/document side effects and effectiveness . provide medications (levetiracetam) for [MEDICAL CONDITION] . During a review of Professional reference from https://www.[MEDICAL CONDITION].com/learn/triggers-[MEDICAL CONDITION]/missed-medicines, titled Missed Medicine dated 3/14, indicated, . Missing doses of [MEDICAL CONDITION] medicine is the most common cause of breakthrough [MEDICAL CONDITION]. Missed medicines can trigger [MEDICAL CONDITION] in people with both well-controlled and poorly controlled [MEDICAL CONDITION]. [MEDICAL CONDITION] can happen more often than normal, be more intense or develop into long [MEDICAL CONDITION] called [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED] is a medical emergency and can lead to death if the [MEDICAL CONDITION] aren't stopped. Missing doses of medicine can also lead to falls, injuries and other problems from [MEDICAL CONDITION] and changes in medicine levels . 6. During a concurrent interview and record review, on 12/18/19, at 2:09 p.m., with RN 3, the Medication administration audit report dated 12/18/19 indicated, . (Resident 6) [MEDICATION NAME] 200 mg give 1 (tablet) by mouth two times a day for [MEDICAL CONDITION] . RN 3 stated [MEDICATION NAME] for Residents 6 was unavailable and was not administered by LNs. RN 3 stated the [MEDICATION NAME] should have been administered to Resident 6 as prescribed by the physician and LNs should have notified the pharmacy and MD of the unavailability of the [MEDICATION NAME] and it was not done. During a concurrent interview and record review, on 12/19/19, at 5:50 p.m., with the ADON, Resident 6's physician's orders [REDACTED]. The physician's orders [REDACTED]. [MEDICATION NAME] tablet 100 mg give 1 tablet by mouth at bedtime for [MEDICAL CONDITION] . The ADON reviewed Resident 6's MAR, dated 12/19 and stated Resi (TRUNCATED)

Based on observation, interview, and record review, the facility failed to provide treatment and care for 11 of 12 sampled residents (Residents 1, 2, 3, 4, 6, 7, 8, 9, 10, 11 and 12) in accordance with professional standards of practice and the comprehensive person centered care plan to meet resident's needs when: 1. Licensed nurses (LN) did not administer physician ordered medication to prevent life-threatening illness for Resident 1 for three consecutive days from 12/17/19 to 12/19/19. Resident 1 was admitted to the facility on [DATE] at 7:50 p.m. from the General Acute Care Hospital (GACH) with a [DIAGNOSES REDACTED]. Resident 1 was prescribed [MEDICATION NAME] (a medication to prevent blood clot) 40 milligrams (mg- a unit of dry measurement) per (/) 0.4 milliliters (ml) subcutaneous (SC- under the skin) one time a day (8 a.m.) and LNs did not administer the [MEDICATION NAME]. LNs were aware the [MEDICATION NAME] was not delivered by the pharmacy and was not available to be administered. The LNs did not inform the facility's Medical Director (MD) of the unavailability of the medication. LN's did not conduct an assessment on Resident 1 for potential signs and symptoms of [MEDICAL CONDITION] ([MEDICAL CONDITION]- blood clot that develops in the leg and thigh) such as pain, swelling and tenderness. These failures resulted in the serious potential harm of Resident 1 developing a blood clot directly related to the diagnosed fractures of the leg and the blood clot could have traveled in the blood stream to the lungs, heart and/or brain to cause a life-threatening situation. 2. LNs had not administered physician ordered medications to Resident 2 from 12/12/19 through 12/19/19. Resident 2 was not administered [MEDICATION NAME] (a medication to treat migraine- a potentially severe type of headache) 50 mg prn (as needed) medication from 12/12/19 to 12/19/19 and [MEDICATION NAME] 50 micrograms (mcg) (a nasal spray medication used to relieve stuffy or runny nose, itching and sneezing) from 12/12/19 to 12/19/19. Licensed Nurses did not assess Resident 2 for signs and symptoms of worsening migraine and nasal congestion and did not notify the MD of the unavailability of medications for Resident 2. These failures resulted in Resident 2 experiencing severe pain from migraine attacks and nasal congestion from 12/12/19 to 12/19/19. 3. LNs had not administered physician ordered [MEDICATION NAME] (a medication to relieve nerve pain) 400 mg on 12/18/19 for Resident 3's [DIAGNOSES REDACTED]. Licensed Nurses did not assess Resident 3 for pain and did not notify the MD of the unavailability of medication or request an alternate pain medication for Resident 3. This failure resulted in the serious potential harm of Resident 3 to experience severe pain. 4. LNs had not administered physician ordered medication to treat a known [MEDICAL CONDITION] disorder (a disorder characterized by sudden uncontrollable muscle contractions caused by electrical disturbance in the brain) of Resident 4 for three consecutive days. Resident 4 was not administered Levetiracetam (a medication used to treat [MEDICAL CONDITION]) 500 mg on 12/17/19, 12/18/19 and 12/19/19. LNs did not assess Resident 4 for signs and symptoms of [MEDICAL CONDITION] activity and did not notify the MD of the unavailability of medications for Resident 4. This failure resulted in the serious potential for Resident 4 to experience a [MEDICAL CONDITION] episode. 5. Licensed nurses did not administer physician ordered antipsychotic medication to treat Resident 6's [DIAGNOSES REDACTED]. Resident 6 was not administered [MEDICATION NAME], (a medication used to reduce behaviors of aggression in people with [MEDICAL CONDITION]-a disorder that affects a person's ability to think, feel, and behave clearly) 100 mg on 12/17/19 and 12/18/19. LNs had not assessed Resident 6 for increased risk of suicidal behavior and had not notified the MD of the unavailability of medications for Resident 6. This failure resulted in the serious potential harm of Resident 6 to experience increased behaviors of [MEDICAL CONDITION] such as aggression and agitation. 6. LNs had not administered physician ordered antipsychotic medication to treat Resident 7's [MEDICAL CONDITION] for two consecutive days 12/17/19 through 12/18/19. Resident 7 was not administered [MEDICATION NAME] (a medication used to treat [MEDICAL CONDITION]) 5 mg on 12/17/19 and 12/18/19. LNs had not assessed Resident 7 for increased behaviors of agitation and striking out and had not notified the MD of the unavailability of medications for Resident 7. This failure resulted in the serious potential harm for Resident 7 to experience increased behaviors of agitation and aggression. 7. LNs had not administered physician ordered medication, Potassium, to treat Resident 8's [DIAGNOSES REDACTED] (low potassium level in the blood) for two consecutive days, 12/18/19 and 12/19/19. Resident 8 was not administered Potassium Extended Release (ER) 8 milliequivalent (mEq) on 12/18/19 and 12/19/19. LNs had not assessed Resident 8 for signs and symptoms of a low potassium level such as muscle cramps, muscle weakness and abnormal heart rhythms. LNs were aware of the unavailability of the Potassium and had not notified the MD about the unavailability of the potassium for Resident 8. This failure resulted in the serious potential harm of Resident 8 to experience muscle weakness and heart palpitations from the low potassium level. 8. LNs had not administered physician ordered [MEDICATION NAME] (a medication cream used to treat rash) cream solution 0.05% from 12/14/19 to 12/18/19. LNs had not assessed Resident 9 for signs and symptoms of worsening rash and did not notify the MD for the unavailability of medication for Resident 9. This failure resulted in the potential harm of Resident 9's rash to worsen. 9. LNs had not administered physician ordered duloxetine (a medication used to treat diabetic [MEDICAL CONDITION] (numbness and loss of sensation in the feet, legs or hands) 30 mg and [MEDICATION NAME] solution (a medication used for increased agitation) 125 mg on 12/18/19 and 12/19/19. LNs had not assessed Resident 10 for signs and symptoms of pain and behaviors which included screaming. These failures resulted in the serious potential harm of Resident 10 to experience decreased sensation and increased behaviors of agitation. 10. LNs had not administered physician ordered Losartan Potassium (a medication used to treat high blood pressure) 50 mg on 12/18/19 and [MEDICATION NAME] sodium, delayed release, 250 mg on 12/18/19. LNs had not assessed Resident 11 for signs and symptoms of elevated blood pressure, increased behaviors of yelling and screaming and had not notified the MD of the unavailability of the medications for Resident 11. These failures resulted in the serious potential harm for Resident 11 to develop an elevated blood pressure. 11. LNs had not administered physician ordered umeclidinium/vilanterol Aerosol Powder (a medication used to control and prevent symptoms such as wheezing and shortness of breath caused by an ongoing lung disease such as [MEDICAL CONDITION]- [MEDICAL CONDITION]) 62.5-2.5 mcg/inhaler on 12/18/19. LNs had not assessed Resident 12 for signs and symptoms of [MEDICAL CONDITION] exacerbation such as shortness of breath, cough and wheezing and had not notified the MD of the unavailability of medication for Resident 12. This failure resulted in the serious potential harm of Resident 12 to experience [MEDICAL CONDITION] exacerbation such as shortness of breath and wheezing. Because of the serious potential harm related to not administering physician ordered medications to Residents 1, 2, 3, 4, 6, 7, 8, 9, 10, 11 and 12 diagnosed with [REDACTED]. The facility submitted an acceptable Action Plan (AP) that addressed the IJ situation. The AP included in-service education to the LNs on assessment, documentation and notification of the MD when a medication is unavailable. The AP also included Resident 1's transfer to GACH for evaluation for a possible [MEDICAL CONDITION] and administration of [MEDICATION NAME]. Resident 2 received [MEDICATION NAME] and [MEDICATION NAME] on 12/19/19 and was assessed for signs and symptoms of migraine headaches and nasal congestion. Resident 3 received [MEDICATION NAME] on 12/19/19 and was assessed for signs and symptoms of pain. Resident 4 received Levetiracetam on 12/20/19 and was assessed for signs and symptoms of [MEDICAL CONDITION] activity such as loss of consciousness and uncontrollable jerking movements of the arms and legs. Resident 6 received [MEDICATION NAME] on 12/19/19 and was assessed for signs and symptoms of increase behaviors of aggression. Resident 7 received [MEDICATION NAME] on 12/20/19 and was assessed for signs of increased behaviors of agitation and aggression. Resident 8 received PotassiumER on [DATE] and was assessed for signs and symptoms of [DIAGNOSES REDACTED] such as muscle weakness and heart palpitations. Resident 9 received [MEDICATION NAME] cream 12/19/19 and was assessed for signs and symptoms of worsening rash. Resident 10 received Duloxetine and [MEDICATION NAME] sodium on 12/20/19 and was assessed for signs and symptoms of increased behaviors of agitation. Resident 11 received Losartan Potassium and [MEDICATION NAME] sodium delayed released on 12/19/19 and was assessed for signs and symptoms of elevated blood pressure. Resident 12 received umeclidinium/vilanterol Aerosol on 12/19/19 and was assessed for signs and symptoms for [MEDICAL CONDITION] exacerbation such as shortness of breath and wheezing. The interventions to address the IJ situation on the AP were fully implemented and the IJ was removed on 12/23/19 at 4:52 p.m. Findings: 1. During an observation on 12/17/19, at 10 a.m., Resident 1 laid in bed and had a gastrostomy tube ([DEVICE]-a medical device used to give direct access to resident's stomach for supplemental feeding or medications). Resident 1 did not respond to questions when asked and continued to stare at the ceiling. During a concurrent interview and record review on, 12/18/19, at 2:09 p.m., with Registered Nurse (RN) 3, the Medication administration audit report dated 12/18/19 indicated, . (Resident 1) [MEDICATION NAME] Sodium 40 mg/0.4 ml subcutaneously (under the skin) one time a day for blood clot prevention for 30 days . RN 3 stated the medication reviewed for Resident 1 was unavailable and was not administered by LNs to Resident 1. RN 3 stated all medications should have been administered to the residents as prescribed by the physician. RN 3 stated if a medication was unavailable, LNs should have informed the pharmacy, notified the MD and assessed the residents for serious medical complications. During a concurrent interview and record review on 12/19/19, at 9:58 a.m., with the ADON, Resident 1's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. see progress notes) in the box for Resident 1's Enoxaprin 40 mg/0.4 ml. Resident 1's Progress Notes dated 12/18/19 was reviewed by the ADON which indicated there was no documentation of Enoxaprin having been administered to Resident 1, no MD notification and no assessment. Resident 1's Progress Notes dated 12/19/19 was reviewed by the ADON which indicated Resident 1's Enoxaprin was unavailable and was not administered by the LNs. The ADON stated the LNs should have notified the MD of the unavailability of the Enoxaprin for Resident 1 and should have conducted an assessment to ensure Resident 1 did not have signs and symptoms of a blood clot and the LNs had not. During a record review on 12/19/19, at 10:15 a.m., with the ADON, Resident 1's face sheet (a document containing personal and medical information) dated 12/16/19, indicated Resident 1 was admitted to the facility with [DIAGNOSES REDACTED]. Resident 1's physician's orders [REDACTED].(Exoxaprin 40 mg/0.4 ml) inject 40 mg subcutaneously one time a day for blood clot prevention for 30 days . During an interview on 12/19/19, at 10:35 a.m., with Licensed Vocational Nurse (LVN) 7, LVN 7 stated she was the LN on duty the morning of 12/19/19 and she had not administered Resident 1's [MEDICATION NAME] because it was unavailable and had not been delivered by the pharmacy. LVN 7 stated, The dose is missing since 12/17/19. It's very important to assess and document for signs of (blood clot) . MD should have been notified and the (Responsible Party) should have been notified . (Resident 1) vital signs should have been monitored . and it was not done. During a concurrent observation and interview on, 12/19/19, at 10:45 a.m., with LVN 7 in nursing station two, medication cart 4, LVN 7 checked medication cart 4 for Resident 1's Enoxaprin 40 and was unable to find the medication. LVN 7 stated, It's not here. During a telephone interview on, 12/19/19, at 2:12 p.m., with the Pharmacy Owner (PO), the PO stated, (Name of Pharmacy) is still in transition with the facility. If (LNs) notified and followed up with the pharmacy with urgency, the ([MEDICATION NAME] for Resident 1) would have been sent (stat-as soon as possible) within 4 hours. It would have been delivered and the medication would not be missed for 3 days . During a concurrent interview and record review of Resident 1's Care Plan, on 12/19/19, at 4:16 p.m., with LVN 5, LVN 5 stated he was the LN on duty on 12/18/19 and he had not administered Resident 1's [MEDICATION NAME] because it was unavailable and had not been delivered by the pharmacy. LVN 5 stated, The ([MEDICATION NAME]) was not in the (medication cart) because there was a transition from the pharmacy. (Facility) used to have another pharmacy and there is a new pharmacy. The MD should have been notified and (Resident 1) should have been assessed for signs and symptoms of blood clot and it was not done. LVN 5 reviewed Resident 1's Care Plan dated 12/19 and was unable to find a care plan for [MEDICATION NAME] and to monitor Resident 1 for signs and symptoms of blood clot. LVN 5 stated, There was no care plan and there should be a care plan to monitor (Resident 1) for bleeding . especially it's a high risk medication . a blood clot could develop. During a telephone interview on, 12/19/19, 4:32 p.m., with the MD, the MD stated, I was not informed that ([MEDICATION NAME]) was not given on (12/17/19, 12/18/19, and 12/19/19) . the dose has to be given immediately . to prevent blood clot. It's a very important medication so it should not be missed and (Resident 1) should have been assessed for blood clots. During a telephone interview on, 12/23/19, at 4:59 p.m., with Registered nurse (RN) 2, RN 2 stated she was the LN on duty on 12/17/19. RN 2 stated she had not administered the ([MEDICATION NAME]) on 12/17/19 because the medication was not available and was not delivered by the pharmacy. RN 2 stated, I was never trained (by the facility on medication administration) . I was just thrown in the (medication) cart . I don't know these residents . I should have called the doctor and charted that I did not give ([MEDICATION NAME]). RN 2 stated Resident 1 had a history of [REDACTED]. RN 2 stated Resident 1 was prescribed [MEDICATION NAME] to prevent blood clots. RN 2 stated Resident 1 should have been assessed for signs and symptoms of blood clot and it was not done. During a review of Professional reference from https://orthoinfo.aaos.org/en/diseases--conditions/deep-vein-[MEDICAL CONDITION], titled, [MEDICAL CONDITION], dated 6/15, indicated, . [MEDICAL CONDITION], or [MEDICAL CONDITION], occurs when a blood clot forms in one of the deep veins of the body. This can happen if a vein becomes damaged or if the blood flow within a vein slows down or stops. While there are a number of risk factors for developing a [MEDICAL CONDITION], two of the most common are experiencing an injury to your lower body . that involves your hips or legs . A [MEDICAL CONDITION] can have serious consequences. If a blood clot breaks free, it may travel through the bloodstream and block blood flow to the lungs . this complication-called a [MEDICAL CONDITION] embolism-can be fatal. Even if a blood clot does not break free, it may cause permanent damage to the valves in the vein. This damage can lead to long-term problems in the leg such as pain, swelling, and leg sores . In many cases, [MEDICAL CONDITION] occurs without noticeable symptoms and is very difficult to detect. For this reason, doctors focus on preventing the development of [MEDICAL CONDITION] using different types of therapies, depending upon a patient's needs. Your doctor will take steps to prevent [MEDICAL CONDITION] if you have a major fracture .A broken hip or leg . on your hip, knee or lower leg can affect normal blood flow and clotting. In these orthopedic situations, three primary factors contribute to the formation of blood clots in veins: slow blood flow, hyper-coagulation, and damage to the veins . Nonsurgical treatment usually consists of taking anticoagulants-blood thinning medications that will prevent further clotting and help dissolve existing clots . [MEDICATION NAME]. treatment for [REDACTED]. Standard [MEDICATION NAME] is given intravenously (injection into a vein) while LMWH is given by subcutaneous injection under the skin. LMWH has a short half-life and is eliminated from the body in 12 hours . During a review of Professional reference from https://www.ncbi.nlm.nih.gov/books/NBK 7/, titled, Low Molecular Weight [MEDICATION NAME] (LMWH), dated 2/19, indicated, .Low-molecular-weight [MEDICATION NAME] (LMWHs), for example . ([MEDICATION NAME]), among others are anticoagulants. These drugs are used in the [MEDICATION NAME] of venous [MEDICAL CONDITION] disease (VTE) on acute or elective admission to hospital, and they are used in the treatment of [REDACTED]. 2. During an interview on 12/18/19, at 11:05 a.m., with Resident 2, Resident 2 stated, I didn't have my medication for migraine since (12/12/19). I didn't even get my nasal spray because (the facility) does not have it. I had migraine attacks and I need that medication but since (the facility) does not have it, I had to wait. I even had stuffy and congested nose and not enough sleep. During a review of Resident 2's face sheet, dated 7/26/19, the face sheet indicated Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During a review of Resident 2's Minimum Data Set (MDS-assessment of healthcare and functional needs) assessment dated [DATE], the MDS assessment indicated Resident 2's Brief Interview for Mental Status (BIMS- assessment of cognitive status) score was 15 of 15 points which indicated Resident 2 had no cognitive impairment. During a review of Resident 2's physician's orders [REDACTED]. [MEDICATION NAME] Propionate suspension 50 mcg/act one spray in each nostrils every 12 hours for allergies . During a concurrent interview and record review, on 12/18/19, at 11:15 a.m., with the ADON, Resident 2's Care plan was reviewed. The ADON was unable to find a care plan for Resident 2's migraine and nasal allergies. The ADON stated Resident 2 should have a care plan to address and manage Resident 2's migraine and nasal allergies and it was not done. During a concurrent interview and record review on, 12/18/19, at 1:17 p.m., with LVN 1, Resident 2's MAR indicated [REDACTED]. LVN 1 stated Resident 2's [MEDICATION NAME] 50 mg and [MEDICATION NAME] 50 mcg/act was not available and should be readily available in the event Resident 2 experienced a Migraine attack and nasal allergies. During a concurrent interview and record review, on 12/18/19, at 2:09 p.m., with RN 3, the Medication Administration Audit Report dated 12/18/19 indicated, . (Resident 2) [MEDICATION NAME] Propionate Suspension 50 mcg/act 1 spray in each nostril every 12 hours for allergy . ([MEDICATION NAME]) 50 mg prn every 2 hours as needed for migraines . RN 3 stated the medications reviewed for Residents 2 was unavailable and was not administered by LNs to the residents. RN 3 stated all medications should be administered to the residents as prescribed by the physician. RN 3 stated if a medication was unavailable, LNs should have informed the pharmacy, notified the MD and assessed the residents for serious medical complications. During a concurrent interview and record review, on 12/19/19, at 1:46 p.m., with RN 3, Resident 2's MAR indicated [REDACTED]. RN 3 stated she was the LN assigned to Resident 2 on 12/18/19 and 12/19/19. RN 2 stated Resident 2 experienced migraine headaches on 12/18/19 and 12/19/19 and the medication for migraines was not administered because the [MEDICATION NAME] 50 mg was not available. RN 2 stated Resident 2's [MEDICATION NAME] 50 mg and [MEDICATION NAME] 50 mcg/act were not available and should be readily available in the event Resident 2 experienced a migraine attack and nasal allergies. During a concurrent observation and interview on, 12/19/19, at 1:50 a.m., with RN 3, in nursing station 1, medication cart 1, RN 3 checked the medication cart 1 for Resident 2's [MEDICATION NAME] 50 mg and [MEDICATION NAME] propionate suspension 50 mcg/act and was unable to find the medications. RN 3 stated the medications were not available. During an interview on, 12/19/19, at 2:02 p.m., with Resident 2, Resident 2 stated she experienced a migraine headache on 12/18/19 and 12/19/19 and the migraine medication ([MEDICATION NAME] 50 mg) was not available. Resident 2 stated, My migraine starts with a headache and blurry vision. I've had blurry vision all day the night before (12/18/19) and today (12/19/19). If I took the migraine medication, it (headache) would not get worst. I feel so congested in my sinus because I have not had my [MEDICATION NAME] inhaler. During an interview on 12/19/19, at 2: 19 p.m., with RN 3, RN 3 stated she was the LN assigned to Resident 2 on 12/18/19 and 12/19/19. RN 3 stated, (Resident 2) asked for [MEDICATION NAME] (50 mg) yesterday (12/18/19) and today (12/19/19). (Resident 2) said she feels a migraine attack coming but I told her the medication ([MEDICATION NAME]) is not available. RN 3 stated Resident 2's [MEDICATION NAME] should have been available and administered to Resident 2 to relieve migraine headaches. During a review of professional reference from https://www.mayoclinic.org/diseases-conditions/migraine-headache/symptoms-causes/syc- 201, titled, Migraine dated, 12/19, indicated, .A migraine can cause severe throbbing pain or a pulsing sensation, usually on one side of the head. It's often accompanied by nausea, vomiting, and extreme sensitivity to light and sound. Migraine attacks can last for hours to days, and the pain can be so severe that it interferes with your daily activities . A migraine usually lasts from four to 72 hours if untreated. How often migraines occur varies from person to person . prescription drugs such as . ([MEDICATION NAME]) . are prescription drugs used for migraine because they block pain pathways in the brain. Taken as pills, shots or nasal sprays, they can relieve many symptoms of migraine . 3. During a concurrent interview and record review on 12/18/19, at 2:09 p.m., with RN 3, the Medication administration audit report dated 12/18/19 indicated, . (Resident 3) [MEDICATION NAME] 400 mg give 1 capsule by mouth three times a day for nerve pain . RN 3 stated the medications reviewed for Residents 3 was unavailable and was not administered by the LNs to the residents. RN 3 stated all medications should be administered to the residents as prescribed by the physician. RN 3 stated if a medication was unavailable, LNs should inform the pharmacy, notify the MD and assess residents for serious medical complications. During a concurrent interview and record review on, 12/19/19, at 5:35 p.m., with the ADON, Resident 3's MAR, dated 12//18/19 was reviewed. The ADON stated Resident 3 was not administered [MEDICATION NAME] (a medication to relieve nerve pain) 400 mg on 12/18/19. The ADON stated the LNs should have assessed Resident 3 for signs and symptoms of nerve pain and should have notified the MD and it was not done. During a review of Resident 3's face sheet, dated 9/20/19, the face sheet indicated Resident 3 was admitted in the facility with [DIAGNOSES REDACTED]. During a review of Resident 3's physician's orders [REDACTED]. During a concurrent interview and record review on 12/19/19, at 5:40 p.m., with the ADON, Resident 3's care plan was reviewed. The ADON was unable to find a care plan for Resident 3's nerve pain. The ADON stated Resident 3 should have a care plan to address and manage her nerve pain. During a review of professional reference from https://www.healthline.com/health/[MEDICATION NAME]-oral-capsule#alternatives, titled, [MEDICATION NAME], Oral Capsule undated, indicated, .[MEDICATION NAME] oral capsule is used for short-term or long-term treatment. The length of treatment depends on what condition it's being used to treat. It comes with serious risks if you don't take it as prescribed . Your medication may not work as well or may stop working completely. In order for this drug to work well, a certain amount needs to be in your body at all times . 4. During a concurrent interview and record review on, 12/18/19, at 2:09 p.m., with RN 3, the Medication administration audit report dated 12/18/19 indicated, . (Resident 4) levetiracetam tablet 500 mg give 2 tablets by mouth in the morning for [MEDICAL CONDITION] . RN 3 stated the medications reviewed for Resident 4 was unavailable and was not administered by the LNs to the residents. RN 3 stated all medications should be administered to the residents as prescribed by the physician. RN 3 stated if a medication was unavailable, LNs should inform the pharmacy, notify the MD and assess residents for serious medical complications. During a concurrent interview and record review on 12/19/19, at 5:45 p.m., with the ADON, Resident 4's Physician order [REDACTED]. The physician's orders [REDACTED]. give 1 tablet by mouth in the evening for [MEDICAL CONDITION] . levetiracetam tablet 500 mg . give 2 tablets by mouth in the morning for [MEDICAL CONDITION] . The ADON reviewed Resident 4's MAR, dated 12/19 and stated Resident 4's levetiracetam 500 mg was unavailable and was not administered on 12/17/19, 12/8/19 and 12/19/19. The ADON stated LNs did not notify the MD the levetiracetam 500 mg medication for Resident 5 was unavailable and was not administered to Resident 4 on 12/17/19, 12/18/19 and 12/19/19. The ADON stated it was important LNs assess Resident 4 for signs and symptoms of [MEDICAL CONDITION] and it was not done. During a review of Resident 4's face sheet, dated 1/12/13, the face sheet indicated Resident 4 was admitted in the facility with [DIAGNOSES REDACTED]. During a review of Resident 4's care plan, dated 1/9/18, the care plan indicated, . (Resident 4) has a [MEDICAL CONDITION] disorder related to brain trauma (head injury) . Give [MEDICAL CONDITION] medication as ordered by doctor. Monitor/document side effects and effectiveness . provide medications levetiracetam for [MEDICAL CONDITION] . During a review of Professional reference from https://www.[MEDICAL CONDITION].com/learn/triggers-[MEDICAL CONDITION]/missed-medicines, titled Missed Medicine dated 3/14, indicated, . Missing doses of [MEDICAL CONDITION] medicine is the most common cause of breakthrough [MEDICAL CONDITION]. Missed medicines can trigger [MEDICAL CONDITION] in people with both well-controlled and poorly controlled [MEDICAL CONDITION]. [MEDICAL CONDITION] can happen more often than normal, be more intense or develop into long [MEDICAL CONDITION] called [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED] is a medical emergency and can lead to death if the [MEDICAL CONDITION] aren't stopped. Missing doses of medicine can also lead to falls, injuries and other problems from [MEDICAL CONDITION] and changes in medicine levels . 5. During a concurrent interview and record review on, 12/18/19, at 2:09 p.m., with RN 3, the Medication Administration Audit Report dated 12/18/19 indicated, . (Resident 6) [MEDICATION NAME] 200 mg give 1 (tablet) by mouth two times a day for [MEDICAL CONDITION] . RN 3 stated the medications reviewed for Resident 6 was unavailable and was not administered by LNs to the residents. RN 3 stated all medications should be administered to the residents as prescribed by the physician. RN 3 stated if a medication was unavailable, LNs should inform the pharmacy, notify the MD and assess residents for serious medical complications. During a concurrent interview and record review on, 12/19/19, at 5:50 p.m., with the ADON, Resident 6's physician's orders [REDACTED]. The physician's orders [REDACTED]. [MEDICATION NAME] tablet 100 mg give 1 tablet by mouth at bedtime for [MEDICAL CONDITION] . The ADON reviewed Resident 6's MAR, dated 12/19 and stated Resident 6's [MEDICATION NAME] 200 mg and [MEDICATION NAME] 100 mg was unavailable and was not administered to Resident 6 on 12/17/19 and 12/18/19. The ADON stated LNs did not notify the MD of the unavailability of the medication and did not assess Resident 6 for signs and symptoms of increased behaviors of agitation. During a review of Resident 6's face sheet, dated 11/26/19, the face sheet indicated Resident 6 was admitted to the facility with a [DIAGNOSES REDACTED]. During a review of Resident 6's care plan, dated 11/26/19, the care plan indicated, . (Resident 6) has a history of aggressive behavior r/t (related to) [MEDICAL CONDITION] . administered meds as per order . 6. During a concurrent interview and record review of 12/18/19, at 2:09 p.m., with RN 3, the Medication administration audit report dated 12/18/19 indicated, . (Resident 7) [MEDICATION NAME] 5 mg give 5 mg by mouth a day for agitation and striking out . RN 3 stated the medications reviewed for Resident 7 was unavailable and was not administered by LNs to the residents. RN 3 stated all medications should be administered to the residents as prescribed by the physician. RN 3 stated if a medication was unavailable, LNs should inform the pharmacy, notify the MD and assess residents for serious medical complications. During a concurrent interview and record review on 12/19/19, at 5:55 p.m., with the ADON, Resident 7's Physician order [REDACTED]. The physician's orders [REDACTED]. give 5 mg by mouth one time a day for agitation and striking out . The ADON reviewed Resident 7's MAR, dated 12/19 and stated Resident 7's [MEDICATION NAME] 5 mg was unavailable and was not administered to Resident 7 on 12/17/19 and 12/18/19. The ADON stated LNs had not notified the MD of the unavailability of the medication and had not assessed Resident 7 for signs and symptoms of increased behaviors of agitation and striking out. During a revi (TRUNCATED)

Based on observation interview and record review, the facility failed to ensure residents were free from neglect when: 1. The facility failed to ensure residents goods and services were provided when the Administrator (ADM), who was aware of the new pharmacy contract neglected to coordinate timely delivery, receipt and administration of medication from 12/7/19 to 12/19/19 for 11 of 12 residents (Residents 1, 2, 3, 4, 6, 7, 8, 9, 10, 11, and 12). 2. Licensed Nurses (LNs) were aware of the [DIAGNOSES REDACTED]. 2a. For Resident 1, LNs were aware of his [DIAGNOSES REDACTED]. LNs had not assessed for symptoms of [MEDICAL CONDITION]- or inform the Medical Director (MD) of the delay in administration of [MEDICATION NAME] or attempted to expedite the delivery of the [MEDICATION NAME] from the pharmacy. These failures resulted in the serious potential harm of Resident 1 developing a blood clot directly related to the diagnosed fractures of the leg and the blood clot could have traveled to the blood stream to the lungs, heart and/or brain to cause a life-threatening situation. 2b. For Resident 2, LNs were aware of the migraine [DIAGNOSES REDACTED]. LNs knowingly did not assess the pain nor attempt to expedite delivery of the prescribed pain medications meant to treat the migraine. LNs did not inform the MD or offer Resident 2 non-pharmacologic methods to alternately treat the pain. These failures resulted in Resident 2 experiencing severe pain from migraine attacks and nasal congestion from 12/12/19 to 12/19/19. 2c. For Resident 3, LNs were aware of her [DIAGNOSES REDACTED]. LNs did not assess for signs and symptoms of nerve pain or inform the MD [MEDICATION NAME] had not been given as ordered or attempted to expedite the delivery of [MEDICATION NAME] from the pharmacy. This failure resulted in the serious potential harm for Resident 3 to experience severe pain. 2d. For Resident 4, LNs were aware of her [DIAGNOSES REDACTED]. LNs had not assessed for signs and symptoms of [MEDICAL CONDITION] or informed the MD nor attempted to expedite the delivery of levetiracetam from the pharmacy. This failure resulted in the serious potential for Resident 4 to experience a [MEDICAL CONDITION] episode. 2e. For Resident 6, LNs were aware of his [DIAGNOSES REDACTED]. LNs had not assessed for signs and symptoms of an increased risk of suicidal behavior or inform the MD the medication had not been given or attempted to expedite the delivery of the [MEDICATION NAME] from the pharmacy. This failure resulted in the serious potential harm of Resident 6 to experience increased behaviors of [MEDICAL CONDITION] such as aggression and agitation. 2f. For Resident 7, LNs were aware of his [DIAGNOSES REDACTED]. LNs had not assessed for signs and symptoms of increased behaviors of agitation and striking out or informed the MD the medication had not been given or attempted to expedite the delivery of the [MEDICATION NAME] from the pharmacy. This failure resulted in the serious potential harm for Resident 7 to experience increased behaviors of agitation and aggression. 2g. For Resident 8, LNs were aware of her [DIAGNOSES REDACTED]. LNs had not assessed for signs and symptoms of a low potassium level such as muscle cramps, muscle weakness and abnormal heart rhythms or inform the MD the medication had not been given or attempted to expedite the delivery of the potassium ER from the pharmacy. This failure resulted in the serious potential harm of Resident 8 to experience muscle weakness and heart palpitations from the low potassium level. 2h. For Resident 9, LNs were aware of her [DIAGNOSES REDACTED]. LNs had not assessed for signs and symptoms of worsening rash or informed the MD the medication had not been given or attempted to expedite the delivery of the [MEDICATION NAME] from the pharmacy. This failure resulted in the potential harm of Resident 9's rash to worsen. 2i. For Resident 10, LNs were aware of her [DIAGNOSES REDACTED]. The LNs had not assessed for signs and symptoms of pain and behaviors which included screaming or informed the MD the medications had not been given or attempted to expedite the delivery of the duloxetine and [MEDICATION NAME] from the pharmacy. These failures resulted in the serious potential harm of Resident 10 to experience decreased sensation and increased behaviors of agitation. 2j. For Resident 11, LNs were aware of his [DIAGNOSES REDACTED]. LNs hade not assessede for signs and symptoms of elevated blood pressure and increased behaviors of yelling and screamingd or inform the MD the medications had not been given or attempted to expedite the delivery of the losartan potassium and [MEDICATION NAME] from the pharmacy. These failures resulted in the serious potential harm for Resident 11 to develop an elevated blood pressure. 2k. For Resident 12, LNs were aware of her [DIAGNOSES REDACTED]. LNs had not assessed for signs and symptoms of [MEDICAL CONDITION] exacerbation such as shortness of breath, cough and wheezing or informed the MD the medication had not been givene or attempted to expedite the delivery of umeclidinium/vilanterol from the pharmacy. This failure resulted in the serious potential harm of Resident 12 to experience [MEDICAL CONDITION] exacerbation such as shortness of breath and wheezing. 3. The ADM and LNs were aware laboratory services were not available for 14 of 14 sampled residents (Resident 16, 18, 11, 21, 22, 23, 24, 25, 26, 15, 27, 30, 31, and 32) and knowingly withheld the laboratory services prescribed by the physician between the dates of 12/4/19 and 12/16/19. 3a. For Resident 16, her Hemoglobin A1C (test used to diagnose and verify blood sugar levels over a period of time for diabetes mellitus - a group of diseases that result in too much sugar in the blood) was not performed on 12/3/19 as ordered by the physician. 3b. For Resident 18, her Complete Blood Count (CBC-a blood test used to evaluate overall health and detect a wide range of disorders, including [MEDICAL CONDITION]- is a condition in which there is a lack of enough healthy red blood cells to carry adequate amounts of oxygen to your body), Basic Metabolic Panel (BMP-a blood test that includes information about the body's fluid balance and how well the kidneys are working) was not performed on 12/8/19 as ordered by the physician. 3c. For Resident 11, his CBC, Comprehensive Metabolic Panel (CMP- a test that provides important information about the current status of metabolism - the process by which the body converts what is eaten or drank into energy) was not performed on 12/13/19 as ordered by the physician. 3d. For Resident 21, his Liver Function Tests (a test that checks the overall health of the liver) was not performed on 12/12/19 as ordered by the physician. 3e. For Resident 22, his CBC and BMP was not performed on 12/6/19 as ordered by the physician. 3f. For Resident 23, his BMP and CBC was not performed on 12/6/19 as ordered by the physician. 3g. For Resident 24, his CMP and CBC was not performed on 12/3/19 as ordered by the physician. 3h. For Resident 15, his CBC and BMP was not performed on 12/5/19 as ordered by the physician. 3i. For Resident 25, his levetiracetam (a medication use to treat [MEDICAL CONDITION] (a sudden, uncontrolled electrical disturbance in the brain. It can cause changes in behavior, movements or feelings, and in levels of consciousness) level (a test to determine the concentration of levetiracetam in the blood to establish an individualized dose; to detect toxicity or verify the medication is taken as prescribed (to verify compliance) . CBC and CMP was not performed on 12/5/19 as ordered by the physician. 3j. For Resident 26, his CBC and CMP was not performed on 12/6/19 as ordered by the physician. 3k. For Resident 27, his A1C was not performed on 12/3/19 as ordered by the physician. 3l. For Resident 30, her CMP and CBC was not performed on 12/6/19 as ordered by the physician. 3m. For Resident 31, his weekly CBC was not performed on 12/2/19 as ordered by the physician. 3n. For Resident 32, his blood ammonia level (test measures the level of ammonia-a waste product made by the body during the digestion of protein) was not performed on 12/6/19 as ordered by the physician. These failures had the potential for residents to experience health complications from laboratory services not performed as prescribed by the physician. Because of the serious potential harm related to not administering physician ordered medications to Residents 1, 2, 3, 4, 6, 7, 8, 9, 10, 11 and 12 diagnosed with [REDACTED].) and the Minimum Data Set (MDS) assessment Coordinator in attendance. After supervisorial review of the findings under F684 and F755 and following consultation with CMS San Francisco, the decision was made to cite an Immediate Jeopardy situation under F600 CFR 483.12 for neglect. The facility was served with the IJ template on 1/21/20 at 5:30 p.m. and provided the explanation for the decision. The facility submitted an acceptable Action Plan (AP) that addressed the IJ situation; and the AP addressed elements related to neglect. The AP included in-service education to the LNs on assessment, documentation and notification of the MD when a medication is unavailable. The AP also included Resident 1's transfer to the General Acute Care Hospital for evaluation for a possible [MEDICAL CONDITION] and administration of [MEDICATION NAME]. Resident 2 received [MEDICATION NAME] and [MEDICATION NAME] on 12/19/19 and was assessed for signs and symptoms of migraine headaches and nasal congestion. Resident 3 received [MEDICATION NAME] on 12/19/19 and was assessed for signs and symptoms of pain. Resident 4 received levetiracetam on 12/20/19 and was assessed for signs and symptoms of [MEDICAL CONDITION] activity such as loss of consciousness and uncontrollable jerking movements of the arms and legs. Resident 6 received [MEDICATION NAME] on 12/19/19 and was assessed for signs and symptoms of increased behaviors of aggression. Resident 7 received [MEDICATION NAME] on 12/20/19 and was assessed for signs of increased behaviors of agitation and aggression. Resident 8 received potassiumER on [DATE] and was assessed for signs and symptoms of [DIAGNOSES REDACTED] such as muscle weakness and heart palpitations. Resident 9 received [MEDICATION NAME] cream 12/19/19 and was assessed for signs and symptoms of worsening rash. Resident 10 received duloxetine and [MEDICATION NAME] sodium on 12/20/19 and was assessed for signs and symptoms of increased behaviors of agitation. Resident 11 received losartan potassium and [MEDICATION NAME] sodium delayed released on 12/19/19 and was assessed for signs and symptoms of elevated blood pressure. Resident 12 received umeclidinium/vilanterol aerosol on 12/19/19 and was assessed for signs and symptoms for [MEDICAL CONDITION] exacerbation such as shortness of breath and wheezing. The interventions to address the IJ situation on the AP were fully implemented and the IJ was removed on 12/23/19 at 4:52 p.m. Findings: 1.During an interview on 12/16/19, at 10:14 a.m., with the ADM, the ADM stated he finalized the contract with (Name of New Pharmacy) on 12/12/19. The ADM stated the transition from the facility's previous pharmacy to the new pharmacy started on 12/16/19. The ADM stated (name of pharmacy) was located in (name of city) which was 310 miles away from the facility. The ADM stated Licensed Nurses (LNs) were not fully aware of the transition to their new pharmacy. The ADM stated, (LNs) were still ordering from the previous pharmacy. The ADM stated LNs should have been provided in-service training during the transition from the previous pharmacy to the new pharmacy to ensure all residents' medications were available. The ADM stated, We failed on that part to prepare the Licensed Nurses during the transition (from the previous pharmacy to the new pharmacy). The ADM stated LNs should have notified the Medical Director and the pharmacy when the medications were unavailable and they did not. The ADM stated LNs should have assessed Resident 1, 2,3,4, 6, 7, 8, 9, 10, 11 and 12 when their medications were unavailable and were not administered to ensure residents' health and safety. During a review of the Pharmaceutical Services Agreement, dated 12/12/19, indicated, . This Pharmaceutical Services Agreement is hereby entered into by and between (Name of New Pharmacy), and Central Valley Post-Acute/Riverbank . Pharmacy shall sell and distribute pharmaceutical products . to facility and residents . In accordance with any applicable requirements of federal, state or local laws regulations . (name of pharmacy) will perform deliveries Monday through Sunday, all deliveries shall be performed in a timely manner as required . An emergency kit will be supplied by (name of pharmacy) to the facility containing backup medication doses that are allowed by law and the State of California Pharmacy Board for the use of, and the discretion of the facility for (name of pharmacy) patients only . During a review of the facility's document titled, Job Description of Administrator, undated, indicated, . The Administrator is responsible to plan, organize, develop and direct the overall operation of the skilled nursing services in accordance with current federal, state and local standards, guidelines, and regulations that govern our facility . to ensure that the highest degree of quality care is maintained at all times . Monitor quality and appropriateness of care provided . During a telephone interview on, 12/23/19, at 4:59 p.m., with Registered Nurse (RN) 2, RN 2 stated, . (LNs) were never in-serviced or informed that the pharmacy was transitioning . RN 2 stated the facility should have communicated and provided in-service education to all LNs of the change to the new pharmacy to ensure all medications were available during the transition period. During a telephone interview on 12/19/19, at 2:12 p.m., with the Pharmacy Owner (PO), the PO stated, (Name of New Pharmacy) is still in transition with the facility. The PO stated the pharmacy contract agreement was finalized on 12/12/19 and started delivery of medications to the facility on [DATE]. The PO stated, If (LNs) notified and followed up with the pharmacy with urgency, the ([MEDICATION NAME] for Resident 1) would have been sent (stat)-as soon as possible within 4 hours. It would have been delivered and the medication would not be missed for 3 days . 2. During an observation on 12/17/19 at 10 a.m., Resident 1 laid in bed and had a gastrostomy tube ([DEVICE]-a medical device used to give direct access to resident's stomach for supplemental feeding or medications) in place. Resident 1 did not respond to questions when asked and continued to stare at the ceiling. During a concurrent interview and record review on 12/18/19, at 2:09 p.m., with RN 3, the Medication Administration Audit Report dated 12/18/19 indicated, . (Resident 1s) [MEDICATION NAME] sodium 40 mg/0.4 ml subcutaneously (under the skin) one time a day for blood clot prevention for 30 days . RN 3 stated the medication reviewed for Resident 1 was unavailable and was not administered by LNs to Resident 1. RN 3 stated all medications should have been administered to the residents as prescribed by the physician. RN 3 stated if a medication was unavailable, LNs should have informed the pharmacy, notified the MD and assessed the residents for serious medical complications. During a concurrent interview and record review on 12/19/19 at 9:58 a.m., with the ADON, Resident 1's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. see progress notes) in the box for Resident 1's [MEDICATION NAME] 40 mg/0.4 ml. Resident 1's Progress Notes dated 12/18/19 was reviewed by the ADON which indicated there was no documentation of [MEDICATION NAME] having been administered to Resident 1, no MD notification and no assessment. Resident 1's Progress Notes dated 12/19/19 was reviewed by the ADON which indicated Resident 1's [MEDICATION NAME] was unavailable and was not administered by the LNs. The ADON stated the LNs should have notified the MD of the unavailability of the [MEDICATION NAME] for Resident 1 and should have conducted an assessment to ensure Resident 1 did not have signs and symptoms of a blood clot and the LNs had not. During a record review on 12/19/19 at 10:15 a.m., with the ADON, Resident 1's Face sheet (a document containing personal and medical information) dated 12/16/19, indicated Resident 1 was admitted to the facility with [DIAGNOSES REDACTED]. Resident 1's physician's orders [REDACTED]. ([MEDICATION NAME] 40 mg/0.4 ml) inject 40 mg subcutaneously one time a day for blood clot prevention for 30 days . During an interview on 12/19/19, at 10:35 a.m., with Licensed Vocational Nurse (LVN) 7, LVN 7 stated she was the LN on duty the morning of 12/19/19 and she had not administered Resident 1's [MEDICATION NAME] because it was unavailable and had not been delivered by the pharmacy. LVN 7 stated, The dose is missing since 12/17/19. It's very important to assess and document for signs of (blood clot) . MD should have been notified and the (Responsible Party) should have been notified . (Resident 1) vital signs should have been monitored . and it was not done. During a concurrent observation and interview on, 12/19/19, at 10:45 a.m., with LVN 7 in nursing station two, medication cart 4, LVN 7 checked medication cart 4 for Resident 1's [MEDICATION NAME] and was unable to find the medication. LVN 7 stated, It's not here. During a concurrent interview and record review of Resident 1's Care Plan, on 12/19/19, at 4:16 p.m., with LVN 5, LVN 5 stated he was the LN on duty on 12/18/19 and he had not administered Resident 1's [MEDICATION NAME] because it was unavailable and had not been delivered by the pharmacy. LVN 5 stated, The ([MEDICATION NAME]) was not in the (medication cart) because there was a transition from the pharmacy. (Facility) used to have another pharmacy and there is a new pharmacy. The MD should have been notified and (Resident 1) should have been assessed for signs and symptoms of blood clot and it was not done. LVN 5 reviewed Resident 1's Care Plan dated 12/19 and was unable to find a care plan for [MEDICATION NAME] and one to address the need to monitor Resident 1 for signs and symptoms of a blood clot. LVN 5 stated, There was no care plan and there should be a care plan to monitor (Resident 1) for bleeding . especially it's a high risk medication . a blood clot could develop. During a telephone interview on, 12/19/19, at 4:32 p.m., with the MD, the MD stated, I was not informed that ([MEDICATION NAME]) was not given on (12/17/19, 12/18/19, and 12/19/19) . the dose has to be given immediately . to prevent blood clot. It's a very important medication so it should not be missed and (Resident 1) should have been assessed for blood clots. During a telephone interview on, 12/23/19, at 4:59 p.m., with RN 2, RN 2 stated she was the LN on duty on 12/17/19. RN 2 stated she had not administered the ([MEDICATION NAME]) on 12/17/19 because the medication was not available and was not delivered by the pharmacy. RN 2 stated, I was never trained (by the facility on medication administration) . I was just thrown in the (medication) cart . I don't know these residents . I should have called the doctor and charted that I did not give ([MEDICATION NAME]). RN 2 stated Resident 1 had a history of [REDACTED]. RN 2 stated Resident 1 was prescribed [MEDICATION NAME] to prevent blood clots. RN 2 stated Resident 1 should have been assessed for signs and symptoms of blood clot and it was not done. During a review of Professional Reference from https://orthoinfo.aaos.org/en/diseases--conditions/deep-vein-[MEDICAL CONDITION], titled, [MEDICAL CONDITION], dated 6/15, indicated, . [MEDICAL CONDITION], or [MEDICAL CONDITION], occurs when a blood clot forms in one of the deep veins of the body. This can happen if a vein becomes damaged or if the blood flow within a vein slows down or stops. While there are a number of risk factors for developing a [MEDICAL CONDITION], two of the most common are experiencing an injury to your lower body . that involves your hips or legs . A [MEDICAL CONDITION] can have serious consequences. If a blood clot breaks free, it may travel through the bloodstream and block blood flow to the lungs . this complication-called a [MEDICAL CONDITION] embolism-can be fatal. Even if a blood clot does not break free, it may cause permanent damage to the valves in the vein. This damage can lead to long-term problems in the leg such as pain, swelling, and leg sores . In many cases, [MEDICAL CONDITION] occurs without noticeable symptoms and is very difficult to detect. For this reason, doctors focus on preventing the development of [MEDICAL CONDITION] using different types of therapies, depending upon a patient's needs. Your doctor will take steps to prevent [MEDICAL CONDITION] if you have a major fracture .A broken hip or leg . on your hip, knee or lower leg can affect normal blood flow and clotting. In these orthopedic situations, three primary factors contribute to the formation of blood clots in veins: slow blood flow, hyper-coagulation, and damage to the veins . Nonsurgical treatment usually consists of taking anticoagulants-blood thinning medications that will prevent further clotting and help dissolve existing clots . [MEDICATION NAME]. treatment for [REDACTED]. Standard [MEDICATION NAME] is given intravenously (injection into a vein) while LMWH is given by subcutaneous injection under the skin. LMWH has a short half-life and is eliminated from the body in 12 hours . During a review of Professional reference from https://www.ncbi.nlm.nih.gov/books/NBK 7/, titled, Low Molecular Weight [MEDICATION NAME] (LMWH), dated 2/19, indicated, .Low-molecular-weight [MEDICATION NAME] (LMWHs), for example . ([MEDICATION NAME]), among others are anticoagulants. These drugs are used in the [MEDICATION NAME] of venous [MEDICAL CONDITION] disease (VTE) on acute or elective admission to hospital, and they are used in the treatment of [REDACTED]. During an interview on 12/18/19 at 11:05 a.m., with Resident 2, Resident 2 stated, I didn't have my medication for migraine since (12/12/19). I didn't even get my nasal spray because (the facility) does not have it. I had migraine attacks and I need that medication but since (the facility) does not have it, I had to wait. I even had stuffy and congested nose and not enough sleep. During a review of Resident 2's Face sheet, dated 7/26/19, the face sheet indicated Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During a review of Resident 2's Minimum Data Set (MDS-assessment of healthcare and functional needs) assessment, dated 11/4/19, the MDS assessment indicated Resident 2's Brief Interview for Mental Status (BIMS- assessment of cognitive status) score was 15 of 15 points which indicated Resident 2 had no cognitive impairment. During a review of Resident 2's physician's orders [REDACTED]. [MEDICATION NAME] propionate suspension 50 mcg/act one spray in each nostrils every 12 hours for allergies . During a concurrent interview and record review, on 12/18/19 at 11:15 a.m., with the ADON, Resident 2's Care Plan was reviewed. The ADON was unable to find a care plan for Resident 2's migraine and nasal allergies. The ADON stated Resident 2 should have had a care plan to address and manage Resident 2's migraine headaches and nasal allergies and it was not done. During a concurrent interview and record review on, 12/18/19, at 1:17 p.m., with LVN 1, Resident 2's MAR indicated [REDACTED]. LVN 1 stated Resident 2's [MEDICATION NAME] 50 mg and [MEDICATION NAME] 50 mcg/act was not available and should be readily available in the event Resident 2 experienced a migraine attack and nasal allergies. During a concurrent interview and record review, on 12/18/19 at 2:09 p.m., with RN 3, the Medication Administration Audit Report dated 12/18/19 indicated, . (Resident 2) [MEDICATION NAME] propionate suspension 50 mcg/act(uation) 1 spray in each nostril every 12 hours for allergy . ([MEDICATION NAME]) 50 mg prn every 2 hours as needed for migraines . RN 3 stated the medications reviewed for Resident 2 was unavailable and was not administered by LNs to Resident 2. RN 3 stated all medications should be administered to the residents as prescribed by the physician. RN 3 stated if a medication was unavailable, LNs should have informed the pharmacy, notified the MD and assessed the residents for serious medical complications. During a concurrent interview and record review, on 12/19/19 at 1:46 p.m., with RN 3, Resident 2's MAR indicated [REDACTED]. RN 3 stated she was the LN assigned to Resident 2 on 12/18/19 and 12/19/19. RN 2 stated Resident 2 experienced migraine headaches on 12/18/19 and 12/19/19 and the medication for migraines was not administered because the [MEDICATION NAME] 50 mg was not available. RN 2 stated Resident 2's [MEDICATION NAME] 50 mg and [MEDICATION NAME] 50 mcg/act were not available and should be readily available in the event Resident 2 experienced a migraine attack and nasal allergies. During a concurrent observation and interview on, 12/19/19, at 1:50 a.m., with RN 3, in nursing station 1, medication cart 1, RN 3 checked the medication cart 1 for Resident 2's [MEDICATION NAME] 50 mg and [MEDICATION NAME] propionate suspension 50 mcg/act and was unable to find the medications. RN 3 stated the medications were not available. During an interview on, 12/19/19, at 2:02 p.m., with Resident 2, Resident 2 stated she experienced a migraine headache on 12/18/19 and 12/19/19 and the migraine medication ([MEDICATION NAME] 50 mg) was not available. Resident 2 stated, My migraine starts with a headache and blurry vision. I've had blurry vision all day the night before (12/18/19) and today (12/19/19). If I took the migraine medication, it (headache) would not get worst. I feel so congested in my sinus because I have not had my ([MEDICATION NAME]) inhaler. During an interview on 12/19/19, at 2: 19 p.m., with RN 3, RN 3 stated she was the LN assigned to Resident 2 on 12/18/19 and 12/19/19. RN 3 stated, (Resident 2) asked for [MEDICATION NAME] (50 mg) yesterday (12/18/19) and today (12/19/19). (Resident 2) said she feels a migraine attack coming but I told her the medication ([MEDICATION NAME]) is not available. RN 3 stated Resident 2's [MEDICATION NAME] should have been available and administered to Resident 2 to relieve migraine headaches. During a review of professional reference from https://www.mayoclinic.org/diseases-conditions/migraine-headache/symptoms-causes/syc- 201, titled, Migraine dated, 12/19, indicated, .A migraine can cause severe throbbing pain or a pulsing sensation, usually on one side of the head. It's often accompanied by nausea, vomiting, and extreme sensitivity to light and sound. Migraine attacks can last for hours to days, and the pain can be so severe that it interferes with your daily activities . A migraine usually lasts from four to 72 hours if untreated. How often migraines occur varies from person to person . prescription drugs such as . ([MEDICATION NAME]) . are prescription drugs used for migraine because they block pain pathways in the brain. Taken as pills, shots or nasal sprays, they can relieve many symptoms of migraine . During a concurrent interview and record review on 12/18/19 at 2:09 p.m., with RN 3, the Medication Administration Audit Report dated 12/18/19 indicated, . (Resident 3) [MEDICATION NAME] 400 mg give 1 capsule by mouth three times a day for nerve pain . RN 3 stated the medications reviewed for Residents 3 was unavailable and was not administered by the LNs to the residents. RN 3 stated all medications should be administered to the residents as prescribed by the physician. RN 3 stated if a medication was unavailable, LNs should inform the pharmacy, notify the MD and assess residents for serious medical complications. During a concurrent interview and record review on, 12/19/19 at 5:35 p.m., with the ADON, Resident 3's MAR, dated 12//18/19 was reviewed. The ADON stated Resident 3 was not administered [MEDICATION NAME] 400 mg on 12/18/19. The ADON stated the LNs should have assessed Resident 3 for signs and symptoms of nerve pain and should have notified the MD and it was not done. < (TRUNCATED)

Based on observation, interview and record review the facility failed to ensure an accident and hazard free environment was maintained for two of three sampled residents (Resident 15 and Resident 23's) when: 1. Resident 15 was not provided with the assistance of one staff and experienced an avoidable fall on 12/20/19; individualized care plan interventions for fall prevention were not implemented after experiencing recurrent falls and the fall risk assessment was inaccurate. This failure resulted in Resident 15's repeated falls with a fall that caused a left [MEDICAL CONDITION] (broken bone) and pain, requiring hospitalization and surgical repair of the left [MEDICAL CONDITION]. 2. Resident 23 was not provided with the assistance of two staff members during bed mobility as indicated in his assessment and care plan This failure resulted in Resident 23's avoidable fall from bed which caused a fracture to the right elbow, pain and transfer to the acute care hospital emergency room for evaluation and potential treatment. Findings: 1. During a concurrent observation and interview on 12/30/19, at 9:55 a.m., with Resident 15, Resident 15 was observed lying in bed, face up. Resident 15 stated, When I fell (on 12/20/19) I came out of the bathroom .and fell . Resident 15 stated his fall caused the fracture to his left hip. Resident 15 stated he did not trip or stumble on anything. Resident 15 stated, (I) fell , passed out, didn't trip, didn't stumble, fell and broke my hip . During a review of Resident 15's face sheet (document with demographic information) dated 12/26/19, indicated Resident 15 was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During a review of Resident 15's clinical record titled, Fall Scene Investigation Report dated 12/20/19, at 7:30 p.m., indicated (Resident 15) had an unwitnessed fall while going to the bathroom .INTERVENTIONS DISCUSSED TO PREVENT FUTURE FALLS: Frequent visual checks, make sure call light is in reach, toilet resident after meals. WAS THERE A PREVIOUS FALL: YES .INTERVENTIONS FROM PREVIOUS FALL .Same (interventions). During a review of Resident 15's acute care hospital hip X-ray report, dated 12/20/19, indicated the neck of the left femur (hip bone) was fractured. During a review of Resident 15's Minimum Data Set (MDS-an assessment of memory, functional status and care needs) assessment dated [DATE], indicated Resident 15's had severe cognitive impairment with a Brief Interview for Mental Status (BIMS-assessment of memory function and recall) score of 6 of 15 points (0-7: severe impairment, 8-12: moderately impaired, 13-15: cognitively intact). The MDS assessment indicated Resident 15 required one-person physical assistance for ambulation and for toilet use. The MDS indicated Resident 15's self performance was highly involved in activity; staff provided guided maneuvering of limbs and provided non weight bearing assistance. The MDS assessment indicated Resident 15 experienced falls in the past two to six months. During a review of Resident 15's activities of daily living (ADL) care plan dated 7/11/19, indicated, (Resident 15) has an ADL self -care performance deficit . Interventions/Tasks .TOILET USE: the resident requires (limited assistance) by (1) staff for toileting . TRANSFER: The resident needs limited assistance from one staff for transfers . During a review of Resident 15's fall risk care plan dated 7/11/19, indicated, (Resident 15) is at risk for falls (related to) psychoactive drug use (medications used to treat mental health disorders) .Interventions/Tasks Anticipate and meet the resident needs .Be sure the resident call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance .follow facility fall protocol. During a review of Resident 15's fall risk care plan dated 11/23/19, indicated. (Resident 15) sustained an un-witnessed fall on 11/23/19 .Interventions/Tasks Educate/Remind Resident to ask staff for assistance when needed .Monitor (for 72) hours for delayed adverse reactions (related to) fall. Neuro Checks (assessment to determine a [MEDICAL CONDITION]) as facility protocol .Place Call light within reach of Resident. During an interview on 12/30/19, at 10:37 a.m., with Certified Nursing Assistant (CNA) 3, CNA 3 stated Resident 15 was in the bathroom on 12/20/19, at 6:05 p.m. CNA 3 stated he knew Resident 15 was in the bathroom and did not provide Resident 15 with assistance, because he was, running around, making rounds. CNA 3 stated Resident 15 was found on the floor when he entered the room (at 6:20 p.m.). During a concurrent group interview and a record review on 12/30/19, at 10:51 a.m., with the Assistant Director of Nursing (ADON) and the MDS assistant coordinator (MDSA), the MDSA stated Resident 15 had a history of [REDACTED]. The MDSA stated the fall risk assessment dated [DATE], indicated Resident 15 was at moderate risk for falls with a score of 40. The MDSA stated the fall risk assessment indicated Resident 15 had no history of previous falls. The MDSA stated the no previous falls information documented in the fall risk assessment was not correct. The ADON stated the history of falls would change Resident 15's fall risk score from 40 to 65, which would have placed Resident 15 at high risk for falls. The ADON stated, It makes a big difference and would have probably called for closer monitoring . Absolutely, a correct assessment and proper care planning could have prevented further falls . The ADON stated staff should have known Resident 15 was at high risk for falls because of his history of falls and not solely from the fall scale assessment. The MDSA stated the purpose of the fall risk assessment was to assist with the development and implementation of care planning interventions. During a concurrent group interview and record review on 12/30/19, at 12:51 p.m., with the ADON and the MDSA. The ADON stated Resident 15's clinical record titled, 635 Fall with Head dated 4/3/19, indicated, (Resident 15) was found on the floor in between the two beds . states he blacked out and fell . Gash to left eyebrow . The MDSA stated Resident 15's care plan was not revised to add the actual falls that occurred on 4/3/19 or 6/27/19. The MDSA stated fall interventions were not developed to prevent further falls on 4/3/19 or 6/27/19 and they should have been developed and implemented. The ADON stated Resident 15 returned from the hospital on [DATE], with a new [DIAGNOSES REDACTED]. The ADON reviewed Resident 15's care plan dated 12/21/19, for the fall on 12/20/19, which indicated, (Resident 15) has had an actual fall with injury to left [MEDICAL CONDITION] due to [DIAGNOSES REDACTED]. (Physical Therapy) consult for strength and mobility . The DON stated the interventions were insufficient to prevent further falls from [MEDICAL CONDITION]. During a concurrent interview and record review on 12/30/19, at 2:45 p.m., with the MDSA on 12/30/19, at 2:45 p.m., the MDSA stated Resident 15's MDS assessment dated [DATE], indicated Resident 15 required one-person physical assistance for toilet use. The MDSA stated the care plan initiated 7/11/19 indicated, Resident 15 should not have been getting up and going to the bathroom without the help of staff. During a review of Resident 15's progress notes dated 4/3/19, at 4:06 a.m., indicated, Called in to resident room at 3:40 a.m., due to (Resident 15) being on the floor .he was found lying in between the two beds with head appearing to be on top of bedside table. Upon assessment two gashes noted to left eyebrow and left forehead . During a review of Resident 15's progress notes dated 6/27/19, at 6:55 p.m., indicated, Writer called into the dining room . (Resident 15) falling at 6:42 p.m., resident was on the floor on his bottom .When the resident was asked what happened he stated, I missed the chair. During a review of Resident 15's Situation Background Assessment and Recommendation (SBAR) Communication form dated 11/23/19, at 2:11 p.m., indicated, Resident has sustained an Unwitnessed fall on 11/23/19. No apparent injuries noted .Resident was found lying on the floor right side of Resident's bed . During a review of Resident 15's progress notes dated 12/20/19, indicated, Around 6:20 p.m., .per certified nursing assistant (CNA) and licensed nurse (LVN) (Resident 15) was going to bathroom and slid out of bed and was on floor lying down on his back . (Resident 15) said he has a lot of pain on left and right side hip. (Resident 15) wants to go to the hospital . During a review of Resident 15's acute care hospital clinical record titled, HOSPITALIST HISTORY AND PHYSICAL NOTE dated 12/20/19 at 11:58 p.m., indicated, (Resident 15) stated that he was walking when he blacked out and woke up on the ground . Musculoskeletal: .He exhibits [MEDICAL CONDITION] (swelling) and tenderness (left) hip tenderness on palpation (using hands to check the body) (and movement). During a review of Resident 15's acute care hospital clinical record, HOSPIITALIST DISCHARGE SUMMARY dated 12/24/19, indicated, . (Resident 15) seen in operating room (OR) for open reduction internal fixation (ORIF-surgical implementation of implants for the purpose of repairing a broken bone) for left hip .had postoperative (following surgery) [MEDICAL CONDITION] (low blood count) transfuse 1 unit of (blood) . During a review of the facility policy and procedure (P&P) titled, Falls - clinical Protocol dated 9/07, indicated, .The staff and physician should document in the medical record a history of one or more recent falls . the staff will document risk factors for falling in the resident's record and discuss the resident's fall risk .Risk factors for subsequent falling include lightheadedness or dizziness .Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. During a review of the facility P&P titled, Falls and Fall Risk, managing dated 12/07, indicated, .Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling .The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling . 2. During an interview on 12/30/19, at 2:30 p.m., with the Assistant Director of Nursing (ADON), the ADON stated Resident 23 fell out of bed to the floor on 12/26/19. The ADON stated the fall occurred during care while the assigned Certified Nursing Assistant (CNA 4) provided bed mobility without the assistance of an additional nursing staff member. The ADON stated Resident 23 required the assistance of two staff members for bed mobility. During a concurrent observation and interview on 12/30/19, at 3:30 p.m., with Resident 23, in his room, Resident 23 was observed in a wide bed wearing a dark-colored sling on his right arm. Resident 23 stated, Usually, they have two caregivers, but not that time (the time his shoulder was injured when he fell out of bed on 12/26/19). During a review of Resident 23's face sheet dated 12/30/19, the face sheet indicated Resident 23 had a [DIAGNOSES REDACTED]. During a review of Resident 23's MDS assessment dated [DATE], indicated Resident 23 had no cognitive impairment with BIMS score of 15. Resident 23's MDS assessment indicated he required two-person physical assistance with bed mobility, toilet use and personal hygiene. The MDS indicated Resident 23's self performance status was extensive assistance (weight bearing support) during activity functions. During an interview on 12/31/19, at 7:46 a.m., with CNA 3, CNA 3 stated he always got help and provided care to Resident 23 with the assistance of another staff member. During an interview on 12/31/19, at 8 a.m., with CNA 4, CNA 4 stated he was providing toileting assistance to Resident 23 who was in bed. CNA 4 stated he provided care by himself and without the assistance of another staff member the day Resident 23 fell out of bed and landed on to the floor. CNA 4 stated, Honestly, not 100% sure if another person would have stopped the fall. (Resident 23) is a big guy. I did it by myself all the time. I almost never ask for help . CNA 4 stated he did not know what bed mobility needs were care planned and needed to be implemented for Resident 23. During a review of Resident 23's progress notes dated 12/26/19, at 12:34 p.m., indicated, Resident (23) fell out of bed while getting his brief changed. Resident landed on his right side and was complaining of shoulder pain. In addition to shoulder pain he also complained of head and neck pain .Resident sent to ER (the hospital emergency room ) for further evaluation . During a review of Resident 23's progress notes dated 12/26/19, at 6:01 p.m., indicated Resident 23 had returned from the hospital following a witnessed fall . with [DIAGNOSES REDACTED]. Right arm in sling with splint in place. During a review of Resident 23's care plan for activities of daily living performance deficit, initiated 11/27/19, indicated, BED MOBILITY: The resident is totally dependent on (2) staff for repositioning and turning in bed ROUTINELY and as necessary. Another intervention, TOILET USE initiated 8/5/19 indicated, The resident is totally dependent on (2) staff for toilet use. During a review of Resident 23's emergency room documentation titled, Preliminary Report dated 12/26/19 at 1:26 p.m., indicated, .Elbow x-ray findings .Interpretation: radial head (elbow) fracture .History of Present Illness The patient presents following fall .The fall was described as fell out of bed .Locations; Right upper extremity. The character of symptoms is pain . During a review of the facility P&P titled, Goals and Objectives, Care Plans dated 4/09, indicated, .Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence . During a review of the facility P&P titled, Comprehensive Assessment and the care Delivery Process dated 12/16, indicated, .Comprehensive assessments will be conducted to assist in developing person-centered care plans .Comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions .

Based on interview and record review, the facility failed to provide sufficient preparation for a safe and orderly discharge for one of three sampled Residents (Resident 1), when Resident 1, who was known by the facility to have serious mental illness, inability to care for herself and an unhealed right foot wound that required treatment was permitted to plan her own discharge. Resident 1 was discharged to the care of a taxi driver and traveled by taxi and bus to a city 70 miles away from the facility with no arranged wound care, personal care or housing in place upon arrival. This failure placed Resident 1 at risk for serious physical harm from an untreated wound and lack of ability to meet her own need for food and shelter. Findings: Resident 1's clinical record titled, Admission Record, indicated Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. blood pressure) and Noncompliance with Medical Treatment and Regimen (failure to follow medical recommendations and treatments). Review of Resident 1's clinical record from the Acute Care Hospital (ACH) 1 titled, Diagnostic Impression for (ACH 1). Mental Health Exam (of Resident 1) dated 12/14/16, indicated . Insight - poor; Judgment- poor; Impulse control - poor . Very limited coping techniques . Resident 1's Care Plan dated initiated 12/15/16, indicated Focus: Resident has multiple behavior/mood issues such as verbal and physical aggression, uses foul language, paranoid (thinks everyone is trying to hurt her or steal from her), constant talking to self and others not present (frequently tells imaginary person to get off me), very frequent refusals of care including meds (medications) and wound care, can be very delusional(beliefs that are firmly held, contrary to reality)/flight of thoughts, very poor reality awareness, nonsensical conversations . Review of Resident 1's clinical record titled, Minimum Data Set (MDS) (a resident assessment tool used to plan care) assessment, dated 1/18/17, indicated Resident 1 had not walked in the hallway during the 7 days prior to the assessment and required extensive assistance of two staff members for personal hygiene. The MDS indicated Resident 1 had delusions and verbal behavioral symptoms directed toward others such as threatening, screaming and cursing. Review of Resident 1's clinical record titled, Wound Care Specialist Initial Evaluation, dated 12/9/16, indicated, . Stage 4 pressure wound of the right heel .on my examination I noted an exposed bone in the wound bed (on the right heel) . There is moderate serous exudate (clear drainage). Resident 1's physician's orders [REDACTED]. Apply calcium alginate with silver (type of wound dressing that absorbs drainage, protects against bacteria and reduces odor) dressing and cover with dry dressing every day. Review of Resident 1's clinical record titled, Wound Care Specialist Progress Note, dated 1/6/17, indicated . Assessment & Plan: Stage 4 pressure wound of the right heel - no change . On 2/2/17 at 11:15 a.m., during an interview, Social Services Director (SSD) 1 stated Resident 1 was discharged from the facility on 1/18/17. SSD 1 stated Resident 1 had been talking about going to a women's center in (a city 70 miles from the facility) and to a women's shelter two blocks from the women's center. SSD 1 stated, (Resident 1) said there was a women's shelter 2 blocks away from the center and that she had stayed there before several times. I didn't get the name (of the shelter). She (Resident 1) did not share any information about the shelter . SSD 1 stated the facility's Interdisciplinary Team (IDT, a team of facility healthcare professionals who meet to plan resident care) did not meet before Resident 1's discharge on 1/18/17 to plan Resident 1's possible discharge to the women's center. SSD 1 stated she communicated with the facility Administrator (Admin) and Resident 1's Medical Doctor (MD) 1 regarding the discharge. SSD 1 stated she asked the facility nurses to contact MD 1 for a discharge order for Resident 1. SSD 1 stated she wrote MD 1 a letter regarding Resident 1's discharge from the facility. SSD 1 stated a taxi ride from the facility to the bus station was set-up the day before Resident 1's discharge on 1/18/17. The SSD stated a bus voucher and a wheelchair were purchased for Resident 1. The SSD stated the taxi took Resident 1 to the bus station and Resident 1 took the bus to (city 70 miles away from the facility). SSD 1 stated she called a taxi company in (the city 70 miles away from the facility) to arrange for a taxi to meet Resident 1 at the bus station and transport Resident 1 from the bus station to the women's center. SSD 1 stated she purchased two backpacks for Resident 1 to take with her upon discharge. One backpack contained wound care supplies and the second backpack contained clothes and personal care supplies. SSD 1 stated the facility gave Resident 1 $30.00 in cash, two packs of cigarettes and a $25.00 gift card upon discharge. On 2/2/17 at 12:39 p.m., during an interview, Licensed Nurse (LN) 3 stated Resident 1 had a stage 4 pressure ulcer on her right heel that required treatment while she was in the facility. LN 3 stated, I don't think she is capable of taking care of herself because of this [MEDICAL CONDITION] (severe mental illness causing loss of contact with reality) personality that she has, plus her wound. She won't have proper care .lots of potential problems. On 2/2/17 at 12:58 a.m., during an interview, Licensed Nurse (LN) 1 stated, It was about one to two days before discharge that I did her wound care last. The wound had maceration (moist white tissue) around the edges .0.3 cm (centimeter, a linear measurement) deep, three inches by five inches around on the right heel. Yes it was a stage 4 sore. She (Resident 1) refused teaching about her wound care .She has the mental capacity to take care of the wound if she tries. The question would be .would she do it? On 2/2/17 at 1:26 p.m., during an interview, LN 2 stated, Most of the time she (Resident 1) is in her own world; talking away; soft to loud to yelling. It don't know if it was safe to discharge her (Resident 1 on 1/18/17). I am scared for her. On 2/3/17 at 10:50 a.m., during an interview, the Admin stated the facility IDT normally met to discuss and plan resident discharges but the IDT did not meet to plan Resident 1's discharge on 1/18/17. The Admin stated Resident 1 left against medical advice (AMA, leaving despite physician recommendations to stay in the facility and continue treatment) and the IDT did not meet if the discharge was AMA. The Admin stated there was no psychiatric evaluation of Resident 1's condition prior to discharge on 1/18/17 because Resident 1 left the facility AMA. Review of Resident 1's clinical record titled, Social Service Progress Note dated 1/5/17 at 11:26 a.m., indicated, Resident (Resident 1) has been stating that she wants to leave this facility. Social Services has called the shelter and they only have breakfast from 8-11 (a.m.) and then everybody leaves. It (the women's center) is not a shelter. They do not have rooms. They are a hospitality place. Resident will not be discharging to (women's center). The progress note was signed by SSD 2. Review of facility document, untitled, dated 1/9/17, indicated (MD) 1, Can you please re-evaluate (Resident 1's) orders for capacity (mental capacity)? Please re-evaluate and update so we can have appropriate orders . The document was signed by SSD 1. MD 1's response indicated, .She (Resident 1) clearly understand what she want and not want and decide what she want and not want clearly. But she has mental issues which need psych eval (evaluation by psychiatrist) and treatment. Review of facility document, untitled, dated 1/11/17, indicated (MD 1) (Resident 1) is requesting to be discharged to a women's center in (city). She wants to take a taxi to the bus station, a bus to (city), and then a taxi to the women's center. We have called and verified that the women's center assists with food, clothing, shelter, etc. At this time (Resident 1) continues to have the open wound on her foot which she seldom allows us to treat. (Resident 1) states that she would allow HH (home health) RN (registered nurse) to come to the women's center and provide wound care. We have contacted (HH) and they go to the center. I have contacted the Ombudsman (name) and she has spoken to (Resident 1). She agrees that (Resident 1) has the right to go. So our question is, can we get a Discharge order such as: Discharge to Shelter of choice, Follow up with local clinic for wound care. Continue current meds as ordered. Or .AMA? The document was signed by SSD 1. Review of MD 1's response indicated, Had a detail discussion with my NP (nurse practitioner) about patient care and DC (discharge plan). Both of us agree that patient need more care than at woman shelter with home health for wound care. She refuses care at SNF. We cannot hold pt (patient) against her will. She can be discharged at AMA. We still can try to arrange what she needs. But will be AMA discharge. The response was signed by MD 1. Review of facility document titled, (MD 1) Discharge Instructions dated 1/11/17, indicated 1) Check list for discharge if: Vital signs stable and wound improved/stabilized .Cleared by Physical Therapy. Home safety evaluation done, and home health care set up as indicated. The document was signed by MD 1. Review of Resident 1's clinical record titled, Progress Notes dated 1/18/17 at 5:17 a.m., indicated, Pt (patient ) was assisted into taxi cab, seatbelt fastened, at 0430 hours ( 4:30 a.m.), leaving facility AMA. Pt refused all care when preparing to leave, including shower, clean clothes, dressing change to foot wound, clean socks and protective booties .Pt was offered oral medications, but refused, stating, I will see my own doctor when I get there .Pt was asked to sign the AMA statement, she refused . On 2/2/17 at 2:28 p.m., during an interview, Licensed Social Worker (LSW) from the acute care hospital (ACH) 1 in (city) stated Resident 1 arrived in the ACH 1 Emergency Department (ED) on 1/18/17 at about 8 p.m. and spent the night in the ED. The LSW stated Resident 1 told her the skilled nursing facility gave her a bus voucher earlier that day and she had come to the ER from the bus depot which was about two blocks from ACH 1. The LSW stated ACH 1 found a board and care placement for Resident 1 and Resident 1 was transferred to the board and care on 1/19/17. The LSW stated Resident 1 was kicked out of the board and care the next day for aggressive behavior. The LSW stated the board and care owner had called 911 (emergency response number) to take Resident 1 to ACH 2. Review of ACH 1 record, titled, Clinical Social Work Progress Note, dated 1/19/17, indicated placement for Resident 1 was initially made at a motel with referral to a senior placement organization to follow up. The note indicated, This writer witnessed pt (Resident 1) outside attempting to get into cab; pt unable to transfer self. Pt soiled her clothes. This writer and SW (ACH 1 LSW) went out to assess situation. Pt is currently unable to transfer self or toilet self at this time. Pt does not have a way to care for self or obtain food while staying in hotel for 3 days; this discharge plan deemed unsafe .new plan in process .needs higher level of care .Approval granted for 1 month of board and care as well as case mgmt. (management) services . Review of ACH 1 progress notes dated 1/20/17 and signed by ACH 1 LSW indicated Adult Protective Services (APS) had been notified of Resident 1's situation regarding removal from the board and care facility. The progress note indicated, APS worker reported that she has contacted all (hospitals) in the surrounding area however have not been able to locate pt (Resident 1). As of the time of this writing pt (Resident 1) has not returned to (ACH 1). Review of Resident 1's clinical record from ACH 1 indicated an admission date of [DATE] and a discharge date of [DATE]. The clinical record titled ED Progress Notes section Medical Decision Making indicated . this is a [AGE] year old female who has dementia (cognitive deficits and memory loss) .She is clearly unable to care for herself . On 2/13/17 at 3 pm during a telephone interview, SSD 1 stated she had not verified services offered at the women's center prior to Resident 1's discharge on 1/18/17. SSD 1 stated she understood SSD 2 had verified services were offered at the center. SSD 1 stated no arrangements were made with the women's center and the women's center was not notified by the facility regarding Resident 1's pending arrival on 1/18/17. On 2/13/17 at 6:12 p.m., during an interview, the Social Worker (SW) from the woman's center stated she had been in front of the women center about 1:30 p.m. on 1/18/17. The SW stated as she was leaving the center a taxi pulled up with Resident 1 inside. The SW stated Resident 1, upon arrival, was disheveled, very confused and agitated. The SW stated, Somebody did this person wrong. It was the worst scenario ever. I could not believe that a facility would have sent this person to us that way. I have never known a facility to do that. It was pouring rain. This woman came to the center in a taxi. I went out and told the taxi driver and the woman to not even get out of the taxi. I told the taxi driver to take her to the emergency room . The SW stated, We are open only from 7:30 a.m. to 11:30 a.m. Why would a facility send a patient to here in a bus without any arrangement of any kind? There's no available shelter in (city). I have many, many people waiting for a shelter. If the facility would have asked for me, I would have told them not to send anybody up this way because there is no available placement up here. That woman (Resident 1) was in no form to take care of herself. It really bothered me that a facility would trust that person's judgement. Review of facility policy titled, Transfer and Discharge dated 7/1/16, indicated II. Compliance Guidelines 1. Complete and accurate patient information, in sufficient detail to provide for continuity of care shall be transferred with the resident at the time of transfer .5. Refusal of treatment does not constitute grounds for transfer, unless the needs of the resident cannot be met or the health and safety of others is endangered .12 d. Orienting caregivers at the receiving site to the resident's daily patterns and psychosocial needs identified by the resident's assessment and care plan .14. For an anticipated discharge (not an emergency or not due to the resident's death), a discharge summary is prepared that includes: a. A recapitulation of the resident's stay; b. A final summary of the resident's status for all MDS items at the time of discharge; and c. A post-discharge plan of care developed in conjunction with the resident and his or her family. Review of facility policy titled, Discharge Against Medical Advice dated 7/1/16, indicated I. Purpose: To delineate the procedure when a resident chooses to leave the facility against medical advice. II. Policy: .B. The charge nurse and/or the Skilled Nursing Director, Director of Nursing as to the necessity of continued treatment as ordered by the physician, the social worker or other members of the staff who have developed positive relations with the patient may be asked to assist. C. If the resident insists on leaving against medical advice, a report will be made to Adult Protective Services if determined necessary because of anticipated harm to the resident .E. The facility will provide discharge information necessary for the continuity of care .

Based on observation, staff interview, clinical record and administrative document review, the facility failed to ensure each resident's right to be free from abuse, when Resident 1, was verbally abused, taunted, and slapped by Certified Nursing Assistant 1 (CNA 1). This failure resulted in Resident 1 feeling hurt, disrespected, humiliated, and placed Resident 1 at risk for emotional or psychosocial deterioration. Findings: On 10/1/14 at 1:00 p.m., during review, Resident 1's clinical record reflected the following: Resident 1 was a [AGE] year old male who was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment (a federally mandated assessment of residents in a skilled nursing facility to identify functional abilities and health problems) dated 6/21/14, indicated Resident 1 was totally dependent on staff for activities of daily living such as repositioning in bed, dressing, eating, personal hygiene, and bathing. In addition, Resident 1's upper extremity (shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle, foot) range-of motion were impaired. The Brief Interview for Mental Status (BIMS) indicated Resident 1 was alert and oriented and had correct recall of words, day, month, and year. On 10/1/14 at 1:20 p.m., Licensed Nurse 1 (LN 1) was interviewed. LN 1 stated on 9/23/14 just past midnight, CNA 1 reported to her (LN 1) Resident 1 had turned his call light on. LN 1 stated when she answered the call light, Resident 1 refused to receive care from CNA 1 and yelled at her to get out of his room. LN 1 stated she told CNA 1 to leave Resident 1 alone and specifically instructed her not to go back to Resident 1's room. LN 1 stated upon her return to the nursing station, she heard a loud exchange of (Spanish) words coming from Resident 1's room. LN 1 stated as she walked toward Resident 1's room to investigate what was going on, she heard CNA 1 tell the resident: "You are not gonna talk to me like that!" LN 1 stated she then heard a loud "slapping" sound. LN 1 stated she called out CNA 1's name and as CNA 1 exited the room, LN 1 entered to check on Resident 1. LN 1 stated she asked Resident 1 what had happened. Resident 1 responded, "Did you hear the slapping? She slapped me!" LN 1 stated, "He looked shocked and his right cheek was reddened. He was quiet, subdued...shocked. He asked me to not allow CNA 1 to come back to his room." On 10/1/14 at 2:15 p.m., an interview with Resident 1 was conducted in his room. Resident 1 was in bed, alert and oriented. He was holding his computer tablet, but he could not lift or raise his arms. Resident 1 stated he was "paralyzed" from the neck down and relied on staff for care. Resident 1 stated he had a "special bond" with CNA 1 up until his return from the hospital on [DATE]. He stated, "We were not officially boyfriend-girlfriend but she spent a lot of time with me on her break time 'making out,' you know, like hugging and kissing. Then she was controlling me, calling me on my phone, texting me, coming to my room all the time and I didn't like that, so I told her not to come to my room anymore." Resident 1 stated, the night of 9/23/14, he had turned his call light on. Resident 1 stated CNA 1 came to his room instead of his regular CNA. Resident 1 stated he was angry and cussed at her and told her to get out of his room and not to come back. Resident 1 stated CNA 1 left but came back and argued, cussed at him, and told him he was a "pathetic loser," and he shouldn't treat her like s-t because he needed her to take care of him. Resident 1 stated CNA 1 told him not to ever talk to her like that again and then slapped him hard on his right cheek. Resident 1 stated, "I was defenseless and felt so helpless, I could not bend my elbows or raise my arms to protect myself. My cheek 'stung' from the force of her slap and I was shocked at what she did. " On 10/1/14 at 2:40 p.m., the Social Services Notes dated 9/25/14 was reviewed. The notes reflected: "Resident has been thinking about the incident...stated, "I feel 90% disrespected and 10% guilty. I just wished she stayed out of my room and this would not have occurred. I just can't believe she hit me." On 10/1/14 at 2:43 p.m., the facility's investigation report dated 9/30/14 reflected in part: "On 9/23/14 on the night shift, (CNA 1) answered (Resident 1's) call light and he asked her to get his assigned CNA for him. He did not want (CNA 1) to take care of him ... A little later, his call light was on again and (CNA 1) answered it and he told her to leave his room and stay away from him. He cursed at her ...and she cursed back at him and then walked to his bedside and slapped him on his right cheek with her open left hand. The charge nurse (LN 1) was at the nurse's station and heard them yelling in Spanish and was coming to the room to see what was happening and heard the smack of the slap right before she entered the room ... " On 10/1/14 at 2:45 p.m., during interview, the Administrator stated when she interviewed CNA 1 to get her side of the story, CNA 1 did not confirm nor deny that she slapped Resident 1 and repeatedly stated she didn't want to "remember." The Administrator stated, "I did not need her confirmation: I had the staff's and Resident 1's credible account of what happened."