Every finding on record at Riviera Healthcare Center

Based on observation, interview and interview review, the facility failed to ensure infection prevention and control practices were implemented, by failing to: Ensure Resident 9's indwelling urinary catheter (catheter that drains urine from bladder into a bag outside the body) drainage bag was not dragging the floor. Ensure the Treatment Nurse used a disposable cloth (paper towel) to establish a clean field (table) before placing Resident 5's wound care supplies on the bedside table, as indicated in its policy and procedure (P&P) titled Wound Care. The facility had a system in place in the management and care of a resident's pet (dog) within the facility. Ensure linen barrels (bin) containing used protective personal protective equipment (PPE-specialized clothing/equipment worn by healthcare staff to protect themselves, residents and others from exposure to infectious agents and the transmission of disease) in two of four residents' rooms (Residents 6 and 7) who were on Enhanced Barrier Precautions (EBP, infection control measures using gowns and gloves during high-contact care to prevent the spread of multidrug-resistant organisms [MDROs]), were not overflowing and not left open/ exposed. These failures violated infection prevention and control practices and had the potential for cross-contamination of organisms, placing other residents, staffs and visitors at risk for infections.Findings: 1). During an observation on 5/20/2026 at 9:05 a.m., Resident 9 was observed up on a wheelchair propelling himself out of the room. Resident 9's catheter drainage bag was attached to the wheelchair and was dragging on the floor. During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 9's diagnoses included urinary tract infection (UTI- an infection in the bladder/urinary tract) and Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities). During a review of Resident 9's care plan titled Alteration in urinary elimination secondary to use of indwelling foley catheter, dated 11/17/2024, the interventions indicated to do foley catheter care every shift and monitor indwelling catheter. During a review of Resident 9's H&P dated 1/7/2026, the H&P indicated Resident 9 did not have the capacity to understand and make decisions. During a review of Resident 9's MDS dated [DATE], the MDS indicated Resident 9 had severe cognition was severe cognitive impairment. Resident 9 was dependent with staff in putting on footwear, toileting, showering, and lower body dressing. During interview with the DON on 5/20/2026 at 12:00 p.m. the DON stated the catheter bag should not be touching the floor and that would pose an infection control risk to the resident. During a review of the facility's P& P titled Catheter Care, Urinary, dated 1/2026, the P&P indicated, to prevent catheter-associated urinary tract infections, be sure the catheter tubing and drainage bag are kept off the floor. 2). During an observation on 5/20/2026 at 10:30 a.m., the Licensed Vocational Nurse (LVN) 1 was observed placing wound care supplies (4x4 gauze [dressing], tape, scissors, a thick pad dressing and a cling wrap) on Resident 5's overbed table, for Resident 5's right great toe wound care. During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was admitted to the facility on [DATE] with diagnoses including gangrene (death of body tissue caused by lack of blood supply) of the toe, Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and chronic ulcer of the right foot. During a review of Resident 5's H &P dated 12/7/2025, the H &P indicated Resident 5 did not have the capacity to understand or make decisions. During a review of Resident 5's Minimum Data set the (MDS- a resident assessment tool) dated 3/6/2026, the MDS indicated Resident 5 had moderate cognitive impairment. The MDS indicated Resident 5 was dependent on staff for personal hygiene, lower body dressing and bathing. During review of Resident 5's physician orders dated 4/29/2026, the physician orders indicated cleanse right great toe with normal saline, pat dry paint with betadine solution apply abdominal pad wrap with roll gauze secure with tape every shift. During a review of Resident 5's care plan titled Resident has gangrene vascular ulcer on the right great toe, revised 5/13/2026, the goal indicated the resident will not have signs and symptoms of infection. The interventions indicated to monitor, document, report signs and symptoms of infections and treatment as ordered. During an interview on 5/20/2026 at 12:30 p.m. with the DON, the DON stated using a barrier (lining) to establish a clean field during wound care was a facility policy. Not following facility's policy placed the resident at risk for infections and violates infection control. During a review of the facility's P&P titled wound Care, dated 1/2026, the P&P indicated, the facility will use disposable cloth (paper towel is adequate) to establish a clean field to resident's overbed table. Place all items to be used during procedure on the clean field. Place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites. 3). During observation on 5/20/2026 at 10:24 a.m., a dog was observed tethered (tied with a rope) on an outside patio accessible to residents. The dog was lying on a white blanket and a soiled blue blanket with several wheelchair pads on the ground. The wheelchair was soiled and dog feces were observed in the patio area. During an interview on 5/20/2026 2:45 p.m., with the Administrator, the Administrator stated the dog belonged to Resident 8. The Administrator stated the facility did not have a P&P related to having animal (pet) on the premises. The Administrator stated the patio area should be cleaned by maintenance to prevent any infection control concerns. 4). During an observation on 5/20/2026 at 10:47 a.m., of Resident 6's room, the door had a signage indicating Enhanced Barrier Precautions. of Resident 6's room, the door had a signage indicating Enhanced Barrier Precautions. A linen barrel inside the resident's room was observed with soiled (dirty) PPEs that were overflowing, with lid open, exposing the used PPEs. During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 6's diagnoses included stage 4 (full thickness skin loss with extensive destruction; tissue necrosis; or damage to muscle, bones) pressure ulcer to right shoulder and sacral area, gastrostomy tube (GT, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 6's care plan titled Enhanced Barrier Precautions due to the presence of GT and Stage 3 P.I. (pressure injury). At risk of acquiring or being a source of MDRO, initiated 4/23/2025, the goal indicated preventing the spread of microorganism among residents, visitors and staff. One of the interventions indicated to render enhanced precaution procedures as a precautionary measure in accordance with the facility's infection control plan, consistent with the requirement of the local health department. During a review of Resident 6's History and Physical (H&P) dated 10/10/2025, the H&P indicated Resident 6 did not have the capacity to understand or make decisions. During a review of Resident 6's, MDS, dated [DATE], the MDS indicated Resident 6 had severe cognitive (thinking process) impairment. Resident 6 was dependent upon the assistance of staff for all activities of daily living (dressing, bathing, toileting, and hygiene). 5). During an observation 5/20/2026 at 11:05 a.m., of Resident 7's room, the door had a signage indicating Enhanced barrier precaution. A linen barrel inside the resident's room was observed with soiled PPEs that were overflowing, with lid open, exposing the used PPEs. During a review of Resident 7's admission Record, the admission Record indicated Resident 7 was admitted to the facility on [DATE] with diagnoses including sacral stage 3 pressure (deep and painful wounds in the skin), local infection of the skin and subcutaneous tissue and chronic ulcer of the right lower leg (a slow healing leg wound). During a review of Resident 7's care plan titled Enhanced barrier precautions due to chronic wounds. At risk for acquiring or being a source of MDRO, initiated 2/14/2026, the goal indicated to prevent the spread of microorganism among residents, visitors and staff. One of the interventions indicated to render enhanced precaution procedures as a precautionary measure in accordance with the facility's infection control plan, consistent with the requirement of the local health department. During a review of Resident 7's H&P dated 4/13/2026, the H &P indicated Resident 7 had the capacity to understand and make decisions. During a concurrent interview and record review on 5/20/2026 at 11:30 a.m. with the Director of Nursing (DON), the facility's P&P titled, Handling, Sorting and Disposal of Soiled Linen and Resident Personal Clothing, dated 1/2026 was reviewed. The P & P indicated cart must always be kept closed when not in use.

Based on observation, interview and record review, the facility failed to ensure:1. The garbage was properly disposed of in the designated dumpsters.2. The dumpster lids were maintained in a closed position to prevent exposure to the environment.3. Timely removal or management of accumulated trash when scheduled waste collection did not occur.These deficient practices had the potential to contribute to environmental contamination, pest infestation, odors and unsanitary conditions that could negatively impact the health and safety of residents, staff, and visitors.Findings:During concurrent interview and observation on 3/9/2026 at 9:05 a.m., with the Dietary Supervisor (DS), three dumpsters were observed in the facility's designated trash disposal area. Multiple bags filled with trash were noted placed on the ground outside of the dumpsters rather. The lids of the three dumpsters were observed to be unable to close properly due to the dumpsters being overfilled with trash. The DS stated the trash bags should not have been left on the ground and should have been properly placed inside the dumpsters with the lids fully closed. The DS stated the dumpsters were overfilled and stated that leaving trash outside the dumpsters and failing to maintain the lids in a closed position could have attracted rodents and pests, which could create an unsanitary environment and negatively impact the health and wellbeing of residents.During an interview on 3/11/2026 at 8:30 a.m. with the Maintenance Supervisor (MS), the MS stated that all trash generated by the facility should be placed inside the designated dumpsters and that dumpster lids should remain closed to prevent exposure to the environment. The MS stated that trash should never be left on the ground outside of the dumpsters. The MS stated that when dumpsters become full, staff should notify the maintenance department or administration so arrangements can be made for additional waste removal. The MS stated overfilled dumpsters and trash left outside of the containers could attract rodents, insects, and other pests and create an unsanitary condition on the facility grounds, which could potentially impact the health and safety of residents, staff, and visitors. The MS confirmed that the observed condition did not meet the facility's expectations for proper waste management.During a review of the facility's Policy and Procedures (P&P) titled, Waste Disposal dated 1/2026, the P&P indicated All infectious and regulated waste shall be handled and disposed of in a safe appropriate manner.During a review of the facility's P&P titled Pest Control dated 1/2026, the P&P indicated Garbage and trash are not permitted to accumulate and are removed from the facility daily.

Based on observation, interview, and record review, the facility failed to ensure the urine characteristics were appropriately assessed and the urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) drainage bag was kept off the floor for five out of eight sampled residents (Resident 9, Resident 10, Resident 2, Resident 34, and Resident 3).These deficient practices had the potential to lead to delay in treatment and identification of urinary tract infections (UTI- an infection in the bladder/urinary tract) for Residents 9 and 10, and the development of UTIs due to improper urinary catheter management for Residents 2, 3, 9, and 34.Findings: 1a. During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 9's diagnoses included dementia (a progressive state of decline in mental abilities), hypertension (high blood pressure), and chronic kidney disease (long-term condition where the kidneys are damaged). During a review of Resident 9's Minimum Data Set (MDS- a resident assessment tool), dated 2/2/2026, the MDS indicated Resident 9's cognition (process of thinking) was moderately impaired. The MDS indicated Resident 9 was dependent on staff's assistance with toileting, bathing, and lower body dressing. The MDS indicated Resident 9 had an indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine). During a review of Resident 9's History and Physical (H&P), dated 11/8/2025, the H&P indicated Resident 9 had fluctuating capacity to understand and make decisions. During a review of Resident 9's Physician Orders, dated 11/8/2025, the Physician Order indicated to monitor Resident 9's urine for color, odor, and sediments (solid matter in the urine that could contain cells, bacteria, mucus, or minerals) every shift. During a review of Resident 9's Care Plan titled, Alteration in Urinary Elimination, dated 8/27/2025, the care plan indicated to monitor Resident 9's urine for sediments, cloudiness, odor, blood, and amount of output. During observations on 3/9/2026 at 9:58 a.m., 3/9/2026 at 2:06 p.m., 3/10/2026 at 8:38 a.m., 3/10/2026 at 1:27 p.m., and 3/11/2026 at 8:15 a.m., in Resident 9's room, Resident 9 was observed lying in bed. The indwelling urinary catheter bag hung on the left side of the bed frame. Resident 9's indwelling urinary catheter tubing had an off-white, thick, milky sediment present. During a concurrent observation and interview on 3/11/2026 at 9:09 a.m., with Treatment Nurse (TN) 1, in Resident 9's room, Resident 9 was observed lying in bed. The indwelling urinary catheter bag hung on the left side of the bed frame. Resident 9's indwelling urinary catheter tubing had an off-white, thick, milky sediment present. TN 1 stated Resident 9 had sediment in her urine which was visible in the urinary catheter tubing. During a concurrent interview and record review on 3/11/2026 at 9:15 a.m., with TN 1, Resident 9's Treatment Administration Record (TAR), dated 3/1/2026 through 3/31/2026, was reviewed. The TAR did not indicate the presence of sediment from 3/9/2026 through 3/11/2026. TN 1 stated sediment should have been identified as early as possible because the presence of sediments could indicate a urinary tract infection (UTI- an infection in the bladder/urinary tract). During a concurrent interview and record review, on 3/11/2026 at 10:07 a.m., with the Infection Preventionist Nurse (IPN), photos of Resident 9's indwelling urinary catheter tubing, dated 3/9/2026 at 9:58 a.m., 3/9/2026 at 2:06 p.m., 3/10/2026 at 8:38 a.m., 3/10/2026 at 1:27 p.m., and 3/11/2026 at 8:15 a.m., were reviewed. The photos revealed the presence of sediment in Resident 9's indwelling urinary catheter tubing. The IPN stated the urinary sediment should have been identified by the treatment nurses, licensed nurses, and/or certified nursing assistants (CNAs) because the sediments were present as early as 3/9/2026. The IPN stated the presence of urinary sediment could indicate a UTI and require antibiotic treatment (medication to treat a bacterial infection). 1b. During observations on 3/9/2026 at 2:06 p.m. and 3/10/2026 at 1:27 p.m., in Resident 9's room, Resident 9 was lying in bed. The indwelling urinary catheter bag hung on the left side of the bed frame. Resident 9's bed was in a low-to-the-floor position and the indwelling urinary catheter bag was touching the floor. During an interview on 3/11/2026 at 10:09 a.m., with the IPN, the IPN stated indwelling urinary catheter bags should be hung on the side of the resident's bed and should not touch the floor. The IPN stated the drainage tip on the drainage bag was covered, however, bacteria on the drainage bag could migrate to the tip. The IPN stated if bacteria entered the drainage tip, the bacteria could move through the urinary catheter system and enter Resident 9's bladder and kidneys. The IPN stated Resident 9's urinary catheter bag touching the floor placed Resident 9 at risk for a UTI. During an interview on 3/12/2026 at 9:25 a.m., with the Director of Nursing (DON), the DON stated indwelling urinary catheter bags should never touch the floor. The DON stated the floor was dirty and if the drainage bag drags along the floor, the drainage tip could become contaminated with bacteria. The DON stated having Resident 9's indwelling urinary catheter bag touching the floor placed Resident 9 at risk for a UTI. 2. During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was initially admitted on [DATE] and readmitted on [DATE]. Resident 10's diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke- caused by a blocked blood vessel in the brain) affecting the right side, vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to the brain, damaging brain tissue), and neuromuscular dysfunction of the bladder (loss of bladder control caused by [NAME] damage). During a review of Resident 10's MDS, dated [DATE], the MDS indicated Resident 10's cognition was severely impaired. The MDS indicated Resident 10 was dependent on staff's assistance with toileting, bathing, and lower body dressing. The MDS indicated Resident 10 had an urinary catheter. During a review of Resident 10's H&P, dated 10/24/2025, the H&P indicated Resident 10 had fluctuating capacity to understand and make decisions. During a review of Resident 10's Physician Orders, dated 10/24/2025, the Physician Orders indicated to monitor Resident 10's urine for color, odor, and sediment every shift. During a review of Resident 10's Care Plan titled, Alteration in Urinary Elimination, dated 2/29/2024, the care plan indicated to monitor Resident 10's urine for sediment, cloudiness, odor, blood, and amount of output. During observations on 3/9/2026 at 10:03 a.m., 3/9/2026 at 2:07 p.m., 3/10/2026 at 8:38 a.m., 3/10/2026 at 1:27 p.m., and 3/11/2026 at 8:15 a.m., in Resident 10's room, Resident 10 was observed lying in bed. The suprapubic catheter (an indwelling hollow tube inserted through a small incision in the lower abdomen into the bladder to drain or collect urine) bag hung on the left side of the bed frame. Resident 10's suprapubic catheter tubing had an off-white, thick, milky sediment present. During a concurrent observation and interview on 3/11/2026 at 9:10 a.m., with TN 1, in Resident 10's room, Resident 10 was observed lying in bed. The suprapubic catheter bag hung on the left side of the bed frame. Resident 10's subrapubic catheter tubing had an off-white, thick, milky sediment present. TN 1 stated Resident 10 had sediment in her urine which was visible in the urinary catheter tubing. During a concurrent interview and record review on 3/11/2026 at 9:15 a.m., with TN 1, Resident 10's TAR, dated 3/1/2026 through 3/31/2026, was reviewed. The TAR did not indicate the presence of urinary sediment from 3/9/2026 through 3/11/2026, TN 1 stated Resident 10's sediment should have been identified as early as possible because the presence of sediment could indicate an UTI. During a concurrent interview and record review, on 3/11/2026 at 10:07 a.m., with the IPN, photos of Resident 10's indwelling tubing, dated 3/9/2026 at 10:03 a.m., 3/9/2026 at 2:07 p.m., 3/10/2026 at 8:38 a.m., 3/10/2026 at 1:27 p.m., and 3/11/2026 at 8:15 a.m., were reviewed. The photos revealed sediment was present in the indwelling urinary catheter tubing. The IPN stated Resident 10's sediment should have been identified by the treatment nurses, licensed nurses, and/or CNAs because the sediment was present as early as 3/9/2026. The IPN stated the presence of urinary sediment could indicate an UTI and require antibiotic treatment. During an interview on 3/12/2026 at 9:22 a.m., with the DON, the DON stated the licensed nurses were responsible for monitoring the urine output, color, consistency, presence of sediment, and other signs of infections for residents with indwelling urinary catheters. The DON stated residents with indwelling urinary catheters were at a higher risk of developing a UTI and early identification of sediment could result in early treatment. The DON stated the delay in identifying sediment in Resident 10's urinary catheter placed her at risk of developing a UTI. During a review of the facility's policy and procedure (P&P) titled, Urinary Tract Infections/Bacteriuria, revised 1/2026, the P&P indicated nurses should observe, document, and report any signs and symptoms of a possible UTI. 3a. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE]. Resident 2's diagnoses included gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), dysphagia (difficulty swallowing), pedestrian on foot collision with a motor vehicle, and fractures (broken bones) of the vertebrae (spine), ribs, left tibia (leg bone), right femur (thigh bone), skull and facial bones. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 2 was dependent on staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 2's H&P, dated 6/15/2025, the H&P indicated Resident 2 did not have the capacity to understand and make decisions. During a review of Resident 2's Physician Order, dated 2/7/2026, the Physician Order indicated indwelling urinary catheter. During observations made on 3/9/2026 at 9:30 a.m., 12:19 p.m. and 2:49 p.m., Resident 2's indwelling urinary catheter drainage bag was observed resting on the floor. 3b. During a review of Resident 34's admission Record, the admission Record indicated Resident 34 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 34's diagnoses included UTI, chronic kidney disease, Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), and muscle weakness. During a review of Resident 34's MDS, dated [DATE], the MDS indicated Resident 34's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 34 was dependent on staff for toileting, showering, and dressing. During a review of Resident 34's H&P, dated 1/1/2026, the H&P indicated Resident 34 did not have the capacity to understand and make decisions. During observations made on 3/9/2026 at 2:49 p.m. and 3/10/2026 at 12:29 p.m., observed Resident 34's indwelling urinary catheter drainage bag resting on the floor. During a concurrent interview and record review on 3/11/2026 at 9:10 a.m. with Registered Nurse (RN) 1, a photo of Resident 2's and Resident 34's urinary catheter drainage bag, dated 3/9/2026 and timed at 2:49 p.m., was reviewed. The photo revealed Resident 2 and 34's urinary catheter drainage bags resting on the floor. RN 1 stated the nurses were expected to keep the urinary catheter drainage bags off the floor to prevent contamination and reduce the risk of infection. RN 1 stated if Resident 2's and Resident 34's urinary catheter drainage bags were left touching the ground, the residents' drainage bags could become contaminated, which increased the risk of Resident 2 and Resident 34 developing a UTI. 4. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 3's diagnosis included dementia (a progressive state of decline in mental abilities), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension (HTN- high blood pressure). During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 3 was dependent on staff for ADLs. During a review of Resident 3's H&P, dated 3/3/2026, the H&P indicated Resident 3 did not have the capacity to understand and make decisions. During a review of Resident 3's care plan titled The resident has Foley (indwelling) catheter., initiated revised 2/18/2026, the care plan indicated Resident 3 was to have no signs and symptoms of infection. The interventions indicated to monitor proper alignment of the Foley and Foley catheter bag. During observations on 3/10/2026 at 8:48 a.m., and 2:45 p.m., and on 3/11/2026 at 8:52 a.m., at Resident 3's bedside, Resident 3 was observed lying in bed. The Foley catheter drainage bag was observed on the left side of Resident 3's bed, touching the floor. During a concurrent observation and interview on 3/11/2026 at 8:52 a.m., with the DON, at Resident 3's bedside, Resident 3 was observed lying in bed. The Foley catheter drainage bag was directly on the floor on the left side of the bed. The DON stated the catheter drainage bag should be kept off the floor and below the level of the bladder to prevent contamination and backflow of the urine. The DON stated the catheter bag should not have been touching the floor because of infection control. The DON stated that when the bag was on the floor, bacteria from the floor could contaminate the drainage bag and travel into Resident 3's urine. The DON stated the Foley catheter drainage bag should be placed in a clean basin (container) when the resident was in bed. The DON stated failing to ensure Resident 3's catheter drainage bag was kept off the floor exposed the drainage bag to contamination. The DON stated this placed the resident at risk for infection, development of a catheter-associated UTI, and other preventable infection-related complications. During a review of the facility's P&P titled Catheter Care, Urinary, revised 1/2026, the P&P indicated the facility will ensure the catheter tubing and bag were kept off the floor to prevent catheter-associated urinary tract infections.

Based on observation, interview, and record review, the facility failed to ensure that one of six sampled residents (Resident 64) was free from the use of an unauthorized physical restraint when the resident's bed was positioned directly against the wall.This deficient practice had the potential to restrict Resident 64's freedom of movement and function as a physical restraint negatively impacting Resident 64's psychosocial well-being.Findings:During a review of Resident 64's admission Record, the admission Record indicated Resident 64 was admitted to the facility on [DATE]. Resident 64's diagnoses included hypertension (HTN- high blood pressure), dementia (a progressive state of decline in mental abilities), epilepsy (a chronic brain disorder characterized by recurring, unprovoked movements caused by abnormal electrical activity), dysphagia (difficulty swallowing) and splenomegaly (an enlarged spleen, an organ in the upper left abdomen that filters blood and supports the immune system).During a review of Resident 64's History and Physical (H&P), dated 3/4/2026, the H&P indicated Resident 64 had fluctuating capacity to understand and make decisions.During a review of Resident 64's Minimum Data Set ([MDS], a resident assessment tool), dated 12/28/2026 the MDS indicated Resident 64's cognitive skills (ability to think and reason) for daily decision making were severely impaired. The MDS indicated Resident 64 was dependent on staff for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).During concurrent observation and interview on 3/10/2025 at 3:46 p.m., in Resident 64's room, with the Director of Nursing (DON), Resident 64's bed was positioned directly against the bedroom wall. The DON stated the damage on the wall correlated with the bed being directly against the wall. The DON stated that placing a resident's bed directly against the wall could be considered a form of physical restraint if it restricted Resident 64's ability to freely move. The DON stated the beds should not be positioned against the wall unless there were a physician's order and proper assessment supporting the need. The DON stated residents have the right to move freely, and positioning the bed against the wall may impede that movement and limit residents' independence. The DON stated that this practice is not in accordance with the facility policy and should not have occurred, as it had the potential to negatively impact the Resident 64's safety, dignity, and psychosocial well-being.During a review of the facility's policy and procedure (P&P) titled Use of Restraints. revised 1/2026, the P&P indicated The facility promotes a restraint-free environment and ensures every resident has the right to be free from any physical or chemical restraints.During a review of the P&P titled, Bed Safety revised 1/2026, the P&P indicated Our facility shall strive to provide a safe sleeping environment for the resident.

Based on interview and record review, the facility failed to ensure a PRN (as needed) order for Ativan (a psychotropic medication- drug that affects mental processes, moods, and behaviors) was not continued beyond 14 days for two of six sampled residents (Residents 103 and 83). This deficient practice placed Residents 103 and 83 at risk for continued use of unnecessary psychotropic medication without timely physician reassessment and had the potential for Resident 103 and 83 to be chemically restrained by the administration of unnecessary psychotropic medication, and/or suffer extrapyramidal symptoms (a group of movement disorders that can occur because of certain medications, particularly antipsychotics) due to prolonged use.Findings:a. During a review of Resident 103's admission Record, the admission Record indicated Resident 103 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 103's diagnosis included schizophrenia (a mental illness that is characterized by disturbances in thought), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (a feeling of fear, unease and restlessness). During a review of Resident 103's Minimum Data Set ([MDS]- a resident assessment tool), dated 12/3/2025, the MDS indicated Resident 103's cognition (the ability to think and process information) was moderately impaired. The MDS indicated Resident 103 was dependent (helper does all the effort) on staff for activity of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 103's physician order, dated 3/10/2026, the physician order indicated to administer Ativan (a psychotropic medication- drug that affects mental processes, moods, and behaviors) 1 milligrams ([mg]- metric unit of measurement, used for medication dosage and/or amount), one (1) tablet by mouth every six (6) hours as needed for anxiety. The order indicated to continue the medication for 60 days with stop date of 5/9/2026. During a telephone interview and record review on 3/11/2026 at 1:45 p.m., with the Psychiatrist (PST), Resident 103's physician order, dated 3/10/2026, was reviewed. The physician order indicated to administer Ativan 1 mg, 1 tablet by mouth every 6 hours as needed for anxiety. The order indicated the medication was to continue for 60 days with stop date of 5/9/2026. The PST stated Resident 103's physician order for Ativan exceeded the 14 days PRN requirement. The PST stated the resident should be reevaluated every 14 days and the clinical justification documented if the PRN psychotropic medication was to continue beyond 14 days. b. During a review of Resident 83's admission Record, the admission Record indicated Resident 83 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 83's diagnosis included anxiety, and major depression disorder. During a review of Resident 83's MDS, dated [DATE], the MDS indicated Resident 83's cognition was moderately impaired. The MDS indicated Resident 83 was dependent on staff for ADLs. During a review of Resident 83's physician order, dated 2/9/2026, the physician order indicated to administer Ativan 1 mg one (1) tablet by mouth every six (6) hours as needed for anxiety. The order indicated the medication was to continue for 60 days with stop date of 4/10/2026. During a review of Resident 83's Medication Administration Record (MAR), dated 2/9/2026 through 2/28/2026 and 3/1/2026 through 3/11/2026, the MAR indicated Ativan 1 mg was administered daily. The MAR indicated Resident 83 received Ativan 1 mg a total of 31 doses. During a concurrent interview and record review on 3/11/2026 at 2:55 p.m., with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled Antipsychotic Medication Use, revised 1/2026, were reviewed. The DON stated the P&P indicated the resident's PRN orders for psychotropic medication was to be written by a physician for specific time period. The DON stated the P&P indicated PRN orders for psychotropic medications will not be renewed beyond 14 days. The DON stated Resident 103 and Resident 83's Ativan orders were not in alignment with the facility's P&P. The DON stated the purpose of the 14-day limit was to ensure the continued need for the psychotropic medication was clinically justified to prevent unnecessary use of such medications.

Based on observation, interview, and record review, the facility failed to ensure two of 12 sampled residents (Resident 103 and Resident 31) were treated with dignity and respect.This deficient practice had the potential to cause Residents 103 and 31 to feel disregarded, humiliated, emotionally distressed, and also had the potential to compromise the residents' dignity and quality of life. Findings: a. During a review of Resident 103's admission Record, the admission Record indicated Resident 103 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 103's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), and anxiety (a feeling of fear, unease and restlessness). During a review of Resident 103's Minimum Data Set ([MDS]- a resident assessment tool), dated 12/3/2025, the MDS indicated Resident 103's cognition (the ability to think and process information) was moderately impaired. The MDS indicated Resident 103 was dependent (helper does all the effort) on staff for activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 103's care plan titled Resident with mittens only during dialysis session., dated 6/13/2025, the care plan indicated Resident 103 would have mittens applied during her dialysis sessions and would be removed during ADLs and mealtimes. During an observation on 3/9/2026 at 12:26 p.m., at Resident 103's bedside, Resident 103 was observed lying in bed. Latex gloves were applied to both hands. During a concurrent observation and interview on 3/10/2026 at 12:27 p.m., with Certified Nursing Assistant (CNA) 4, in Resident 103's room, Resident 103 was observed sitting on a wheelchair with latex gloves to both hands. CNA 4 was providing care to Resident 103. CNA 4 stated the latex gloves were to prevent Resident 103 from scratching her lips and mouth. CNA 4 stated applying latex gloves did not maintain the resident's dignity. CNA 4 stated Resident 103 should be treated with dignity and respect. During an interview on 3/10/2026 at 1:21 p.m., with the Director of Nursing (DON), the DON stated the staff were expected to follow the resident's care plan and provide care in a manner that maintained dignity and respect. The DON stated latex gloves had the potential to cause humiliation and emotional distress. The DON stated the staff failed to ensure the Resident 103 was treated with dignity and respect. During a review of the facility's policy and procedure (P&P) titled Quality of Life - Dignity revised 1/2026, the P&P indicated residents shall be treated with dignity and respect at all times. The P&P indicated each resident shall be cared for in a manner that promotes and enhance quality of life. b. During a review of Resident 31's admission Record, the admission Record indicated Resident 31 was admitted to the facility on [DATE]. Resident 31's diagnoses included diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control), blindness glaucoma ( an eye disease that damages the eye and can slowly cause blindness), low vision of the right eye, blindness to the left eye, hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on the side of the body, like one arm and one leg not working as well) affecting the left dominant side. During a review of Resident 31's History and Physical (H&P) dated 10/20/2025 indicated Resident 31 did not have the capacity to understand and make decisions. During a review of Resident 31's MDS dated [DATE] indicated Resident 31's cognitive skills for daily decision making were moderately impaired. The MDS indicated Resident 31 required set-up assistance for oral hygiene, personal hygiene, and upper body dressing. During an observation on 3/10/2026 at 7:51 a.m., in Resident 31's room, Resident 31 was observed seated upright at the edge of the bed. Resident 31 was eating his breakfast using his hands. Oatmeal, eggs, and juice were observed on Resident 31's clothing, lap, and bed linens. There were no staff providing feeding assistance to Resident 31. During a concurrent observation and interview on 3/10/2026 at 7:53 a.m. with CNA 1, in Resident 31's room, Resident 31 was observed seated upright at the edge of the bed. CNA 1 stated she was busy with other residents and did not know if Resident 31 was an assigned feeder for the day. During an interview on 3/10/2026 at 8:03 a.m. with Resident 31, Resident 31 stated he always feeds himself and did not remember staff assisting him during meals. Resident 31 stated, I am legally blind and I feel like I don't matter in this facility. During a concurrent interview and record review on 3/12/2026 at 12:56 p.m. with the Director of Staff Development (DSD), the facility's document titled Assigned Feeders dated 3/10/2026 was reviewed. The Assigned Feeders document indicated CNA 1 was assigned to Resident 31 and another resident for feeding assistance during the day shift (7:00 a.m. to 3:00 p.m.). The DSD stated she overlooked the daily assignment. The DSD stated CNA 1 should only be assigned to assist one resident with feeding per shift. During an interview on 3/12/2026 at 11:35a.m. with the Director of Nursing (DON), the DON stated staff must ensure residents receive meals with dignity. The DON stated staff assigned to feeder residents should promote a sense of belonging so residents feel respected.

Based on interview and record review, the facility failed to obtain and/or renew informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for psychotropic medication (a drug that changes brain function and results in alterations in perception, mood, consciousness or behavior) for two of six sampled residents (Resident 103 and Resident 41), by failing to:1. Obtain informed consent from Resident 103 and/or their responsible party (RP) for the administration of Olanzapine (a medication used to treat schizophrenia [a mental illness that is characterized by disturbances in thought] and bipolar disorder [sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs]) 2.5 milligram ([mg]- a unit of dose measurement).2. Ensure Resident 41's informed consent for Depakote (a medication used to treat mood disorder and seizure [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]) and Seroquel (antipsychotic medication used to treat schizophrenia) was renewed every six months.These deficient practices had the potential to result in Residents 103 and 41 receiving psychotropic medication without consent. Findings: a. During a review of Resident 103's admission Record, the admission Record indicated Resident 103 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 103's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 103's Minimum Data Set (MDS- a resident assessment tool), dated [DATE], the MDS indicated Resident 103's cognitive (the ability to think and process information) skills for daily decision making was moderately impaired. The MDS indicated Resident 103 was dependent (helper does all the effort) on staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 103 received antipsychotic medication. During a review of Resident 103's physician order, dated [DATE], the physician order indicated Resident 103 was to receive Olanzapine (antipsychotic medication) 2.5 milligrams ([mg]- metric unit of measurement, used for medication dosage and/or amount) daily for schizophrenia. During a review of Resident 103's Medication Administration Record (MAR) dated [DATE] through [DATE] and [DATE] through [DATE], the MAR indicated Olanzapine 2.5 was administered daily, a total of 39 doses. During a concurrent interview and record review on [DATE] at 1:10 p.m., with the Director of Nursing (DON), Resident 103's medical records were reviewed. The medical records did not indicate written informed consent was obtained for the administration of Olanzapine 2.5 mg prior to initiation. The DON stated informed consent should be obtained and documented prior to initiating and/or making dosage changes to Olanzapine to ensure the resident and/or RP were aware of the medication's intended purpose, potential benefits, possible risks and side effects, and available alternatives. The DON stated residents and their RP had the right to be informed and provided the opportunity to accept or refuse treatment. b. During a review of Resident 41's admission Record, the admission Record indicated Resident 41 was admitted to the facility on [DATE]. Resident 41's diagnoses included dementia (a progressive state of decline in mental abilities), metabolic encephalopathy (a change in how the brain works due to an underlying condition ), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), hypertension (HTN- high blood pressure), and hyperlipidemia (high cholesterol). During a review of Resident 41's History and Physical (H&P), dated [DATE], the H&P indicated Resident 41 had fluctuating capacity to understand and make decisions. During a review of Resident 41's MDS, dated [DATE] the MDS indicated Resident 41's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 41 required supervision or touching assistance from staff for toileting, showering, and lower body dressing. During a review of Resident 41's physician orders dated [DATE], the physician orders indicated Resident 41 was to receive Depakote Oral Capsule Delayed Release Sprinkle 125 mg. Give 2 capsules by mouth every 12 hours for mood swings. During a review of Resident 41's physician order dated [DATE], the physician order indicated Resident 41 was to receive Seroquel Oral Tablet 50 mg. Give 1 tablet by mouth one time a day for psychosis manifested by angry outburst. During a concurrent interview and record review on [DATE] at 2:27 p.m., with the DON, Resident 41's consent forms were reviewed. The DON stated that the consent forms for Depakote and Seroquel had not been renewed as required. The DON stated that this failure did not meet facility policy or regulatory standards and should have been completed to ensure compliance and protection of resident rights. The DON stated that it was the facility's responsibility to ensure that informed consent for all prescribed medications were obtained, current, and maintained in the resident's medical record. The DON stated consents must be renewed at least every six months, including when medications were continued over time or when prior consents have expired. The DON stated that medications such as Depakote and Seroquel required documented informed consent due to their potential risks and side effects, and that failure to maintain current consent forms may result in residents or resident representatives not being fully informed regarding treatment. During a review of the facility's policy and procedure (P&P) titled Informed Consent, revised 1/2026, the P&P indicated the facility would ensure residents' rights to informed consent for psychotherapeutic drugs. The P&P indicated renewal every 6 months, and provide written notice of dosage changes.

Based on interview and record review, the facility failed to ensure two of four sampled residents' (Residents 147 and 61) medical records were complete and accurate when:1. Resident 147's hospice (compassionate care for people who are near the end of life provided at the person's home or within a health care facility) record binder and medical record binder contained conflicting Physician Orders for Life-Sustaining Treatment (POLST - a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) forms.This deficient practice had the potential for licensed staff to rely on inaccurate or conflicting information and follow the incorrect POLST during a life-threatening emergency.2. Licensed Vocational Nurse (LVN) 3 did not document Resident 61's Change in Condition (COC) after his roommate tried to touch him inappropriately.These deficient practices resulted in the lack of care plan development and intervention implementation to monitor Resident 61 for psychosocial distress and trauma. Cross Reference F656 and F684.Findings: 1. During a review of Resident 147's admission Record, the admission Record indicated Resident 147 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 147's diagnoses included palliative care (specialized medical care focused on improving quality of life for people with serious illnesses and their families, addressing physical, emotional, and practical needs), chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing) and dysphagia (trouble with swallowing). During a review of Resident 147's Minimum Data Set ([MDS], a resident assessment tool), dated [DATE], the MDS indicated Resident 147's cognition (process of thinking) was moderately impaired. The MDS indicated Resident 147 was dependent on staff for toileting, showering, and lower body dressing. During a review of Resident 147's History and Physical (H&P), dated [DATE], the H&P indicated Resident 147 did not have the capacity to understand and make decisions. During a review of Resident 147's Nursing Progress Note, dated [DATE], the note indicated Resident 147 was readmitted to the facility with a new diagnosis of an acute stroke (loss of blood flow to a part of the brain) affecting the right side. During a concurrent interview and record review on [DATE] at 9:22 a.m. with Registered Nurse (RN) 1, Resident 147's Physician Orders for Life-Sustaining Treatment (POLST – a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) Forms, dated [DATE] and [DATE], were reviewed. The POLST, dated [DATE], located in Resident 147's medical record binder, indicated Resident 147 elected full life-sustaining measures with long term artificial nutrition. The POLST, dated [DATE], located in Resident 147's hospice medical record binder, indicated Resident 147's surrogate decision maker elected do not resuscitate (DNR- a medical order written by a doctor to instruct health care providers NOT to do cardiopulmonary resuscitation [CPR, an emergency, life-saving procedure] if breathing stops or the heart stops beating), comfort-focused treatment, and no artificial means of nutrition. There was no documentation to indicate the POLST dated [DATE] had been voided, superseded, or removed from Resident 147's active medical record. RN 1 stated the presence of both POLST documents with conflicting treatment preferences had the potential for licensed staff to follow the incorrect POLST in the event of a life-threatening emergency for Resident 147. During a review of the facility's Policy and Procedure (P&P) titled, Charting and Documentation, revised 1/2026, the P&P indicated the facility was to ensure documentation in the medical record would be complete and accurate. 2. During a review of Resident 61's admission Record, the admission Record indicated Resident 61 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 61's diagnoses included type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic kidney disease (kidney damage that occurs over time), and hypertension (high blood pressure).During a review of Resident 61's MDS, dated [DATE], the MDS indicated Resident 61's cognition (process of thinking) was intact. The MDS indicated Resident 61 was independent with eating, oral hygiene, and toileting. During a review of Resident 61's H&P, dated [DATE], the H&P indicated Resident 61 had the capacity to understand and make decisions.During an interview on [DATE] at 12:20 p.m., with LVN 3, LVN 3 stated, on [DATE], she was the nurse assigned to Resident 61. LVN 3 stated Resident 61 informed her that his roommate tried to touch his genitals (external reproductive organ). LVN 3 stated Resident 61 was very upset. LVN 3 stated after the incident, a change in condition (COC) should have been documented in Resident 61's electronic health record (eHR).During a concurrent interview and record review on [DATE] at 12:31 p.m., with LVN 3, Resident 61's eHR, dated [DATE], was reviewed. Resident 61 did not have a documented COC on [DATE]. LVN 3 stated she recalled calling the physician, however, she did not document. LVN 3 stated documenting the COC was important to show proof of Resident 61's assessment, physician notification, and any pertinent orders. LVN 3 stated COC documentation was also important to communicate to the oncoming nurses of the incident that occurred and to initiate 72-hour monitoring for potential psychosocial distress. During an interview on [DATE] at 9:58 a.m., with the Director of Nursing (DON), the DON stated the COC should always be documented in the resident's eHR to ensure the licensed nurses were aware of details of the COC and to monitor for worsening behavior, adverse effects, or distress of any kind. The DON stated Resident 61's COC was not documented which resulted in the lack of a care plan and implementation of interventions such as monitoring for psychosocial distress and trauma. During a review of the facility's P&P titled, Charting and Documentation, revised 1/2026, the P&P indicated changes in the resident's condition were to be documented in the resident's medical record.

Based on observation, interview, and record review, the facility failed to ensure food was palatable (tastes good and enjoyable to eat) and consistent with resident preferences for one of seven sampled residents (Resident 124).The deficient practice resulted in the residents not eating their food and had the potential to result in nutritional requirements not being met.Findings:During a review of Resident 124's admission Record, the admission Record indicated Resident 124 was admitted to the facility on [DATE]. Resident 124's diagnoses included chronic respiratory failure with hypoxia (the body or brain is not getting enough oxygen), diabetes mellitus (DM- disorder characterized by difficulty in blood sugar control and poor wound healing), and muscle weakness (loss of muscle strength).During a review of Resident 124's History and Physical (H&P), dated 11/10/2025, the H&P indicated Resident 124 had the capacity to understand and make decisions.During a review of Resident 124's Minimum Data Set (MDS- a resident assessment tool), dated 2/12/2026, the MDS indicated Resident 124 was cognitively intact (the ability to think and process information). The MDS indicated Resident 124 required setup and clean -up assistance (helper sets up and cleans up; resident completes activity) from staff with activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily).During a concurrent observation and interview on 3/10/2026 at 12:59 p.m., with Resident 124, in Resident 124's room, Resident 124 was observed seated upright in bed with a lunch tray placed on the overbed table. The lunch tray contained meatballs. Resident 124 stated that the menu rarely changed and she repeatedly received meatballs despite expressing dislike (things a person does not like or enjoy) to kitchen staff. Resident 124 stated requests for alternate meals were often ignored. Resident 124 stated that this ongoing issue was frequently mentioned to staff, however no changes were done.During a concurrent interview and record review on 3/10/2026 at 3:02 p.m., with the Dietary Supervisor (DS), Resident 124's lunch meal ticket (a document that lists the resident's name, diet order, food preferences, allergy, likes and dislikes), dated 3/10/2026 was reviewed. The lunch meal ticket, indicated Resident 124 dislikes meatballs. The DS stated, the lunch meal ticket may not have been checked as meatballs was served to Resident 124, which could make the resident feel their food preferences were not followed.During an interview on 3/13/2026 at 1:20 p.m., with the Director of Nursing (DON), the DON stated that staff must check meal tickets and ensure residents' food preferences are followed.During a review of the facility's policy and procedure (P&P) titled Meal Service, dated 1/2026, the P&P indicated, nursing and food personnel will serve the trays immediately after checking the tray to be sure nothing is missing from the tray and food preferences are correct.

Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was less than five percent (%). Three medication errors out of a total of thirty-six opportunities contributed to an overall medication error rate of 8.33 %, for two of five sampled residents (Resident 1 and Resident 132) observed for medication administration (med pass). The medication errors noted were as follows:1. Failed to ensure Ferrous Sulfate (used to treat or prevent anemia [a lower-than-normal number of red blood cells]) Oral Solution 220 milligrams per five milliters (mg/ml, a unit of measurement) 7.4 ml was administered to Resident 1 one to two hours before or after tube feeding (method of delivering liquid nutrients, fluids, and medications directly into the stomach via a flexible tube) in accordance with physician's order.2. Failed to ensure Zinc Sulfate (a medication essential for wound healing) Oral Tablet 220 mg via gastrostomy tube (a tube that is surgically inserted to allow feedings to be administered directly to the stomach common for people with swallowing problems) was administered to Resident 1 in accordance with physician's order.3. Failed to ensure Metoprolol Tartrate (a medication used to treat high blood pressure) Oral Tablet 25 mg was administered to Resident 132 with a meal in accordance with physician's order.These deficient practices to administer medications in accordance with the physician's orders and standards of practice placed Resident 1 at risk for reduced therapeutic effectiveness due to impaired absorption and altered medication delivery. This also placed Resident 132 at risk for gastrointestinal (stomach) intolerance.Findings:1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE]. Resident 1's diagnoses included gastrostomy (g-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), iron deficiency anemia (not enough iron in the blood) due to blood loss, and cachexia (severe weight and muscle loss).During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool), dated 2/16/2026, the MDS indicated Resident 1's cognitive skills (ability to think and reason) for daily decision making were severely impaired. The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort) for oral hygiene, dressing and toileting.During a review of Resident 1's Physician Order, dated 2/10/2026, the order indicated to administer Ferrous Sulfate Oral Solution 220 milligrams per five milliters (mg/ml, a unit of measurement) 7.4 ml via g-tube daily, one to two hours before or after tube feeding.During a medication administration observation on 3/10/2026 at 8:20 a.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 prepared Ferrous Sulfate Oral Solution (220 mg/ 5ml) 7.4 ml in a medicine cup. At 8:43 a.m., LVN 3 proceeded to enter Resident 1's room and paused Resident 1's g-tube feeding. LVN 3 verified g-tube placement and administered Resident 1's dose of Ferrous Sulfate Oral Solution (220 mg/ 5ml) 7.4 ml at 8:45 a.m. The g-tube feeding was resumed at 8:55 a.m.During a concurrent interview and record review on 3/10/2026 at 9:00 a.m. with LVN 3, Resident 1's Physician Order, dated 2/10/2026, and Medication Administration Record (MAR), dated 3/2026, were reviewed. The Physician Order and MAR indicated to administer Ferrous Sulfate Oral Solution (220 mg/5ml) 7.4 ml via g-tube daily and to administer one to two hours before or after tube feeding. LVN 3 stated she did not administer the medication as ordered because the feeding was paused shortly before and resumed shortly after administration of the ferrous sulfate (iron). LVN 3 stated the feeding should have been held one to two hours prior to administration to allow for proper absorption of the medication. LVN 3 stated this placed Resident 1 at risk for gastric side effects and reduced therapeutic effectiveness due to impaired iron absorption.2. During a review of Resident 1's MAR, dated 3/10/2026, the MAR indicated to administer Zinc Sulfate Oral Tablet 220 mg via g-tube one time a day.During a medication administration observation on 3/10/2026 at 8:20 a.m. with LVN 3, LVN 3 prepared Zinc Sulfate Oral Capsule 220 mg. LVN 3 opened the capsule, poured the contents into a medication cup, and administered the medication via g-tube to Resident 1.During a concurrent interview and record review on 3/10/2026 at 9:00 a.m. with LVN 3, Resident 1's Medication Administration Record (MAR), dated 3/2026, was reviewed. The MAR indicated to administer Zinc Sulfate Oral Tablet 220 mg via g-tube. LVN 3 stated the medication administered was a capsule formulation, which was not in accordance with the physician's order. LVN 3 stated the pharmacy supplied capsules rather than tablets. LVN 3 stated this placed Resident 1 at risk for altered medication absorption.3. During a review of Resident 132's admission Record, the admission Record indicated Resident 132 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 132's diagnoses included cerebral infarction (stroke, loss of blood flow to a part of the brain), heart failure (a heart disorder which causes the heart to not pump the blood efficiently), and hypertension (high blood pressure).During a review of Resident 132's MDS, dated [DATE], the MDS indicated Resident 132's cognitive skills for daily decision making were intact. The MDS indicated Resident 132 required setup assistance for oral hygiene, dressing and toileting.During a review of Resident 132's Physician Order, dated 12/26/2025, the order indicated to administer Metoprolol Tartrate Oral Tablet 25 mg one tablet two times a day with meals.During a medication administration observation on 3/10/2026 at 10:07 a.m. with LVN 1, LVN 1 prepared and administered Metoprolol Tartrate Oral Tablet 25mg to Resident 132. There was no meal tray observed. LVN 1 stated at approximately 7:30 a.m., Resident 132 ate her breakfast meal tray.During a concurrent interview and record review on 3/10/2026 at 10:11 a.m. with LVN 1, Resident 132's Physician Order, dated 12/26/2025, and MAR, dated 3/2026, were reviewed. The Physician Order and MAR indicated to administer Metoprolol Tartrate Oral Tablet 25 mg with meals. LVN 1 stated she did not administer the medication to Resident 132 as ordered, which placed Resident 132 at risk for unwanted gastric (stomach) side effects from the medication.During a review of the facility's Policy and Procedure (P&P) titled, Administering Medications, revised 1/2026, the P&P indicated the following:1. Medications should be administered in a safe and timely manner, as prescribed.2. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.3. The medications must be administered in accordance with the orders, including any required time frame.

Based on observation, interview, and record review, the facility failed to ensure safe medication administration practices were observed when the following occurred for three of five sampled residents (Resident 1, Resident 66, and Resident 132):1. Failed to ensure Ferrous Sulfate (used to treat or prevent anemia [a lower-than-normal number of red blood cells]) Oral Solution 220 milligrams per five milliters (mg/ml, a unit of measurement) 7.4 ml was administered to Resident 1 one to two hours before or after tube feeding (method of delivering liquid nutrients, fluids, and medications directly into the stomach via a flexible tube) in accordance with physician's order for Resident 1.2. Failed to ensure Zinc Sulfate (a medication essential for wound healing) Oral Tablet 220 mg via g -tube was administered to Resident 1 in accordance with physician's order for Resident 1.3. Failed to ensure Metoprolol Tartrate (a medication used to treat high blood pressure) Oral Tablet 25 mg was administered to Resident 132 with a meal in accordance with physician's order for Resident 132.4. Failed to ensure an accurate narcotic (prescription medication that, because of its potential to cause addiction, misuse, or physical/mental dependence, is tightly regulated) count on the Medication Count Sheet for Resident 66.These deficient practices to administer medications in accordance with the physician's orders and standards of practice placed Resident 1 and Resident 132 at risk for reduced therapeutic effectiveness due to impaired absorption and altered medication delivery. The deficient practice of not ensuring an accurate narcotic count placed Resident 66 at risk for unaccounted controlled substances (prescription medication that, because of its potential to cause addiction, misuse, or physical/mental dependence, is tightly regulated) and potential diversion (when a medication is taken for use by someone other than whom it is prescribed or for an indication other than what is prescribed).Findings:1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE]. Resident 1's diagnoses included gastrostomy (g-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), iron deficiency anemia (not enough iron in the blood) due to blood loss, and cachexia (severe weight and muscle loss).During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool), dated 2/16/2026, the MDS indicated Resident 1's cognitive skills (ability to think and reason) for daily decision making were severely impaired. The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort) for oral hygiene, dressing and toileting.During a review of Resident 1's Physician Order, dated 2/10/2026, the order indicated to administer Ferrous Sulfate Oral Solution 220 milligrams per five milliters (mg/ml, a unit of measurement) 7.4 ml via g-tube daily, one to two hours before or after tube feeding.During a medication administration observation on 3/10/2026 at 8:20 a.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 prepared Ferrous Sulfate Oral Solution (220 mg/ 5ml) 7.4 ml in a medicine cup. At 8:43 a.m., LVN 3 proceeded to enter Resident 1's room and paused Resident 1's g-tube feeding. LVN 3 verified g-tube placement and administered Resident 1's dose of Ferrous Sulfate Oral Solution (220 mg/ 5ml) 7.4 ml at 8:45 a.m. The g-tube feeding was resumed at 8:55 a.m.During a concurrent interview and record review on 3/10/2026 at 9:00 a.m. with LVN 3, Resident 1's Physician Order, dated 2/10/2026, and Medication Administration Record (MAR), dated 3/2026, were reviewed. The Physician Order and MAR indicated to administer Ferrous Sulfate Oral Solution (220 mg/5ml) 7.4 ml via g-tube daily, one to two hours before or after tube feeding. LVN 3 stated she did not administer the medication as ordered because the feeding was paused shortly before and resumed shortly after administration of the ferrous sulfate (iron). LVN 3 stated the feeding should have been held one to two hours prior to administration to allow for proper absorption of the medication. LVN 3 stated this placed Resident 1 at risk for gastric side effects and reduced therapeutic effectiveness due to impaired iron absorption.2. During a review of Resident 1's MAR, dated 3/10/2026, the MAR indicated to administer Zinc Sulfate Oral Tablet 220 mg via g-tube one time a day.During a medication administration observation on 3/10/2026 at 8:20 a.m. with LVN 3, LVN 3 prepared Zinc Sulfate Oral Capsule 220 mg. LVN 3 opened the capsule, poured the contents into a medication cup, and administered the medication via g-tube to Resident 1.During a concurrent interview and record review on 3/10/2026 at 9:00 a.m. with LVN 3, Resident 1's Medication Administration Record (MAR), dated 3/2026, was reviewed. The MAR indicated to administer Zinc Sulfate Oral Tablet 220 mg via g-tube. LVN 3 stated the medication administered was a capsule formulation, which was not in accordance with the physician's order. LVN 3 stated the pharmacy supplied capsules rather than tablets. LVN 3 stated this placed Resident 1 at risk for altered medication absorption.3. During a review of Resident 132's admission Record, the admission Record indicated Resident 132 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 132's diagnoses included cerebral infarction (stroke, loss of blood flow to a part of the brain), heart failure (a heart disorder which causes the heart to not pump the blood efficiently), and hypertension (high blood pressure).During a review of Resident 132's MDS, dated [DATE], the MDS indicated Resident 132's cognitive skills for daily decision making were intact. The MDS indicated Resident 132 required setup assistance for oral hygiene, dressing and toileting.During a review of Resident 132's Physician Order, dated 12/26/2025, the order indicated to administer Metoprolol Tartrate Oral Tablet 25 mg one tablet two times a day with meals.During a medication administration observation on 3/10/2026 at 10:07 a.m. with LVN 1, LVN 1 prepared and administered Metoprolol Tartrate Oral Tablet 25mg to Resident 132. There was no meal tray observed. LVN 1 stated at approximately 7:30 a.m., Resident 132 ate her breakfast meal tray.During a concurrent interview and record review on 3/10/2026 at 10:11 a.m. with LVN 1, Resident 132's Physician Order, dated 12/26/2025, and MAR, dated 3/2026, were reviewed. The Physician Order and MAR indicated to administer Metoprolol Tartrate Oral Tablet 25 mg with meals. LVN 1 stated she did not administer the medication to Resident 132 as ordered, which placed Resident 132 at risk for unwanted gastric (stomach) side effects from the medication.4. During a review of Resident 66's admission Record, the admission Record indicated Resident 66 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 66's diagnoses included cerebral infarction, dysphagia, and diabetes (poor blood sugar control).During a review of Resident 66's MDS, dated [DATE], the MDS indicated Resident 66's cognitive skills for daily decision making were moderately intact. The MDS indicated Resident 66 required maximal assistance for showering, dressing and toileting.During a concurrent observation, interview, and record review on 3/11/2026 at 10:40 a.m. with the Assistant Director of Nursing (ADON), Resident 66's Hydrocodone- Acetaminophen (pain medication)10-325 mg bubble pack (packaging for medications) was observed, and Resident 66's Medication Count Sheet , dated 3/2026, was reviewed. Resident 66's Hydrocodone- Acetaminophen 10-325 mg bubble pack had 19 tablets remaining. The Medication Count Sheet indicated there were 20 tablets remaining. The ADON stated the Medication Count Sheet was inaccurate and stated it was important to ensure controlled medications (prescription medication that, because of its potential to cause addiction, misuse, or physical/mental dependence, is tightly regulated) were accurately accounted for to prevent discrepancies and potential diversion (when a medication is taken for use by someone other than whom it is prescribed or for an indication other than what is prescribed).During an interview on 3/11/2026 at 10:50 a.m. with LVN 5, LVN 5 the normal process for controlled medication administration was to prepare the medication and document on the Medication Count Sheet. LVN 5 stated he administered Resident 66's dose of Hydrocodone- Acetaminophen 10-325 mg but forgot to document it in the Medication Count Sheet, resulting in an inaccurate count. LVN 5 stated that this placed Resident 66 at risk for unaccounted controlled substances.During a review of the facility's Policy and Procedure (P&P) titled, Administering Medications, revised 1/2026, the P&P indicated the following:1. Medications should be administered in a safe and timely manner, as prescribed.2. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.3. The medications must be administered in accordance with the orders, including any required time frame.During a review of the facility's Policy and Procedure (P&P) titled, Controlled Substances, revised 1/2026, the P&P indicated the resident controlled substance record must contain the name of the resident, name and strength of the medication, number on hand, time of administration, method of administration and signature of nurse administering medication.

Based on observation, interview, and record review, the facility failed to provide feeding assistance during breakfast for one of seven sampled residents (Resident 31).This deficient practice had the potential to negatively affect the residents' quality of life, and feeling of self-worth.Findings:During a review of Resident 31's admission Record, the admission Record indicated Resident 31 was admitted to the facility on [DATE]. Resident 31's diagnoses included diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control), blindness glaucoma ( an eye disease that damages the eye and can slowly cause blindness), low vision to the right eye, blindness to the left eye, hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on the side of the body, like one arm and one leg not working as well) affecting the left dominant side.During a review of Resident 31's History and Physical (H&P), dated 10/20/2025, the H&P indicated Resident 31 did not have the capacity to understand and make decisions.During a review of Resident 31's Minimum Data Set (MDS- a resident assessment tool), dated 1/16/2026, the MDS indicated Resident 31's cognitive skills (ability to think and reason) for daily decision making were moderately impaired (having some trouble doing things). The MDS indicated Resident 31 required set-up assistance for oral, personal hygiene (keeping your body clean and healthy, like brushing teeth and bathing), and upper body dressing. During an observation on 3/10/2026 at 7:51 a.m., in Resident 31's room, Resident 31 was observed alone, seated upright at the edge of the bed. A breakfast tray was observed. Resident 31 was eating with his hands. Oatmeal, eggs, and juice were observed on Resident 31's clothing, lap, and bed linens. During an interview on 3/10/2026 at 9:20 a.m., with CNA 1, CNA 1 stated, morning shift was understaffed (when there are not enough workers) they can only pass breakfast trays and cannot help feeder (a person who needed help eating) residents as scheduled.During an interview on 3/11/2026 at 12:30 p.m., with the Director of Staff Development (DSD), the DSD stated, adequate (enough workers to do the job) staffing and assignments are important to ensure residents receive timely feeding assistance, prevent neglect (not taking care of someone) and delays (taking longer) in care.During an interview on 3/12/2026 at 11:48 a.m., with the Director of Nursing (DON), the DON stated adequate staffing ensured residents' needs were met, care provided as planned, and residents were not left unattended.During a review of the facility's policy and procedure (P&P), titled Scheduling Nursing Assignment, revised 1/2026, the P&P indicated the facility ensures competent nursing staff are scheduled and assigned to meet resident needs.

Based on observation, interview, and record review, the facility failed to ensure a dialysis (treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) emergency kit (e-kit, a kit used for the management of emergency bleeding on venous access [catheter or device is inserted into a vein to deliver medications or fluids] was kept at the bedside for one of three sampled residents (Resident 142).This deficient practice placed Resident 142 at risk for uncontrolled bleeding and serious harm.Findings:During a review of Resident 142's admission Record, the admission Record indicated Resident 142 was initially admitted to the facility on [DATE]. Resident 142's diagnoses included dependence on dialysis, end stage renal disease (irreversible kidney failure), and muscle weakness.During a review of Resident 142's Minimum Data Set ([MDS], a resident assessment tool), dated, 2/15/2026, the MDS indicated Resident 142's cognitive skills (ability to think and reason) for daily decision making was intact. The MDS indicated Resident 142 required substantial assistance (helper does more than half the effort) for toileting, showering, and lower body dressing.During a review of Resident 142's History and Physical (H&P), dated 2/14/2026, the H&P indicated Resident 142 had the capacity to understand and make decisions.During a review of Resident 142's care plan, titled, Emergency Bleeding, initiated 2/12/2026, the care plan indicated to ensure an e-kit was placed at the bedside for management of emergency bleeding to the venous access site. The care plan indicated to include gauze dressing, wrap bandage, and tape.During an observation on 3/9/2026 at 9:57 a.m., in Resident 142's room, there was no dialysis e-kit observed at the bedside.During an interview on 3/10/2026 at 3:00 p.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 stated it was important to have the e-kit at the bedside to ensure bleeding was managed in the event of an emergency. LVN 4 stated that if there was no dialysis e-kit at the bedside, there was a potential Resident 142 could suffer from extreme blood loss.During a review of the facility's Policy and Procedure (P&P) titled, End- Stage Renal Disease, Care of a Resident with, revised 1/2026, the P&P indicated the facility was to provide education and training to ensure the dialysis e-kit was available at the nurses' station or at bedside.

Based on observation, interview, and record review, the facility failed to maintain resident rooms in good repair and ensure a functioning television was provided for two of 12 sampled residents (Resident 64 and Resident 76).These deficient practices had the potential to negatively impact Residents 64 and 76's well-being and contributed to an environment that did not promote comfort and homelike atmosphere. Findings: a. During a review of Resident 64's admission Record, the admission Record indicated Resident 64 was admitted to the facility on [DATE]. Resident 64's diagnoses included hypertension (HTN- high blood pressure), dementia (a progressive state of decline in mental abilities), epilepsy (a chronic brain disorder characterized by recurring, unprovoked movements caused by abnormal electrical activity), dysphagia (difficulty swallowing) and splenomegaly (an enlarged spleen, an organ in the upper left abdomen that filters blood and supports the immune system). During a review of Resident 64's History and Physical (H&P), dated 3/4/2026, the H&P indicated Resident 64 had fluctuating capacity to understand and make decisions. During a review of Resident 64's Minimum Data Set (MDS, a resident assessment tool), dated 12/28/2026 the MDS indicated Resident 64's cognitive skills (ability to think and reason) for daily decision making were severely impaired. The MDS indicated Resident 64 was dependent on staff for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During an observation on 3/9/2026 at 10:18 a.m., in Resident 64's room, observed a vertical indent with chipped paint and exposed underlying material, measuring approximately nine inches in length and four inches in width on the wall directly above and adjacent to the right side of Resident 64's bed. Resident 64's bed rail was touching the damaged area on the wall. During a concurrent observation and interview on 3/10/2025 at 3:46 p.m., in Resident 64's room, with the Director of Nursing (DON), Resident 64's bed and wall were observed. The DON stated that resident care areas should be maintained in good repair and free from damaged surfaces to ensure a clean, sanitary, and safe environment. The DON stated the bed placed against the wall potentially caused the wall damage. The DON stated that the wall damage should have been reported to the maintenance department and repaired immediately. The DON stated that the surfaces with chipped paint or exposed material could not be properly cleaned and disinfected, which may increase the risk of infection and did not meet facility standards for maintenance and infection control. During a concurrent observation and interview on 3/11/2026 at 8:30 a.m., with the Maintenance Supervisor (MS), the MS stated that walls should be promptly repaired when scrapes or holes were present to ensure proper maintenance of the environment. The MS stated resident rooms were expected to always maintain a home-like environment. The MS stated the wall scraping and damage were consistent with the bed being positioned too close to the wall and being moved up and down during care activities, such as cleaning or assisting Resident 64. The MS stated the wall damage would have been prevented if the bed had been positioned at an appropriate distance from the wall. The MS stated nursing staff are responsible for reporting repair needs to the maintenance department when issues related to room integrity are identified. b. During a review of Resident 76's admission Record, the admission Record indicated Resident 76 was admitted to the facility on [DATE]. Resident 76's diagnoses included HTN, dysphagia, and muscle weakness. During a review of Resident 76's H&P dated 2/15/2026, the H&P indicated Resident 76 had the capacity to understand and make decisions. During a review of Resident 76's MDS, dated [DATE], the MDS indicated Resident 76's cognition was intact. The MDS indicated Resident 76 required maximum (helper does more than half the effort) assistance form staff for ADLs. During a concurrent observation and interview on 3/9/2026 at 12:48 p.m., with Resident 76, at Resident 76's bedside, Resident 76 was observed sitting on the bed looking at the television screen. Resident 76's television was nonfunctioning. Resident 76 stated his television had not been working for approximately two weeks. Resident 76 stated he informed an unidentified staff but no action was taken to repair or replace the television. Resident 76 stated he felt pissed off because he was not able to watch television in his room. During a concurrent observation and interview on 3/10/2026 at 1:30 p.m., with the DON, in Resident 76's room, Resident 76's television was nonfunctioning. The DON stated Resident 76's television should be maintained in working condition and issues reported by the residents should be addressed promptly. The DON stated allowing Resident 76's television to remain non-functional did not promote a comfortable and homelike environment. During a review of the facility's policy and procedures (P&P) titled Quality of Life – Homelike Environment. revised 1/2026, the P&P indicated Residents are provided with a safe, clean, comfortable and homelike environment. The facility staff and management shall minimize, to the extent possible, the characteristics of the facility that reflects homelike setting. These characteristics include: clen, sanitary and orderly environment. During a review of the P&P titled, Bed Safety revised 1/2026, the P&P indicated Our facility shall strive to provide a safe sleeping environment for the resident. During a review of the P&P titled, Maintenance Service revised 1/2026, the P&P indicated Maintenance services shall be provided to all areas of the building, grounds and equipment. The maintenance department is responsible for maintaining the buildings, grounds and equipment in a safe and operable manner at all times. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. Maintaining the building in good repair and free from hazards.

Based on observation, interview, and record review, the facility failed to ensure intravenous (IV, administered directly into the blood stream) tubing (the tubing that allows medication to flow into the resident's blood stream) was labeled with the date and time for one of three sampled residents (Resident 87).This deficient practice had the potential to result in a bloodstream infection for Resident 87.Findings:During a review of Resident 87's admission Record, the admission Record indicated Resident 87 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 87's diagnoses included muscle weakness, dementia (a progressive state of decline in mental abilities), and hypertension (high blood pressure).During a review of Resident 87's Minimum Data Set ([MDS], a resident assessment tool), dated 1/28/2026, the MDS indicated Resident 87's cognitive skills (ability to think and reason) for daily decision making were moderately impaired. The MDS indicated Resident 87 required set-up assistance for oral hygiene, toileting, and upper body dressing.During a review of Resident 87's Physician Orders, dated 3/8/2026, the orders indicated to administer ceftriaxone (an antibiotic) one gram IV daily. Change the IV tubing every 24 hours.During an observation on 3/9/2026 at 10:10 a.m., in Resident 87's room, Resident 87 was observed in bed. Ceftriaxone was infusing. The IV tubing was unlabeled.During a concurrent interview and record review on 3/11/2026 at 12:03 p.m. with Registered Nurse (RN) 1, a photograph of Resident 87's IV tubing, dated 3/9/2026 and timed at 10:10 a.m., was reviewed. The photo revealed Resident 87's IV tubing was unlabeled. RN 1 stated that it was important for the licensed RN to label the IV tubing with the date and time to verify when the IV tubing was last changed. RN 1 stated that if Resident 87's IV tubing was not labeled, there was a potential risk for blood stream infection.During a review of the facility's policy and procedure (P&P) titled, Administration Set/Tubing Changes, revised 1/2026, the P&P indicated the facility was to ensure all tubing was labeled with the start and change date and time. The P&P indicated any tubing that was observed not to have a label must be changed and then labeled accordingly.

Based on interview and record review, the facility failed to conduct 72-hour monitoring for two of two sampled residents (Resident 61 and Resident 7), after an allegation of sexual abuse.This deficient practice had the potential to result in a decline in Resident 61's psychosocial well being and potential for Resident 7's sexually inappropriate behavior being undetected.Cross Reference F609 and F842.Findings:1. During a review of Resident 61's admission Record, the admission Record indicated Resident 61 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 61's diagnoses included type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic kidney disease (kidney damage that occurs over time), hypertension (high blood pressure).During a review of Resident 61's Minimum Data Set (MDS- a resident assessment tool), dated 1/15/2026, the MDS indicated Resident 61's cognition (process of thinking) was intact. The MDS indicated Resident 61 was independent with eating, oral hygiene, and toileting.During a review of Resident 61's History and Physical (H&P), dated 9/16/2025, the H&P indicated Resident 61 had the capacity to understand and make decisions.During an interview on 3/10/2026 at 12:50 p.m., with Resident 61, Resident 61 stated, on 1/29/2026, while he was sleeping, Resident 7 tried to touch his genitals. Resident 61 stated he was very upset and told Licensed Vocational Nurse (LVN) 3. Resident 61 stated after the incident, Resident 7 was sent out of the facility and was placed in a different room upon his return.During a concurrent interview and record review on 3/10/2026 at 12:32 p.m., with Licensed Vocational Nurse (LVN) 3, Resident 61's Progress Notes, dated 1/29/2026 through 2/3/2026, were reviewed. The Progress Notes did not indicate Resident 61 was monitored for psychosocial distress following the allegation of sexual abuse from Resident 7 on 1/29/2026. LVN 3 stated Resident 61 should have been monitored for at least 72-hours. LVN 3 stated monitoring Resident 61's psychosocial well-being was important to provide additional resources if Resident 61 felt emotional or psychosocial distress. During an interview on 3/11/2026 at 11:24 a.m., with the Social Services Director (SSD), the SSD stated she was not aware of the details of the incident between Residents 61 and 7 and did not know Resident 61 was the alleged victim. The SSDD stated 72-hour monitoring for Resident 61's psychosocial well-being should have been conducted from the nursing and social services department. The SSD stated throughout the monitoring, psychosocial support would have been given to Resident 61. The SSD stated without the appropriate psychosocial monitoring, Resident 61 could experience trauma from the incident which could be unnoticed and services would not be provided.During a review of the facility's policy and procedure (P&P) titled, Abuse and Neglect, revised 1/2026, the P&P indicated, The staff and physician will monitor individuals who have been abused at least until their medical condition, mood, and function have stabilized, and periodically thereafter.2. During a review of Resident 7's admission Record, the admission Record indicated Resident 7 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 7's diagnoses included dementia (a progressive state of decline in mental abilities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (a mental health condition characterized by excessive fear or worry that interferes with daily life).During a review of Resident 7's MDS, dated [DATE], the MDS indicated Resident 7's cognition was severely impaired. The MDS indicated Resident 7 required setup or clean-up assistance with oral hygiene, upper body dressing, and personal hygiene.During a review of Resident 7's H&P, dated 2/7/2026, the H&P indicated Resident 7 had fluctuating capacity to understand and make decisions.During a review of Resident 7's Change in Condition (COC), dated 1/29/2026, the COC indicated, on 1/29/2026, Resident 7 was transferred to the general acute care hospital (GACH) for behavior evaluation. During a concurrent interview and record review on 3/10/2026 at 12:33 p.m., with LVN 3, Resident 7's Progress Notes, dated 2/6/2026 through 2/9/2026, were reviewed. The Progress Notes indicated, on 2/6/2026, Resident 7 was readmitted to the facility with a medical diagnosis of bizarre behavior. The Progress Notes indicated Resident 7 was monitored for 72 hours upon readmission to the facility but did not indicate monitoring for sexually inappropriate behavior. LVN 3 stated Resident 7 was sent to the GACH for evaluation for sexually inappropriate behavior towards another resident. LVN 3 stated Resident 7 was not monitored for sexually inappropriate behaviors when he was readmitted to the facility. LVN 3 stated monitoring Resident 7 for sexually inappropriate behavior during his readmission was important to identify recurrent episodes and intervene immediately. During an interview on 3/12/2026 at 9:48 a.m., with the Director of Nursing (DON), the DON stated when Resident 7 was readmitted to the facility, the licensed nurses were responsible for monitoring Resident 7 for inappropriate sexual behavior. The DON stated this monitoring was necessary to determine whether Resident 7's treatment at the GACH was effective or if additional referrals were needed. The DON stated Resident 7 was at risk of undetected inappropriate sexual behavior and delay in treatment.During a review of the facility's P&P titled, Abuse and Neglect, revised 1/2026, the P&P indicated, The facility management and staff will institute measures to address the needs of residents/patients and minimize the possibility of abuse and neglect.

Based on interview and record review, the facility failed to revise two of three sampled residents' (Resident 6 and Resident 104) care plans after testing positive for influenza A (a contagious viral infection that affects the respiratory system).This deficient practice had the potential to negatively affect Residents 6 and 104's physical well-being and had the potential to delay the delivery of necessary care and services.Findings:a. During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 6's diagnoses included encephalopathy (damage or brain disease that alters the brain's function), dementia (a progressive state of decline in mental abilities), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).During a review of Resident 6's Minimum Data Set (MDS- a resident assessment tool), dated 1/5/2026, the MDS indicated Resident 6's cognition (process of thinking) was intact. The MDS indicated Resident 6 was dependent on staff's assistance with eating, oral hygiene, toileting, bathing, dressing, and personal hygiene.During a review of Resident 6's History and Physical (H&P), dated 1/2/2026, the H&P indicated Resident 6 did not have the capacity to understand and make decisions.During a review of Resident 6's Change in Condition (COC), dated 3/5/2026, the COC indicated Resident 6 had a nonproductive cough (cough that does not produce mucus) and audible phlegm (mucus). The COC indicated order to test for influenza (a contagious viral infection that affects the respiratory system).During a review of Resident 6's Lab Results Report, dated 3/6/2026, the Lab Results Report indicated Resident 6 was positive for influenza A.During a review of Resident 6's COC, dated 3/7/2026, the COC indicated Resident 6 tested positive for influenza A. The COC indicated order to initiate isolation precaution (procedure to separate sick people from healthy and to prevent the spread of germs) per facility protocol and to start Tamiflu (medication to treat influenza) 75 milligrams (mg, a unit of measurement), twice a day for five days.During a concurrent interview and record review, on 3/11/2026 at 10:17 a.m., with the Infection Preventionist Nurse (IPN), Resident 6's Care Plan titled, Nonproductive Cough and Audible Phlegm, dated 3/5/2026, was reviewed. The Care Plans interventions indicated to test for influenza, encourage deep breathing and coughing exercise, and monitor vital signs. The IPN stated Resident 6's Care Plan was not revised when Resident 6 tested positive for influenza A. b. During a review of Resident 104's admission Record, the admission Record indicated Resident 104 was admitted to the facility on [DATE] with diagnoses that included epilepsy (chronic brain disorder characterized by recurring seizures [sudden burst of uncontrolled electrical activity in the brain that disrupts normal function]), end stage renal disease (irreversible kidney failure), and hypertension (high blood pressure).During a review of Resident 104's MDS, dat3ed 2/18/2026, the MDS indicated Resident 104's cognition was intact. The MDS indicated Resident 104 required moderate assistance (helper does less than half the effort) with oral hygiene, upper body dressing, and personal hygiene.During a review of Resident 104's H&P, dated 2/16/2026, the H&P indicated Resident 104 had the capacity to understand and make decisions.During a review of Resident 104's COC, dated 3/4/2026, the COC indicated Resident 104 complained of cough, sore throat, and body aches and had two episodes of emesis (vomit). The COC indicated order to test for influenza.During a review of Resident 104's Lab Results Report, dated 3/7/2026, the Lab Results Report indicated Resident 104 tested positive for influenza A.During a review of Resident 104's COC, dated 3/7/2026, the COC indicated Resident 104 tested positive for influenza A. The COC indicated order to initiate droplet isolation precautions (infection control measures used to prevent the spread of pathogens transmitted through close respiratory contact) and start Tamiflu 75mg twice a day for five days. During a concurrent interview and record review, on 3/11/2026 at 10:17 a.m., with the IPN, Resident 104's Care Plan titled, Flu-like Symptoms and Two Episodes of Emesis, dated 3/4/2026, was reviewed. The Care Plan's interventions indicated to monitor vital signs and assess for worsening symptoms. The IPN stated Resident 6's Care Plan was not revised when Resident 6 tested positive for influenza A.During an interview on 3/11/2026 at 10:19 a.m., with the IPN, the IPN stated Residents 6 and 104's Care Plans were not revised with their positive influenza A diagnosis and additional interventions. The IPN stated revising the care plan was necessary to know how to treat and monitor Residents 6 and 104. The IPN stated Residents 6 and 104 were on Tamiflu to treat influenza A and there should have been interventions to monitor for adverse reactions. The IPN stated without the necessary revisions, Residents 6 and 104 were at risk of treatment and other interventions not being carried out.During an interview on 3/12/2026 at 9:36 a.m., with the Director of Nursing (DON), the DON stated after Residents 6 and 104 tested positive for influenza A, their care plans should have been revised. The DON stated interventions should have included the treatment of Tamiflu and additional monitoring. The DON stated without a revised care plan, Residents 6 and 104 were at risk of not receiving the appropriate care.During a review of the facility's Policy and Procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 1/2026, the P&P indicated, Assessments of residents are ongoing and care plans are revised as information about the residents' conditions change.

Based on observation, interview, and record review, the facility failed to develop a comprehensive, person-centered care plan for four of eight sampled residents (Resident 61, Resident 93, Resident 41, and Resident 14) for the following:1. Resident 61 was allegedly touched sexually and inappropriately by another resident.2. Resident 93, who had out-on pass privileges, and a known history of alcohol use and relapse (resumption of drinking alcohol after a period of abstinence, often involving a return to previous levels of heavy consumption) behaviors.3. Resident 41's use of Depakote (an anticonvulsant medication, used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] and other behavioral conditions) and Seroquel (an antipsychotic medication [a medication that affects the mind, emotions, and behavior]). 4. Resident 14's use of dentures (removable, custom-made appliances to replace missing teeth and gum tissue). These deficient practices had the potential to negatively affect Residents 61, 93, 41, and 14's physical, mental, and psychosocial well-being and had the potential to delay in the delivery of necessary care and services.Cross Reference F684 and F842. Findings:a. During a review of Resident 61's admission Record, the admission Record indicated Resident 61 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 61's diagnoses included type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic kidney disease (kidney damage that occurs over time), and hypertension (high blood pressure).During a review of Resident 61's Minimum Data Set (MDS- a resident assessment tool), dated 1/15/2026, the MDS indicated Resident 61's cognition (process of thinking) was intact. The MDS indicated Resident 61 was independent with eating, oral hygiene, and toileting.During a review of Resident 61's History and Physical (H&P), dated 9/16/2025, the H&P indicated Resident 61 had the capacity to understand and make decisions.During an interview on 3/10/2026 at 12:20 p.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated on 1/29/2026, Resident 61 informed her that his roommate tried to touch his genitals. LVN 3 stated Resident 61 was very upset.During an interview on 3/10/2026 at 12:50 p.m., with Resident 61, Resident 61 stated, on 1/29/2026, his roommate tried to touch his genitals while he was sleeping. During a concurrent interview and record review on 3/12/2026 at 7:54 a.m., with LVN 3, Resident 61's Care Plans, active and resolved from 1/29/2026 through 3/12/2026, were reviewed. The care plans did not indicate a care plan was developed to address Resident 61's allegation of being inappropriately touched by his roommate. LVN 3 stated after the incident between Resident 61 and his roommate, on 1/29/2026, a care plan should have been developed. LVN 3 stated care plans were used to guide the nurses on Resident 61's plan of care. LVN 3 stated developing a care plan was important to ensure necessary interventions were carried out such as providing emotional support and psychosocial monitoring.During an interview on 3/12/2026 at 10:02 a.m., with the Director of Nursing (DON), the DON stated care plans should always be developed after a change in condition, specifically after an abuse allegation was made. The DON stated Resident 61 did not have a care plan to address his allegation against his roommate, who allegedly touched Resident 61 inappropriately. The DON stated without a care plan, the nurses may not monitor Resident 61 for psychosocial distress which could result in undetected trauma. b. During a review of Resident 93's admission Record, the admission Record indicated Resident 93 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 93's diagnoses included alcohol abuse, other stimulant abuse, alcoholic cirrhosis (scarring) of the liver, hepatic encephalopathy (serious brain dysfunction caused by liver failure), end stage renal disease (irreversible kidney failure), noncompliance with medical treatment, and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 93's MDS, dated [DATE], the MDS indicated Resident 93's cognitive skills for daily decision making were intact. The MDS indicated Resident 93 required moderate assistance (helper does less than half of the effort) for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 93's H&P dated 1/21/2026, the H&P indicated Resident 93 had the capacity to understand and make decisions. During a record review of Resident 93's Change of Condition (COC) Note, dated 7/10/2025, the COC note indicated on 7/10/2025, Resident 93 returned from an out-on-pass visit intoxicated, as evidenced by smell, slurred speech, drowsiness, impaired coordination, and two episodes of vomiting. During a record review of Resident 93's Nursing Progress Note, dated 2/23/2026, the note indicated on 2/23/2026, Resident 93 returned from an out on pass visit with agitation and bleeding to the right side of his lip. The note indicated Resident 93 was holding a brown paper bag containing items and he refused inspection per facility protocol. During a concurrent record review and interview on 3/12/2026 at 10:31 a.m. with the Assistant Director of Nursing (ADON), all of Resident 93's care plans were reviewed. The care plans did not indicate interventions including monitoring, assessing for alcohol use, and re-educating Resident 93 on the risks of alcohol consumption were implemented. The ADON stated Resident 93 had a known history of alcohol use while out on pass. The DON stated there were no care plan interventions addressing Resident 93's continued out-on-pass privileges with known history of alcohol use. The ADON stated proper care plan interventions should have included monitoring behaviors, assessing for alcohol use, and re-educating Resident 93 on the risks of alcohol consumption. The ADON stated the lack of care plan interventions placed Resident 93 at risk for continued alcohol use, adverse health outcomes, and potential drug to drug interactions. c. During a review of Resident 41's admission Record, the admission Record indicated Resident 41 was admitted to the facility on [DATE]. Resident 41's diagnoses included dementia (a progressive state of decline in mental abilities), metabolic encephalopathy (a change in how the brain works due to an underlying condition ), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), hypertension (HTN- high blood pressure), and hyperlipidemia (high cholesterol). During a review of Resident 41's H&P, dated 8/14/2025, the H&P indicated Resident 41 had fluctuating capacity to understand and make decisions. During a review of Resident 41's MDS, dated [DATE] the MDS indicated Resident 41's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 41 required supervision or touching assistance from the staff for toileting, showering, and lower body dressing. During a review of Resident 41's physician order dated 9/30/2025, the physician order indicated Resident 41 was to receive Depakote Oral Capsule Delayed Release Sprinkle 125 milligrams ([mg]- metric unit of measurement, used for medication dosage and/or amount). Give 2 capsules by mouth every 12 hours for mood swings. During a review of Resident 41's physician order dated 10/29/2025, the physician order indicated Resident 41 was to receive Seroquel Oral Tablet 50 mg. Give 1 tablet by mouth one time a day for psychosis manifested by angry outburst. During an interview on 3/12/2026 at 2:17 p.m., with the DON, the DON stated that it was the facility's expectation and standard of practice that all active medications be incorporated into the resident's comprehensive care plan. The DON stated that care plans were essential to ensure staff awareness of the medication's purpose, required monitoring parameters, and potential adverse effects, and to promote consistent, individualized care and resident safety. The DON stated that the failure to include the administration of Depakote and Seroquel in Resident 41's care plan did not meet facility standards and should have been completed. d. During a review of Resident 14's admission Record, the admission Record indicated Resident 14 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 14's diagnoses included diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and hypertension (HTN- high blood pressure). During a review of Resident 14's MDS, dated [DATE], the MDS indicated Resident 14's cognitive skills for daily decision making was intact. The MDS indicated Resident 14 required maximum assistance from staff with ADLs. During a concurrent observation and interview on 3/9/2026 at 1:45 p.m., with Resident 14, at Resident 14's bedside, Resident 14's dentures were observed on the top of the bedside table. Resident 14 stated she used her dentures during meals. During a concurrent interview and record review on 3/11/2026 at 8:23 a.m., with the ADON, Resident 14's medical records were reviewed. The medical records did not indicate a care plan related to Resident 14's use of dentures. The ADON stated a care plan should have been developed to address Resident 14's use of dentures, including interventions to ensure safe use of dentures, monitoring of oral health status, and staff awareness of the resident's needs related to dentures care. During an interview on 3/12/2026 at 9:45 a.m., with the DON, the DON stated residents with dentures should have an individualized care plan to ensure the residents' needs were addressed, communicated, and coordinated with staff for continuity of care and services. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person Centered dated 1/2026, the P&P indicated, A comprehensive, person- centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Care plans reflect treatment goals, timetables and objectives in measurable outcomes. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents condition changes.

Based on interview and record review, the facility failed to report an abuse allegation to the State Agency (California Department of Public Health [CDPH]), the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and local law enforcement for two of two sampled residents (Residents 7 and 61), after Resident 7 allegedly touched Resident 61's genitals (external reproductive organ).This deficient practice resulted in a delay of an onsite investigation by CDPH and had the potential to result in abuse to all residents in the facility.Findings:1. During a review of Resident 61's admission Record, the admission Record indicated Resident 61 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 61's diagnoses included type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic kidney disease (kidney damage that occurs over time), hypertension (high blood pressure).During a review of Resident 61's Minimum Data Set (MDS- a resident assessment tool), dated 1/15/2026, the MDS indicated Resident 61's cognition (process of thinking) was intact. The MDS indicated Resident 61 was independent with eating, oral hygiene, and toileting.During a review of Resident 61's History and Physical (H&P), dated 9/16/2025, the H&P indicated Resident 61 had the capacity to understand and make decisions.During an interview on 3/10/2026 at 12:50 p.m., with Resident 61, Resident 61 stated, on 1/29/2026, while he was sleeping, Resident 7 tried to touch his genitals. Resident 61 stated he was very upset and told Licensed Vocational Nurse (LVN) 3. Resident 61 stated after the incident, Resident 7 was sent out of the facility and was placed in a different room upon his return.2. During a review of Resident 7's admission Record, the admission Record indicated Resident 7 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 7's diagnoses included dementia (a progressive state of decline in mental abilities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (a mental health condition characterized by excessive fear or worry that interferes with daily life).During a review of Resident 7's MDS, dated [DATE], the MDS indicated Resident 7's cognition was severely impaired. The MDS indicated Resident 7 required setup or clean-up assistance with oral hygiene, upper body dressing, and personal hygiene.During a review of Resident 7's H&P, dated 2/7/2026, the H&P indicated Resident 7 had fluctuating (changing) capacity to understand and make decisions.During a review of Resident 7's Change in Condition (COC), dated 1/29/2026, the COC indicated, on 1/29/2026, Resident 7 had sexually inappropriate behavior towards Resident 61. The COC indicated an order to send Resident 7 to the general acute care hospital (GACH) for behavior evaluation.During an interview on 3/10/2026 at 12:20 p.m., with LVN 3, LVN 3 stated, on 1/29/2026, Resident 61 informed her that Resident 7 tried to touch his genitals. LVN 3 stated Resident 61 was very upset about the incident. LVN 3 stated after separating Residents 7 and 61 she reported the incident to Registered Nurse (RN) 1 and the Administrator (ADM). LVN 3 stated she reported the incident to the ADM because it is a sensitive situation and could be seen as an allegation of sexual abuse. LVN 3 stated the ADM was the abuse coordinator and all abuse allegations were reported to him.During an interview on 3/12/2026 at 10:18 a.m., with the ADM, the ADM stated he was the abuse coordinator and was responsible for reporting all abuse allegations to CDPH, law enforcement, and Ombudsman. The ADM stated the staff had the ability to report to the three reporting agencies, however, the staff were responsible for notifying him to ensure that not only the allegation was reported but investigated. The ADM stated immediate reporting was necessary to ensure a thorough investigation was carried out by not only him but by CDPH.During a review of the facility's Policy and Procedure (P&P) titled, Abuse Investigation and Reporting, revised 1/2026, the P&P indicated all alleged violations involving abuse, neglect, exploitation, or mistreatment would be reported by the facility's Administrator or designee to the state licensing/certification agency, the local/State ombudsman, and law enforcement officials immediately but no later than two hours.

Based on observation, interview, and record review, the facility failed to post an oxygen in use sign outside the room of one of three sampled residents (Resident 105). This deficient practice increased the risk for injury related to fire hazards.Findings:During a review of Resident 105's admission Record, the admission Record indicated Resident 105 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 105's diagnoses included pleural effusion (buildup of fluid between the thin layers of tissue lining the lungs and the chest cavity) and pneumonia (an infection/inflammation in the lungs). During a review of Resident 105's Minimum Data Set (MDS- a resident assessment tool), dated 2/3/2026, the MDS indicated Resident 105's cognition (process of thinking) was moderately impaired. The MDS indicated Resident 105 was dependent with toileting, bathing, and lower body dressing. The MDS indicated Resident 105 required oxygen therapy (a medical gas used to help with breathing).During a review of Resident 105's History and Physical (H&P), dated 11/6/2025, the H&P indicated Resident 105 had the capacity to understand and make decisions.During a review of Resident 105's Physician Orders, dated 2/25/2026, the Physician Orders indicated to administer oxygen at 2 liters (L, a unit of volume measurement) per minute via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen), as needed for shortness of breath. During an observation on 3/9/2026 at 10:27 a.m. and 3/9/2026 at 2:09 p.m., in Resident 105's room, Resident 105 was observed lying in bed receiving 2L of oxygen via nasal cannula. Resident 105 did not have an oxygen in use sign posted outside of the doorway.During an interview on 3/11/2026 at 11:41 a.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated Resident 105 was on supplemental oxygen to prevent shortness of breath. LVN 3 stated while Resident 105 was on oxygen therapy, an oxygen in use sign had to be posted outside her door. LVN 3 stated the purpose of the sign was to ensure no one lights an open flame inside the room that could ignite and cause a bigger fire. During an interview on 3/12/2026 at 9:26 a.m., with the Director of Nursing (DON), the DON stated having an oxygen in use sign outside of Resident 105's room was necessary to remind those entering Resident 105's room not to bring any open flames. The DON stated any small flame or spark could cause a fire due to the supplemental oxygen entering the room from Resident 105's nasal cannula.During a review of the facility's Policy and Procedure (P&P) titled, Oxygen Administration, revised 1/2026, the P&P indicated to place an Oxygen in Use sign on the outside of the room entrance door.

Based on observation, interview, and record review, the facility failed to maintain a safe and hazard free environment for two of three sampled residents (Resident 1 and Resident 2), when: 1. Licensed Vocational Nurse (LVN) 1 left Resident 1 unattended and unsupervised at Nurse's Station 3, on 2/14/2025. 2. Activity Staff (AS) 3 left Resident 1 at Nurse's Station 3, without verifying there was a charge nurse present to supervise Resident 1, on 2/14/2025. 3. On 2/25/2025, Resident 1 did not have bilateral fall mats (a cushioned floor pad designed to help prevent injury should a person fall) at her bedside, as ordered by the physician. 4. On 2/25/2025, Resident 1 did not have fall risk indicators outside of her room, or on her Geri-chair (a large, padded chair with a wheeled base, designed to assist individuals with limited mobility), in accordance with Resident 1's care plan. 5. A Morse Fall Scale assessment (a clinical assessment tool used to predict a patient's risk of falling) was not conducted following Resident 2's fall on 12/25/2024. 6. On 2/26/2025, Resident 2 did not have fall risk indicators outside of her room, or on her wheelchair, in accordance with Resident 2's care plan. These deficient practices resulted in Resident 1 falling on 2/14/2025 and sustaining a displaced subcapital left femoral neck fracture (a broken bone in the upper part of the left thigh bone, where the broken pieces are significantly displaced from their normal position) requiring surgical intervention in a general acute care hospital (GACH). These deficient practices also placed Resident 1 and Resident 2 at risk for further falls and fall related injuries. Findings: 1. During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was most recently readmitted to the facility on [DATE]. Resident 1's admitting diagnoses, as of 2/18/2025, included generalized muscle weakness, left thigh bone fracture, history of falling, dementia (a progressive state of decline in mental abilities), epilepsy (a chronic brain disorder characterized by recurrent seizures, which are brief episodes of abnormal brain activity that can cause involuntary movements, loss of consciousness, or other symptoms), and osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D). During a review of Resident 1's History and Physical (H&P), dated 1/10/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. The H&P did not indicate diagnoses of osteoporosis or osteopenia (a condition characterized by low bone mineral density, which makes bones weaker and more prone to fractures). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 1/13/2025, the MDS, indicated Resident 1 had memory problems and severely impaired cognition (a significant decline in cognitive abilities that interferes with daily life and independence). The MDS indicated Resident 1 had impairments to her lower extremities (hip, knee, ankle, and foot) on both sides of her body. The MDS indicated Resident 1 was dependent on staff for all activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) and mobility while in and out of bed. The MDS indicated diagnoses of lack of coordination and generalized muscle weakness. During a review of Resident 1's care plan titled At risk for fall, dated 1/10/2025, the care plan indicated staff were to provide frequent visual monitoring of Resident 1 to reduce the risk of falls and/or injury. During a review of Resident 1's Morse Fall Scale Assessment, dated 1/11/2025, the assessment indicated Resident 1 was at high risk for falls due to impaired gait (an abnormal walking pattern), and overestimation (judging something too highly), and/or forgetfulness of her ability to walk safely. During a review of Resident 1's Change of Condition (COC) assessment, dated 2/14/2025 at 3:10 PM, the COC indicated on 2/14/2025 Resident 1 had a witnessed fall, in the hallway. The COC indicated Resident 1 reported a 4 out of 10 pain (0: no pain, 1 to 3: mild pain, 4 to 6: moderate pain, and 7 to 10: severe pain) to her left hip. The COC indicated Resident 1 was administered Tylenol 650 milligrams (mg, a unit of dose measurement) for pain. The COC indicated Resident 1's physician was notified of the fall and the physician ordered for an immediate x-ray (a procedure that uses radiation to create images of the inside of the body) to rule out broken bones. During a review of the facility record titled Investigation Statement, dated 2/14/2025 at 3:10 PM, the record indicated a handwritten statement by Licensed Vocational Nurse (LVN) 1 regarding Resident 1's fall on 2/14/2025. The record indicated on 2/14/2025 (no time specified), Resident 1 was sitting in a wheelchair near the nurse's station. The record indicated LVN 1 was assisting another resident in the hallway when Resident 1 fell . During a review of Resident 1's COC assessment, dated 2/14/2025 at 9:45 PM, the COC indicated the x-ray revealed Resident 1 had an acute (severe and sudden in onset) left thigh bone fracture related to a witnessed fall. The COC indicated Resident got up unassisted and lost her balance. The COC indicated Resident 1 reported an 8 out of 10 pain. The COC indicated staff administered Norco 5/325 mg (a combination medication used to relieve severe pain when other pain medication was insufficient) for pain. The COC indicated Resident 1's physician gave an order for the resident to be a transferred to a GACH for evaluation and treatment of the left thigh bone fracture. During a review of Resident 1's progress note, dated 2/14/2025 at 11:45 PM, the progress note indicated Resident 1 was transferred to the GACH on 2/14/2025 at 11:30 PM. During a review of Resident 1's GACH record titled History and Physical, dated 2/15/2025 (untimed), the record indicated Resident 1 was brought to the GACH after falling onto her left side while trying to walk. The record indicated a plan to admit Resident 1 to the medical-surgical unit (a unit for patients recovering from surgery, preparing for surgery, or managing various medical conditions). During a review of Resident 1's GACH record titled Radiology Report, dated 2/15/2025 at 2:23 AM, the record indicated an x-ray was taken of Resident 1's left hip. The record indicated Resident 1 had a displaced subcapital left femoral neck fracture. During a review of Resident 1's facility progress note, dated 2/15/2025 at 1:42 PM, the progress note indicated Resident 1 was admitted to the GACH and in the process of being referred to, and evaluated by, an orthopedic physician (a physician who treats injuries and diseases involving muscles, bones, joints, ligaments, and tendons) for a possible left hip hemiarthroplasty (surgical replacement of half of the hip joint) related to her fracture. During a review of Resident 1's GACH record titled Discharge Summary Notes, dated 2/17/2025 at 8:07 AM, the record indicated a final diagnosis of acute left femoral neck fracture. The record indicated Resident 1's conservator (a person appointed by a court to manage her care) declined to provide consent for orthopedic surgery (a surgical procedure on the musculoskeletal system), and Resident 1 was to be discharged back to the facility. During a review of Resident 1's facility progress note, dated 2/18/2025 at 11:45 AM, the progress note indicated Resident 1 was readmitted to the facility on [DATE]. During a review of Resident 1's medical record titled Routine Pain Assessment Flowsheet, undated, and Pain Assessment Flowsheet, undated, the records indicated Resident 1 received Norco 5/325 mg for the following pain levels: 1. On 2/20/2025 at 3:00 AM: 7/10 pain to her left lower extremity (leg). 2. On 2/20/2025 at 9:00 AM: 8/10 pain to her left lower extremity. 3. On 2/21/2025 at 5:00 AM: 7/10 pain to her left lower extremity. 4. On 2/21/2025 at 11:30 AM: 7/10 pain to her left lower extremity. 5. On 2/22/2025 at 9:00 AM: 8/10 pain to her left lower extremity. 6. On 2/22/2025 at 2:00 PM: 8/10 pain to her left lower extremity. 7. On 2/24/2025 at 9:00 AM: 8/10 pain to her left lower extremity. 8. On 2/25/2025 at 9:00 AM: 7/10 pain to her left lower extremity. 9. On 2/27/2025 at 9:00 AM: 8/10 pain to her left lower extremity. 10. On 2/27/2025 at 2:30 PM: 7/10 pain to her left lower extremity. During a telephone interview on 2/26/2025 at 9:14 AM, with LVN 1, LVN 1 stated she was Resident 1's Charge Nurse the afternoon of 2/14/2025, and was aware Resident 1 was at risk for falls. LVN 1 stated she was supervising Resident 1 at the nurse's station and there were no other staff present when Resident 1 fell . LVN 1 stated she did not ask any staff member to supervise Resident 1 before leaving the resident unattended at the nurse's station. LVN 1 stated she was down the hall from Resident 1, with her back towards the resident, when she heard Resident 1's wheelchair alarm. LVN 1 stated she turned around and saw Resident 1 standing up and holding onto the armrest of her wheelchair for support. LVN 1 stated she was too far away from Resident 1 to intervene, and she observed Resident 1 fall to the ground onto her left side. LVN 1 stated Resident 1 denied any pain during the shift, prior to the fall, but complained of pain to her left hip after the fall. LVN 1 stated she should not have left Resident 1 unattended and unsupervised at the nurse's station. LVN 1 stated the fall could have been prevented if Resident 1 was not left unsupervised. During a telephone interview on 2/26/2025 at 4:43 PM, with Registered Nurse (RN) 1, RN 1 stated Resident 1's care plan intervention of frequent visual monitoring meant Resident 1 should not be left unattended. RN 1 stated to implement this intervention, Resident 1 should always be within a supervising staff member's line of sight. RN 1 stated leaving a resident who required frequent visual monitoring unattended could result in a fall and injury. During a concurrent interview and record review, on 2/27/2025 at 1:02 PM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled Safety and Supervision of Residents, revised 1/2025, was reviewed. The DON stated the P&P indicated resident supervision was a core component for resident safety. The DON stated LVN 1 should not have left Resident 1 unattended because Resident 1 was known as a high risk for falls. The DON stated LVN 1 should have ensured another staff was supervising Resident 1, before leaving the resident at the nurse's station. 2. During a review of the facility record titled Investigation Statement, dated 2/18/2025, untimed, the record indicated a handwritten statement by Activity Staff (AS) 1 regarding Resident 1's fall on 2/14/2025. The record indicated on 2/14/2025 (time unspecified) Resident 1 was in the dining room requesting to be taken back to her room. The record indicated an unidentified staff wheeled Resident 1 to an unspecified nurse's station. During a concurrent interview and record review, on 2/25/2025 at 1:03 PM, with AS 1, the facility record titled Investigation Statement, dated 2/18/2025 (time unspecified), was reviewed. AS 1 stated the staff member who took Resident 1 to the nurse's station was identified as AS 3. During a telephone interview on 2/25/2025 at 2:11 PM, with AS 3, AS 3 stated in the afternoon, of 2/14/2025, she took Resident 1 from the dining room to Nurse's Station 2 for supervision because the resident was at risk for falls. AS 3 stated she parked Resident 1's wheelchair at the nurse's station and informed an unidentified individual, who was sitting at the nurse's station, that she (AS 3) was leaving Resident 1 there. AS 3 stated she assumed the individual at the nurse's station was a nurse and (she) returned to the dining room. AS 3 stated she could not state the name of the individual who was sitting at the nurse's station, and did not verify the individual was Resident 1's Charge Nurse. During a telephone interview on 2/26/2025 at 9:14 AM, with LVN 1, LVN 1 stated she was Resident 1's Charge Nurse the afternoon of 2/14/2025. LVN 1 stated she did not recall being notified by AS 3 that Resident 1 was at Nurse's Station 3 for supervision. During a concurrent interview and record review, on 2/27/2025 at 1:02 PM, with the DON, the facility's P&P titled Falling Star Program, revised 1/2025, was reviewed. The DON stated the P&P indicated staff were required to inform the Charge Nurse whenever a resident was transferred to a supervised area, including the nurse's station. The DON stated clinical staff (directly related to patient care) and non-clinical staff (not directly providing care or treatment) both had access to and sometimes sat at the nurse's stations. The DON stated it was not safe to assume an individual was a licensed nurse because they were seated at the nurse's station. The DON stated AS 3 should have verified Resident 1's Charge Nurse was aware Resident 1 was being left at the nurse's station. The DON stated this would ensure Resident 1 received adequate supervision by a qualified staff person. The DON stated lack of supervision placed Resident 1 at risk for falls. 3. During a review of Resident 1's care plan titled At risk for fall, dated 1/10/2025, the care plan interventions indicated Resident 1 was to have bilateral floor mats to minimize potential injury from falls. During a review of Resident 1's active physician order, dated 2/18/2025, the order indicated Resident 1 was required to have bilateral floor mats to minimize potential injury from falls. During an observation on 2/25/2025 at 1:43 PM, at Resident 1's bedside, Resident 1 was observed lying in bed . No fall mats were observed at Resident 1's bedside. During a concurrent observation and interview on 2/25/2025 at 2:32 PM, at Resident 1's bedside, with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 did not have fall mats to either side of her bed. CNA 1 stated Resident 1 did not have fall mats the entire day. CNA 1 stated the purpose of the fall mats was to prevent or minimize risk of injury from a fall. During a concurrent interview and record review, on 2/27/2025 at 1:09 PM, with the DON, Resident 1's physician order dated 2/18/2025, and a photo of Resident 1's room and bedside, taken 2/25/2025 at 1:52 PM, were reviewed. The DON stated the physician order indicated Resident 1 should have bilateral floor mats at her bedside. The DON stated the photo indicated Resident 1 did not have bilateral floor mats as ordered. The DON stated Resident 1 was at risk for injury because the fall mats were not available to reduce the impact of a fall. 4. During a review of Resident 1's care plan titled Falling Star Program ., dated 2/14/2025, the care plan indicated Resident 1 was to have two yellow star-shaped indicators on her wheelchair and outside of her room by her nameplate. During an observation on 2/25/2025 at 1:52 PM, outside of Resident 1's room, Resident 1's nameplate affixed to the wall outside the resident's room did not have star-shaped indicators next to Resident 1's name. During a concurrent observation and interview on 2/25/2025 at 2:35 PM, with CNA 1, in the hallway outside of Resident 1's room, Resident 1's Geri-chair did not have any star-shaped indicators attached to it. CNA 1 stated the star-shaped indicators alerted staff that a resident was at risk for falls. CNA 1 stated Resident 1 used a Geri-chair instead of a wheelchair because she had left thigh bone fracture. During a concurrent observation and interview on 2/25/2025 at 2:39 PM, with CNA 1, the nameplate outside of Resident 1's room was observed. CNA 1 stated Resident 1 did not have any star-shaped indicators next to the resident's name to indicate Resident 1 was a fall risk. During a concurrent interview and record review, on 2/27/2025 at 1:11 PM, with the DON, Resident 1's care plan titled Falling Star Program ., dated 2/14/2025, and the facility's P&P titled Falling Star Program, dated 1/2025, were reviewed. The DON stated the care plan and P&P indicated Resident 1 was required to have two star-shaped indicators next to her name on the nameplate outside of her room, and on her wheelchair and/or Geri-chair. The DON stated the purpose of the star-shaped indicators was to provide a visual reminder to staff of the resident's fall risk, and to remind them to implement the required fall prevention interventions. The DON stated that without the star indicators, staff might not remember or know to implement fall precautions, placing the resident at risk for falls. During a review of the facility's P&P titled Falling Star Program, dated 1/2025, the P&P indicated any resident with a fall while admitted to the facility would be included in the Falling Star Program and was to have star indicators on their door nameplate and wheelchair, if applicable. The P&P indicated there should be two star-shaped indicators if the resident had sustained a fall in the facility. 5. During a review of Resident 2's Admission Record, the Admission Record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's admitting diagnoses included abnormalities of gait (pattern of walking) and mobility, generalized muscle weakness, Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) with dyskinesia (involuntary, repetitive, and abnormal movements). During a review of Resident 2's H&P, dated 11/26/2024, the H&P indicated Resident 2 had fluctuating capacity to understand and make decisions. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had moderately impaired cognition (a decline in thinking and memory that makes it hard to complete complex tasks). The MDS indicated Resident 2 required substantial to maximal assistance from staff to get dressed and maintain personal hygiene after voiding or having a bowel movement. The MDS indicated Resident 2 required partial to moderate assistance from staff for mobility while in bed, to get out of bed, and when transitioning from bed to wheelchair, or wheelchair to bed. During a review of Resident 2's care plan titled Falling Star Program ., dated 12/21/2024, the care plan indicated Resident 2 was to have two yellow star-shaped indicators on her wheelchair and outside of her room by her nameplate. During a review of Resident 2's COC assessment, dated 12/25/2024, the assessment indicated on 12/25/2024 Resident 2 had an unwitnessed fall. The COC indicated staff found Resident 2 lying on her back on the floor near the foot of her roommate's bed. The assessment indicated Resident 2 had an abrasion (scrape or superficial injury) on her left arm and complained of a 3 out of 10 pain. During an observation on 2/25/2025 at 1:52 PM, outside of Resident 2's room, the nameplate outside of Resident 2's room did not have star-shaped indicators next to Resident 2's name. During a concurrent observation and interview, on 2/26/2025 at 1:20 PM, with LVN 2, Resident 2's wheelchair was parked outside of Resident 2's room in the hallway. LVN 2 stated the wheelchair had Resident 2's room and bed indicated on the back of the seat, but did not have any star-shaped indicators attached to it. During a concurrent interview and record review on 2/27/2025 at 1:14 PM, with the DON, Resident 2's COC assessment, dated 12/25/2024, and care plan titled Falling Star Program ., dated 12/21/2024, were reviewed. The DON stated the COC assessment indicated on 12/25/2024 Resident 2 had an unwitnessed fall but a Morse Fall Scale assessment was not done after the fall. The DON stated it was the facility's policy to conduct a fall assessment after any fall, to identify Resident 2's level of risk for falls. The DON stated the assessment would also prompt a review of Resident 2's fall risk care plans to identify if there was a need for new or revised fall prevention interventions. The DON stated a Morse Fall Scale assessment should have been done and failure to complete one placed Resident 2 at risk for repeat falls. The DON stated Resident 2's care plan indicated Resident 2 required star-shaped indicators on her wheelchair and on her nameplate outside of her room. The DON stated the failure to implement the star-shaped indicators placed Resident 2 at risk for falls. During a review of the facility's P&P titled Falling Star Program, dated 1/2025, the P&P indicated fall risk assessments were to be completed as needed. Based on observation, interview, and record review, the facility failed to maintain a safe and hazard free environment for two of three sampled residents (Resident 1 and Resident 2), when: 1. Licensed Vocational Nurse (LVN) 1 left Resident 1 unattended and unsupervised at Nurse's Station 3, on 2/14/2025. 2. Activity Staff (AS) 3 left Resident 1 at Nurse's Station 3, without verifying there was a charge nurse present to supervise Resident 1, on 2/14/2025. 3. On 2/25/2025, Resident 1 did not have bilateral fall mats (a cushioned floor pad designed to help prevent injury should a person fall) at her bedside, as ordered by the physician. 4. On 2/25/2025, Resident 1 did not have fall risk indicators outside of her room, or on her Geri-chair (a large, padded chair with a wheeled base, designed to assist individuals with limited mobility), in accordance with Resident 1's care plan. 5. A Morse Fall Scale assessment (a clinical assessment tool used to predict a patient's risk of falling) was not conducted following Resident 2's fall on 12/25/2024. 6. On 2/26/2025, Resident 2 did not have fall risk indicators outside of her room, or on her wheelchair, in accordance with Resident 2's care plan. These deficient practices resulted in Resident 1 falling on 2/14/2025 and sustaining a displaced subcapital left femoral neck fracture (a broken bone in the upper part of the left thigh bone, where the broken pieces are significantly displaced from their normal position) requiring surgical intervention in a general acute care hospital (GACH). These deficient practices also placed Resident 1 and Resident 2 at risk for further falls and fall related injuries. Findings: 1. During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was most recently readmitted to the facility on [DATE]. Resident 1's admitting diagnoses, as of 2/18/2025, included generalized muscle weakness, left thigh bone fracture, history of falling, dementia (a progressive state of decline in mental abilities), epilepsy (a chronic brain disorder characterized by recurrent seizures, which are brief episodes of abnormal brain activity that can cause involuntary movements, loss of consciousness, or other symptoms), and osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D). During a review of Resident 1's History and Physical (H&P), dated 1/10/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. The H&P did not indicate diagnoses of osteoporosis or osteopenia (a condition characterized by low bone mineral density, which makes bones weaker and more prone to fractures). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 1/13/2025, the MDS, indicated Resident 1 had memory problems and severely impaired cognition (a significant decline in cognitive abilities that interferes with daily life and independence). The MDS indicated Resident 1 had impairments to her lower extremities (hip, knee, ankle, and foot) on both sides of her body. The MDS indicated Resident 1 was dependent on staff for all activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) and mobility while in and out of bed. The MDS indicated diagnoses of lack of coordination and generalized muscle weakness. During a review of Resident 1's care plan titled At risk for fall, dated 1/10/2025, the care plan indicated staff were to provide frequent visual monitoring of Resident 1 to reduce the risk of falls and/or injury. During a review of Resident 1's Morse Fall Scale Assessment, dated 1/11/2025, the assessment indicated Resident 1 was at high risk for falls due to impaired gait (an abnormal walking pattern), and overestimation (judging something too highly), and/or forgetfulness of her ability to walk safely. During a review of Resident 1's Change of Condition (COC) assessment, dated 2/14/2025 at 3:10 PM, the COC indicated on 2/14/2025 Resident 1 had a witnessed fall, in the hallway. The COC indicated Resident 1 reported a 4 out of 10 pain (0: no pain, 1 to 3: mild pain, 4 to 6: moderate pain, and 7 to 10: severe pain) to her left hip. The COC indicated Resident 1 was administered Tylenol 650 milligrams (mg, a unit of dose measurement) for pain. The COC indicated Resident 1's physician was notified of the fall and the physician ordered for an immediate x-ray (a procedure that uses radiation to create images of the inside of the body) to rule out broken bones. During a review of the facility record titled Investigation Statement, dated 2/14/2025 at 3:10 PM, the record indicated a handwritten statement by Licensed Vocational Nurse (LVN) 1 regarding Resident 1's fall on 2/14/2025. The record indicated on 2/14/2025 (no time specified), Resident 1 was sitting in a wheelchair near the nurse's station. The record indicated LVN 1 was assisting another resident in the hallway when Resident 1 fell . During a review of Resident 1's COC assessment, dated 2/14/2025 at 9:45 PM, the COC indicated the x-ray revealed Resident 1 had an acute (severe and sudden in onset) left thigh bone fracture related to a witnessed fall. The COC indicated Resident got up unassisted and lost her balance . The COC indicated Resident 1 reported an 8 out of 10 pain. The COC indicated staff administered Norco 5/325 mg (a combination medication used to relieve severe pain when other pain medication was insufficient) for pain. The COC indicated Resident 1's physician gave an order for the resident to be a transferred to a GACH for evaluation and treatment of the left thigh bone fracture. During a review of Resident 1's progress note, dated 2/14/2025 at 11:45 PM, the progress note indicated Resident 1 was transferred to the GACH on 2/14/2025 at 11:30 PM. During a review of Resident 1's GACH record titled History and Physical, dated 2/15/2025 (untimed), the record indicated Resident 1 was brought to the GACH after falling onto her left side while trying to walk. The record indicated a plan to admit Resident 1 to the medical-surgical unit (a unit for patients recovering from surgery, preparing for surgery, or managing various medical conditions). During a review of Resident 1's GACH record titled Radiology Report, dated 2/15/2025 at 2:23 AM, the record indicated an x-ray was taken of Resident 1's left hip. The record indicated Resident 1 had a displaced subcapital left femoral neck fracture. During a review of Resident 1's facility progress note, dated 2/15/2025 at 1:42 PM, the progress note indicated Resident 1 was admitted to the GACH and in the process of being referred to, and evaluated by, an orthopedic physician (a physician who treats injuries and diseases involving muscles, bones, joints, ligaments, and tendons) for a possible left hip hemiarthroplasty (surgical replacement of half of the hip joint) related to her fracture. During a review of Resident 1's GACH record titled Discharge Summary Notes, dated 2/17/2025 at 8:07 AM, the record indicated a final diagnosis of acute left femoral neck fracture. The record indicated Resident 1's conservator (a person appointed by a court to manage her care) declined to provide consent for orthopedic surgery (a surgical procedure on the musculoskeletal system), and Resident 1 was to be discharged back to the facility. During a review of Resident 1's facility progress note, dated 2/18/2025 at 11:45 AM, the progress note indicated Resident 1 was readmitted to the facility on [DATE]. During a review of Resident 1's medical record titled Routine Pain Assessment Flowsheet , undated, and Pain Assessment Flowsheet, undated, the records indicated Resident 1 received Norco 5/325 mg for the following pain levels: On 2/20/2025 at 3:00 AM: 7/10 pain to her left lower extremity (leg). On 2/20/2025 at 9:00 AM: 8/10 pain to her left lower extremity. On 2/21/2025 at 5:00 AM: 7/10 pain to her left lower extremity. On 2/21/2025 at 11:30 AM: 7/10 pain to her left lower extremity. On 2/22/2025 at 9:00 AM: 8/10 pain to her left lower extremity. On 2/22/2025 at 2:00 PM: 8/10 pain to her left lower extremity. On 2/24/2025 at 9:00 AM: 8/10 pain to her left lower extremity. On 2/25/2025 at 9:00 AM: 7/10 pain to her left lower extremity. On 2/27/2025 at 9:00 AM: 8/10 pain to her left lower extremity. On 2/27/2025 at 2:30 PM: 7/10 pain to her left lower extremity. During a telephone interview on 2/26/2025 at 9:14 AM, with LVN 1, LVN 1 stated she was Resident 1's Charge Nurse the afternoon of 2/14/2025, and was aware Resident 1 was at risk for falls. LVN 1 stated she was supervising Resident 1 at the nurse's station and there were no other staff present when Resident 1 fell . LVN 1 stated she did not ask any staff member to supervise Resident 1 before leaving the resident unattended at the nurse's station. LVN 1 stated she was down the hall from Resident 1, with her back towards the resident, when she heard Resident 1's wheelchair alarm. LVN 1 stated she turned around and saw Resident 1 standing up and holding onto the armrest of her wheelchair for support. LVN 1 stated she was too far away from Resident 1 to intervene, and she observed Resident 1 fall to the ground onto her left side. LVN 1 stated Resident 1 denied any pain during the shift, prior to the fall, but complained of pain to her left hip after the fall. LVN 1 stated she should not have left Resident 1 unattended and unsupervised at the nurse's station. LVN 1 stated the fall could have been prevented if Resident 1 was not left unsupervised. During a telephone interview on 2/26/2025 at 4:43 PM, with Registered Nurse (RN) 1, RN 1 stated Resident 1's care plan intervention of frequent visual monitoring meant Resident 1 should not be left unattended. RN 1 stated to implement this intervention, Resident 1 should always be within a supervising staff member's line of sight. RN 1 stated leaving a resident who required frequent visual monitoring unattended could result in a fall and injury. During a concurrent interview and record review, on 2/27/2025 at 1:02 PM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled Safety and Supervision of Residents, revised 1/2025, was reviewed. The DON stated the P&P indicated resident supervision was a core component for resident safety. The DON stated LVN 1 should not have left Resident 1 unattended because Resident 1 was known as a high risk for falls. The DON stated LVN 1 should have ensured another staff was supervising Resident 1, before leaving the resident at the nurse's station. 2. During a review of the facility record titled Investigation Statement, dated 2/18/2025, untimed, the record indicated a handwritten statement by Activity Staff (AS) 1 regarding Resident 1's fall on 2/14/2025. The record indicated on 2/14/2025 (time unspecified) Resident 1 was in the dining room requesting to be taken back to her room. The record indicated an unidentified staff wheeled Resident 1 to an unspecified nurse's station. During a concurrent interview and record review, on 2/25/2025 at 1:03 PM, with AS 1, the facility record titled Investigation Statement, dated 2/18/2025 (time unspecified), was reviewed. AS 1 stated the staff member who took Resident 1 to the nurse's station was identified as AS [TRUNCATED]

Based on interview and record review, the facility failed to prevent an avoidable fall for one of one sampled resident (Resident 7) by failing to: 1. Provide Resident 7 with the required minimal assistance and supervision from staff when toileting. 2. Follow Resident 7's scheduled toileting plan and ensure the resident was assisted by staff to the toilet or offered a commode and/or bed pan as needed, upon waking in the morning, and before breakfast as per the facility's policy titled, Toileting Program. These deficient practices resulted in Resident 7's having an avoidable fall with subsequent transfer to a general acute care hospital (GACH) for treatment. Resident 7 was diagnosed with a right forehead laceration (deep cut in skin) with hematoma (pool of blood collecting under the skin) and an acute minimally displaced type 3 dens (neck bone) fracture (break in the bone). Findings: During a record review of Resident 7's Admission Record (face sheet), the face sheet indicated Resident 7 was admitted to the facility on [DATE]. Resident 7's diagnoses included atrial fibrillation (abnormal heartbeat), heart failure (heart muscle does not pump blood as well as it should), difficulty walking, muscle weakness, type 2 diabetes (body cannot process glucose [sugar] normally), and dementia (general term of loss of memory, language, problem-solving and other thinking abilities). During a review of Resident 7's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 5/22/2022, the MDS indicated Resident 7 expressed ideas and wants and understood verbal content. The MDS indicated Resident 7 had severely impaired cognitive (ability to learn, remember, understand, and make decision) skills for daily decision making. The MDS indicated Resident 7 required limited one-person physical assistance (resident is highly involved in activity; received physical help in guided maneuvering of limbs or other non-weight bearing assistance) with bed mobility and personal hygiene, and an extensive assistance with transfer, walking in the room and corridor, dressing, and toilet use. The MDS indicated Resident 7 was occasionally incontinent ([inability to control] less than seven episodes) of bladder but continent of her bowels. According to the MDS, Resident 7 was placed in the toileting program (scheduled toileting) with decreased wetness experienced because of the program. During a record review of Resident 7's Morse Fall Scale (used to estimate a resident's fall risk) initiated on 5/16/2022, the fall scale indicated Resident 7 was a high fall risk with a score of 80 (high risk indicates a score of 45 or more, moderate risk was between 25-44, small risk was for 0- 24) and had multiple risk factors that predisposed the resident to falls. The risk factors indicated Resident 7 had the following: 1. A history of falls, 2. Multiple medical diagnosis, 3. Used crutches, cane, or walker, 4. Weak gait (stooped but able to lift head without losing balance, steps are short and resident shuffles), and 5. A problem with overestimating or forgetting limits. During a record review of Resident 7's care plan titled, Self-care Deficit and activities of daily living ([ADL] daily tasks involving personal care) Decline, initiated 5/17/2022, the care plan indicated Resident 7 would be assisted with ADLs as needed. During a record review of Resident 7's care plan titled, Risk for Fall, initiated 5/17/2022, the care plan indicated Resident 7 would receive frequent visual monitoring, functional mobility training, bowel and bladder retraining, Occupational therapist ([OT] healthcare professional assists residents to develop, recover, improve, or maintain skills needed for working and daily living) assessment and toilet program as indicated. During a record review of Resident 7's Physical Therapy ([PT] medical specialist who help improve residents' movements) Evaluation and Plan of Treatment dated 5/17/2022, the evaluation indicated Resident 7 exhibited impaired coordination, muscle weakness and reduced functional activity tolerance (individuals' ability to tolerate completing their activities of daily living). The evaluation indicated Resident 7 was noted with decreased functional mobility and increased risk for falls. PT recommended treatment to improve functional mobility and promote safety awareness. Treatment approaches may include therapeutic activities and exercises, and gait training therapy. During a review of Resident 7's OT Evaluation dated 5/17/2022, the evaluation indicated Resident 7 needed minimal assist (resident requires small amount of help to accomplish activity and requires no more help than touching and expends 75 percent or more of the effort) with toileting. During a record review of Resident 7's Certified Nurse Assistant (CNA) ADL flow sheet, regarding toilet use, the flow sheet, for the month of June 2022, indicated CNA did not provide a one-person physical help and minimum assistance to Resident 7 for the following dates: a. From 6/1/2022 to 6/6/2022 and 6/10/2022. CNA guided the resident with no physical assist b. On 6/11/2022 (date of Resident 7's fall), no documented evidence of any type of CNA assistance noted. During a record review of Resident 7's Bowel and Bladder Assessment (tool used to determine how the facility needs to address a resident's toileting needs) dated 5/17/2022, the assessment indicated Resident 7 scored a 16, (score of 0 to 15 meant candidate for bowel and bladder training, 16 to 19 meant the resident should be on a scheduled toileting plan, 20 or above the resident was not a candidate for toileting program nor bowel and bladder training) which indicated Resident 7 should be on a scheduled toileting plan. The assessment indicated Resident 7 was identified as having the following triggers: 1. Frequently incontinent for one or more years. 2. Occasionally incontinent with bowels. 3. Confused. 4. diagnosed with an old stroke (blood flow to brain is stopped and can cause numbness or weakness or confusion or loss of balance) or debilitating disease (disease that affects physical abilities that affect brain function and impair thought process). 5. Uncooperative. 6. Requiring one person assist with transfer and ambulation with or without assistive devices. 7. High risk for dehydration (condition when person use or lose more fluids than the person takes in). During a record review of Resident 7's Scheduled Toileting Plan for the month of June 2022, there was no documented evidence Resident 7 was assisted to the toilet or offered a urinal/ commode/ bed pan as scheduled on 6/10/2022 and 6/11/2022 (day of the fall) on the night and day shifts. During an interview with Licensed Vocational Nurse (LVN) 1 on 6/24/2022 at 10:59 a.m., LVN 1 stated he was doing a medication pass on 6/11/2022 at approximately 8:40 a.m., when LVN 1 responded to Registered Nurse (RN) 1's call for assistance in Resident 7's restroom. LVN 1 stated upon entry to Resident 7's restroom, Resident 7 was observed sitting upright on the floor of the restroom. LVN 1 stated there was blood observed on the floor and on Resident 7's head. LVN 1 stated Resident 7 reported she was trying to use the restroom and fell . LVN 1 stated Resident 7 did not use the call light. LVN 1 stated he assessed Resident 7, applied pressure to the resident's head, rendered first aid, and called 911. LVN 1 stated Resident 7 was transferred to a general acute care hospital (GACH) for further evaluation. During a concurrent interview and record review on 6/24/2022 at 11:05 a.m. with RN 1, Resident 7's Morse Fall scale dated 6/11/2022, was reviewed, RN 1 stated from 5/17/2022 to 6/11/2022, Resident 7 walked to the restroom unassisted and independently. RN 1 stated Resident 7 would hold on to things or furniture to keep her balance. Resident 7's Morse fall scale dated 6/11/2022 indicated Resident 7 used furniture for support, she was weak and had a history of falling. Per document, Resident 7 overestimates and forgets limits. RN 1 stated Resident 7 needed a one-person physical assist. RN 1 stated she was doing morning rounds on 6/11/2022, at approximately 8:30 a.m. she noticed Resident 7 was not in her bed. RN 1 stated she went to Resident 7's restroom., at approximately 8:40 a.m., and observed Resident 7 sitting on the restroom floor. RN 1 stated she called for help. During a telephone interview with Certified Nurse Assistant (CNA) 2 on 7/15/2022 at 2:58 p.m., CNA 2 stated on the morning of 6/11/2022, before the breakfast trays came out, CNA 2 assisted Resident 7 up out of bed and onto her wheelchair. CNA 2 stated she did not assist Resident 7 to the restroom when Resident 7 woke up nor before breakfast. CNA 2 stated by the time she returned to Resident 7's room at approximately 8:30 a.m., the nurses were in the room and Resident 7 was observed on the restroom floor. During a telephone interview with CNA 3 on 7/15/2022 at 4 p.m., CNA 3 stated she knew Resident 7 urinated a lot. CNA 3 stated Resident 7's functional ability for toileting varied. CNA 3 stated sometimes staff would supervise, and sometimes staff would provide limited to extensive assistance to Resident 7. During a concurrent interview and record review on 7/18/2022 at 12:10 p.m. with LVN 3, Resident 7's scheduled toileting plan for the month of June 2022 was reviewed, LVN 3 stated from 5/17/2022 to 6/11/2022, Resident 7 usually went to the toilet by herself. LVN 3 stated Resident 7 was occasionally supervised meaning staff just looked at the resident and no physical assistance was involved. LVN 3 confirmed there was no documented evidence that Resident 7 was taken to the restroom before breakfast on 6/10/2022 and 6/11/2022; and as needed upon waking during the night shift (11 p.m. to 7 a.m.) on 6/11/2022. LVN 3 stated Resident 7's scheduled toileting plan for the month of June 2022 indicated the night shift before Resident 7 fell , for eight (8) hours on 6/11/2022, and approximately one (1) hour during the day shift before breakfast, on the day she fell , Resident 7 was not assisted to the toilet or offered a commode and/or bed pan as scheduled. LVN 3 stated since Resident 7 was on a toileting schedule plan, the CNAs should have taken the resident to the restroom when she woke up, before breakfast, and as needed on 6/11/2022. LVN 3 stated not taking Resident 7 to the restroom as scheduled increased the risk of incontinence and increased the risk that Resident 7 would attempt to go to the bathroom by herself. LVN 3 stated it was not safe because Resident 7 did not call for help and she was a high risk for falls. During an interview with the Director of Nurses (DON) on 7/18/2022 at 12:27 p.m., the DON stated staff should have assisted Resident 7 to the restroom as indicated in the occupational therapist (OT) assessments and MDS assessments. The DON stated CNAs should have also taken Resident 7 to the bathroom before breakfast and when she woke up on 6/11/2022 AM shift. The DON stated doing so might have prevented Resident 7 from walking to the restroom herself and falling. During a record review of Resident 7's GACH History and Physical (H/P) dated 6/11/2022, the H/P indicated Resident 7 reported going to the restroom three times but did not remember the fall. The H/P indicated Resident 7 complained she had been urinating a lot and reported the dysuria (discomfort or burning urination) to staff. Resident 7's right eyebrow laceration was repaired with sutures (sterile surgical threads used to repair cuts) and Resident 7 was admitted to the hospital for continued evaluation. During a record review of Resident 7's Computed Tomography ([CT] diagnostic imaging that produces images of the inside of the body showing bones, muscles, fats, organs, and blood vessels) of the Head without contrast (a dye or other substance that helps show abnormal areas inside the body) completed on 6/11/2022 at 11:17 a.m., the CT findings indicated right fontal scalp (right forehead area) laceration (cut through the skin) and hematoma (pool of blood under the skin). During a record review of Resident 7's CT of the Spine Cervical (back and neck) without contrast dated 6/11/2022 at 11:32 a.m., the CT findings indicated an acute minimally displaced type 3 dens (neck bone) fracture (break in the bone) with broken bone through the cervical 2 vertebrae [also called the axis or the neck bone, part that enables head rotation]). During a record review of Resident 7's Neurosurgery (specializing in injury or disorders of brain, spinal cord and spinal column, and peripheral nerves) Consult Note dated 6/18/2022 at 8:03 a.m., the note indicated no surgical intervention at present time but Resident 7 needed to wear a cervical collar (medical device used to support a person's neck) at all times and follow up in the Neurosurgery Clinic in 6 weeks. During a record review of facility's undated policy and procedure (P/P) titled, Toileting Program, the P/P indicated the toileting program was to promote continence with bladder function and attempt to decrease episodes of incontinence in residents. The P/P indicated the resident will be assisted to the toilet, commode or offered a bed pan or urinal upon awakening, after meals, after naps and before bed. Toileting will be offered every three to four hours during waking hours and at least two times during sleeping hours. The P/P indicated the toileting will be documented in the plan of care. During a record review of the facility's P/P titled, Falls and Fall Risk Managing, revised 10/2020, the P/P indicated based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The staff, with the input and interdisciplinary team, will identify appropriate interventions to reduce the risk of falls. During a record review of the facility's undated LVN job description, the job description indicated the LVN implements the resident plan of care and evaluates resident response. The job description indicated the LVN was responsible for providing direct nursing care to the residents and supervision of nursing activities performed by nursing assistants in accordance with current federal, state, and local standards, guidelines and regulations and company policies and procedures to ensure that the highest degree of quality care was always maintained.

Based on observation, interview, and record review the facility failed to ensure one of three sampled residents (Resident 1) was fully dressed before going to hemodialysis ([HD] process in which a machine filters wastes, salts and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately), Resident 1 who was dependent on staff for activities of daily living (ADL) was sent to hemodialysis wearing a blouse in adult briefs ( absorbent, disposable underwear and undergarments for people with urinary or fecal incontinence) and without any pants. This deficient practice caused Resident 1 to feel embarrassed, anxious and unable to sleep. Findings: During a record review for Resident 1's, Face Sheet (Admission Record), the face sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a record review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 7/28/21, the MDS indicated Resident 1 had the ability to understand and be understood by others. The MDS indicated Resident 1 required one person assistance with bed mobility, locomotion on and off the unit, dressing, toilet use, and personal hygiene. During a record review of Resident 1's History and Physical (H&P) dated 9/20/2021, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a record review of Resident 1's Nursing Progress Notes dated 10/14/21, at 4:14 p.m., the notes indicated Resident 1 left the facility at 9 a.m. and was returning to the facility. The note did not indicate the location of Resident 1. During a review of another nursing progress notes dated 10/14/21, at 9:11 p.m., the note indicated Resident 1 returned from [CONDITION(S)]. During a record review of Resident 1's Order Summary Report dated 10/21/2021, the report indicated Resident was to have HD on Tuesdays, Thursdays, and Saturday, at 9:30a.m., at a HD center. During a record review of Resident 1's Activities of Daily Living (ADL) flowsheet dated 10/1-26/21, the flowsheet indicated Resident 1 did not help with dressing and required one-person physical assistance. During a record review for Resident 1's Interdisciplinary Team ([IDT] team members from different disciplines working collaboratively, with a common purpose) Conference Record dated 10/14/21, IDT conference record indicated after the hemodialysis center (an entity that provides outpatient [CONDITION(S)] services), notified the facility of the incident, the facility's Director of Staff Development (DSD), in-serviced CNA 1 to ensure residents were fully dressed and cleaned before going to any treatment or appointments outside of the facility. During a record review of the facility's Performance Correction Notice dated 10/14/21, the record indicated CNA 1 received a final written warning for not ensuring a resident wore clothes from the waist down before going to an appointment on 10/14/21. The notice also indicated the resident was embarrassed at the appointment and the facility was notified by the hemodialysis social services Staff (HDSS) During an interview on 10/21/21, at 11:02 a.m., with Certified Nursing Assistant (CNA 1), CNA 1 stated on 10/14/21, she dressed Resident 1 for her hemodialysis appointment with a sweater, a diaper, and a blanket over her legs. CNA 1 stated she sent Resident 1 to her appointment without pants because Resident 1 did not have any pants in her closet, she (CNA 1) was busy, and did not want Resident 1 late for her appointment. CNA 1 also stated she thought Resident 1 was only going to be transferred from one bed to another, and that she had no excuse for not dressing the resident appropriately. During an interview on 10/21/2021, at 11:45 a.m., with the Social Services Director (SSD), SSD stated on 10/14/21, the HD Social Services staff (HDSS) called the facility to report Resident 1 was only wearing a shirt without any pants. SSD stated residents should be fully clothed once they were awake to maintain their dignity and respect. SSD also stated it was improper for Resident 1 to be out of bed naked. During an interview on 10/21/2021, at 12 p.m., Social Services Assistant (SSA) stated he received a call from the HD center notifying him that Resident 1 felt embarrassed for only having a linen covering the bottom of her body. SSA stated Resident 1 stated that Resident 1 told the SSA she felt a little embarrassed for not having pants during her HD appointment. During an interview on 10/21/2021, at 12:22 p.m., with Licensed Vocational Nurse (LVN 2), LVN 2 stated the residents have to be fully clothed with pants and shoes to protect their dignity. LVN 2 stated the residents had rights and should be treated like human beings. LVN 2 also stated it was unethical (not morally correct) to send a resident to an appointment without pants. During an interview on 10/21/21, at 1:36 p.m., with the Director of Nursing (DON), the DON stated sending Resident 1 for an appointment without pants was unacceptable. The DON stated this was an avoidable incident. During a concurrent observation and interview on 10/21/21, at 2:50 p.m., with Resident 1, the resident stated she was sent to her HD appointment without clothes because the staff could not find her clothes. Resident 1 was crying and stated she did not know why her clothes were not in her closet. Resident 1 also stated the incident made her feel sad, anxious, and unable to sleep During a phone interview on 10/28/21, at 11:05 p.m., HDSS stated on 10/14/21 Resident 1 was at her HD appointment crying and in a lot of distress because did not have any pants. HDSS stated the resident was only wearing a shirt without any pants. During an interview on 11/1/21, at 12:52 p.m., with DON 2, DON 2 stated an incident where a resident was sent to an appointment without pants would be embarrassing and did not provide the resident with a dignified existence. The DON stated this incident could affect the resident's quality of life and cause Resident 1 to feel embarrassed. A review of the facility's policy titled Resident's Rights revised 12/2016, indicated employees should treat all residents with kindness, respect, and dignity, including a dignified existence. The facility's policy titled Quality of Life- Dignity revised 8/2009, indicated each resident should be cared for in a manner that promoted and enhanced quality of life, dignity, respect, and individuality at all times. The policy indicated residents would be assisted in maintaining and enhancing their self-esteem and self-worth, would be encouraged and assisted to dress in their own clothes, and that staff should promote, maintain, and protect residents' privacy, including bodily privacy during assistance with personal care and treatment procedures. The policy also indicated demeaning practices and standards of care that compromised dignity were prohibited. The facility undated Certified Nursing Assistant job description indicated CNAs would ensure residents' needs were maintained with highest degree of dignity. The CNA duties and responsibilities included ensuring all residents were treated fairly, with kindness, dignity, and respect, and their rights were protected at all times.

Based on interview and record review, the facility failed to ensure supervision and was provided to prevent falls for one of three sampled residents who had a history of [REDACTED]. Resident 1 had 11 falls within four months resulting in injuries. These deficient practices resulted in Resident 1 falling multiple times and the last fall resulted in serious injury with a bifrontal (situated on both sides of the front of the cranium) subdural hematoma (pool of blood between the brain and its outmost covering). Resident 1 required a transfer to two general acute care hospitals (GACH) for care and treatment as the first GACH was not equipped to provide the higher level of care Resident 1 required. Findings: A review of Resident 1's Admission Record indicated resident was originally admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. (a disease that destroys memory and other mental functions), and [MEDICAL CONDITION] (a mental illness associated with episodes of mood swings), [MEDICAL CONDITION] and [MEDICAL CONDITION] (paralysis or weakness of muscles on one side of the body). A review of Resident 1's Quarterly Minimum Data Set (MDS), a standardized resident assessment and care screening tool), dated 6/18/2020 indicated Resident 1 requires extensive assistance with transferring, toileting, bed mobility, dressing and hygiene and ambulation (walking). A review of a document titled, Morse Fall Scale, (fall risks assessment scale) dated 6/13/2020 indicated Resident 1 had a high risk for falls due to her mental status with a score of 55. According to Morse Fall Scale, a score above 45 represent a high risk. The Morse Scale indicated Resident 1 overestimate and forgets her limitations to ambulate with frequent falls in the past. A review of Resident 1's care plan on fall prevention with initiation date of 6/13/2020, focused on minimizing the risk of falls without injury. The staff's interventions included to assist Resident 1 to bathroom as needed, educate and encouraged Resident 1 to call for help by use of the call light. The care plan also indicated Resident 1 would be place on a toileting program and a falling star program for fall prevention. A review of the facility's Falling Star program on 11/17/2020 indicated frequent resident monitoring, care planning and interventions should be done to reduce the incidence of falls. A review of the facility's Toileting program on 11/17/2020 indicated the staff will take residents to the toilet upon awaken, before and after each meal, and every 2 hours as needed. A review of the facility's document titled, Resident Incident Tracking Log on 10/14/2020 indicated Resident 1 had 11 falls within four (4) months from 6/14/2020 to 9/24/2020. A review of facility's Reports and change of condition (COC) on 10/14/2020 indicated Resident 1 had falls on the following dates: 1. On 6/14/2020 at 1:45 p.m., Resident 1 was found on the floor lying on right side by her assigned certified nursing assistance (CNA). No Injury noted on assessment. 2. On 6/16/2020 at 12:50 p.m., Resident 1 was found on the floor in Resident 1 room, the fall was witnessed by her roommate. Resident 1 sustained redness on the back. 3. On 6/21/2020 at 5:32 a.m., Resident 1 was found sitting on the floor by CNA in her room. resident sustained [REDACTED]. 4. On 7/14/2020 at 2:30 p.m., Resident 1 fell on the hallway while attempting to ambulate (walk). A review of facility's interdisciplinary team ((IDT) group of health care professionals with various areas of expertise who work together towards the goals of the residents) meeting, dated 7/15/2020 indicated Resident 1 fell while ambulating in the hall without assistance and lost her balance. IDT's recommendation was to continue with skilled rehab plan and continue to remind Resident 1 she needs assistance when ambulating and to place Resident 1 on the falling star program (a program where residents will be monitored frequently and interventions care planned). 5. On 7/20/2020 at 3:03 p.m., Resident 1 was found on the floor in the bathroom. Sustained a bump on the eyebrow. A review of an IDT meeting notes, dated 7/22/2020 indicated Resident 1 fell in the bathroom, apparently did not call for assistance she turned lost balance and fell . Resident 1 sustained small bump on the right side of forehead. IDT's recommendation was neuro checks (an evaluation of a person's nervous system, by checking pupils, level of consciousness and extremities strength) continue the on-going reminders to have assistance. 6. On 7/23/2020 at 9:25 p.m., Resident 1 was found on the floor in her room. witnessed by her roommate, who called out for help (no injury mentioned). 7. On 8/22/2020 at 11:05 p.m., Resident 1 was found on the floor in her room. She sustained an injury on the left side of the head and face. A review of IDT meeting notes dated 8/24/2020 indicated on 8/22/2020 Resident 1 was found lying on the floor beside her bed. IDT's recommendation was to keep bed in lowest position, continue rehab skilled services and continue falling star program. 8. On 8/24/2020 at 12 p.m., Resident 1 fell from her wheelchair on the hallway. She was taken to hospital for evaluation (no injury mentioned). A review of an IDT meeting notes, dated 8/24/20 indicated Resident 1 was up in wheelchair (W/C) being physically aggressive, got out of the chair and fell to the floor. Resident was transferred to acute hospital for evaluation. 9. On 8/26/2020 at 10:45 p.m., Resident was found on the floor in her room. Fall witnessed by roommate (no injury indicated). A review of IDT meeting notes dated 8/27/2020 indicated Resident 1 was found sitting on the floor inside her room, per Resident 1 she wanted to go to the restroom. IDT's recommendation was to keep bed in lowest position, continue rehab skilled services, falling star program and toileting program. 10. On 8/28/2020 at 2:59 p.m., Resident 1 was found on the floor in the hallway. Resident 1 had swelling on the right side of the face. A review of an IDT meeting notes, dated 8/31/2020 indicated Resident 1 got up from W/C without calling for help, lost her balance and fell to the floor, Resident 1 stated she wanted to walk. IDT's recommendation was to continue skilled rehab services and falling star program. 11. On 9/24/2020 at 8:15 p.m., Resident 1 fell forward from her wheelchair in the hallway, hitting her head on the wall. Resident 1 was taken to acute hospital (GACH) for evaluation. A review of several of Resident 1's risk for falls care plan on 11/17/2020, indicated after each of Resident 1's falls the care plan was not updated and/or revised to include interventions to prevent the resident from further falls. A review of an IDT meeting notes dated 9/28/2020 indicated Resident 1 had a fall incident on 9/24/2020 and was transferred to acute hospital (GACH) for evaluation. A review of the GACH's record, the emergency department (ED) physician notes dated 9/24/2020 indicated that Resident 1 was brought into the ED by ambulance after a witnessed fall from the facility. According to the ED note, Resident 1 was getting up from wheelchair, lost her balance and fell hitting her head on the floor. Resident 1 sustained a small hematoma (bleeding or collection of blood under the skin) on her scalp and will be admitted for neurological evaluation (assessment of the nervous system). A review of the GACH's discharged Summary, dated 9/30/2020 indicated due to Resident 1's CT scan of the head showing a large subdural hematoma, Resident 1 was referred to a neurologist and needed to be transferred to a higher level of care for evaluation from a neurosurgeon (a physician that specializes in [DIAGNOSES REDACTED]. A review of Resident 1's GACH 2's Admission Face Sheet, indicated Resident 1 was admitted on [DATE] with a [DIAGNOSES REDACTED]. The Discharge summary indicated Resident 1 underwent a bilateral craniotomy (surgical opening into the skull) and an evacuation of a subdural hematoma. Resident 1 was discharged to another skilled nursing facility on 10/9/2020. On 10/13/2020 at 1:30 p.m., during an interview, Resident 1's family member (FM 1) stated Resident 1 had fallen more than 10 times in the facility. FM 1 stated as a result of many falls, Resident 1 had to undergo three surgeries. On 10/14/2020 at 11:26 a.m., during an interview, the administrator (ADM) stated Resident 1's falls was one of the concerns discussed during the facility's inter-disciplinary team (IDT) meetings. The ADM stated that none of Resident 1's fall were reported to the appropriate agencies, because there were no injuries (sic). On 10/14/2020 at 12:02 p.m., during an interview, the assistant director of nursing (ADON) stated Resident 1 was very confused and did not follow directions in calling for assistance, despite the call light being place within her reach. On 11/17/2020 at 1:05 p.m., during an interview, Certified Nurse Assistant 1 (CNA 1) stated Resident 1 was one of her regular residents and she knows that Resident 1 was at high risks for falls. CNA 1 stated so during her shift she would make sure Resident 1 did not fall by constantly monitor the resident. CNA 1 stated Resident 1 was very confused and restless and always wanting to go to the bathroom, but when taken to bathroom the resident did not use the toilet. On 11/17/2020 at 2:45 p.m., during an interview, the director of nursing (DON) stated she was new and just started working in the facility on 10/11/2020. The DON stated her priority was to reduce the number of residents fall incidents by reassessing all residents at risks for falls and updating the care plans and providing in-services to all staff regarding fall prevention. A review of the facility's policy and procedure (P/P), revised on 9/2012 and titled Falls- Clinical Protocol indicated for an individual who has fallen, the staff will attempt to define possible causes within 24-72 hour of the fall and continue to collect and evaluate information until either the cause of falling is identified. Under treatment/management, the staff and physician will identify pertinent interventions to prevent subsequent falls and try various interventions, based on assessment of the nature of the falls until falling is reduced or stops. A review of the facility's undated P/P titled Falling star program, indicated the goal is to reduce the incidence of falls and injury for residents in the program. The risk management committee/interdisciplinary team will determine placement of residents into the falling star program. Residents in the program will be monitored frequently and the intervention will be care planned. A review of the facility's P/P and revised on 7/2019 titled, Safety and Supervision of Residents indicated that facility will strive to make the environment as free from accident hazards as possible by: Monitoring the effectiveness of interventions. Ensuring that interventions are implemented correctly and consistently Evaluating the effectiveness of interventions Modifying or replacing intervention as needed and Evaluating the effectiveness of new or revised interventions.

Based on interview and record review, the facility failed to follow a physician's order to administer a [MEDICATION(S)] (substances to either loosen stool or stimulate a bowel movement [last stop in the movement of food through your digestive tract, stool]) for bowel management, implement a resident's plan of care for monitoring of bowel movements and side effects of medications, which included constipation and fecal impaction (hardened stool that cannot pass out of the colon or rectum) and adhere to its policy and procedures (P/P) to ensure medication was given as prescribed for one of three sampled residents (Resident 1). Resident 1, who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 was diagnosed with fecal impaction (a severe bowel condition in which a hard, dry mass of stool becomes stuck in the colon [large bowel or large intestine] or rectum). This deficient practice resulted in Resident 1 being transferred to a general acute care hospital (GACH) for abdominal pain with distention and was diagnosed with a fecal impaction. Resident 1 had to undergo a surgical procedure which resulted in the removal of the colon and was hospitalized for 11 days. Findings: A review of Resident 1's Face Sheet (Admission Record) indicated the resident's most recent admission to the facility was on 7/7/2020. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 7/1/2020 indicated Resident 1 usually had the ability to understand and be understood by others, but had difficulty communicating some words or finishing thoughts. The MDS indicated Resident 1 required total assistance of a one-person physical assist for toilet use and was always incontinent (inability to control) of bowel and bladder. A review of Resident 1's History and Physical (H/P), dated 4/1/2020 indicated a history of fecal impaction was one of the resident's diagnoses. A review of Resident 1's Care Plan for constipation, revised on 4/3/2020 indicated Resident 1 was at risk for constipation due to impaired mobility, use of [CONDITION(S)] (any mind, behavior and/or emotion altering medication) medications, impaired cognition (mental process of acquiring knowledge and understanding), [CONDITION(S)] accident ([[CONDITION(S)]] a stroke sudden interruption in the blood supply of the brain) with right side [CONDITION(S)]. The Care Plan indicated Resident 1 was dependent on staff for oral fluids intake. The goal of the care plan indicated Resident 1 would have soft, formed stools on a regular basis, at least every three days. The staff's interventions indicated Resident 1 would be given [MEDICATION(S)] (medication that makes bowel movements softer and easier to pass) capsule 100 milligram ([mg] unit of measurement) two times a day for bowel management and [MEDICATION(S)] (medication used to treat occasional constipation or irregular bowel movements) powder 17 gram every day for bowel management. According to the staff's interventions, the staff would observe for signs and symptoms of fecal impaction such as constipation, nausea/vomiting, abdominal distention, pain or discomfort, such as bloating, excessive gas, abdominal tenderness, complaints of feeling full and cramping and notify the physician if identified. A review of Resident 1's physician's orders, dated 7/7/2020 indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] = 1 cup) of water to be given to Resident 1 every day for bowel management. A review of Resident 1's physician's orders, dated 7/7/2020 indicated the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders indicated Resident 1 had an order of [MEDICATION(S)] (medication used to treat anxiety) tablet 5 mg to be given by mouth two times a day for anxiety manifested by constantly screaming to exhaustion. Resident 1 also had an order of [MEDICATION(S)] [MEDICATION(S)] (used to treat depression and anxiety) capsule 40 mg to be given by mouth one time a day for depression manifested by constant crying about wanting old body back. A review of Resident 1's Care Plan for [MEDICATION(S)] [MEDICATION(S)], revised on 7/7/2020 indicated the facility's staff was to monitor Resident 1 for side effects such as dry mouth, [CONDITION(S)], and constipation. The Care Plan indicated to monitor, document, and report as needed for any adverse reactions to the medication such as decline in ADL (activities of daily living) ability, no voiding, constipation, fecal impaction, movement problems and nausea, and vomiting. A review of Resident 1's Care Plan for [MEDICATION(S)], revised on 7/8/2020 indicated for the facility's staff to monitor Resident 1 as an intervention for dry mouth, constipation, difficulty urinating, dark urine and nausea, and vomiting. A review of DailyMed, an online pharmacy site, provided by the National Library of Medicine (NLM) and is the official provider of FDA drug label information (package inserts) indicated [MEDICATION(S)] was indicated for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . According to DailyMed, most common adverse reactions for [MEDICATION(S)] included dry mouth, constipation, and abdominal pain. A review of Resident 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/8/2020 at 2:52 p.m., during an interview, Certified Nursing Assistant 1 (CNA 1) stated the first day she was assigned to Resident 1, during the morning shift on 7/25/2020 she noted Resident 1's stomach bloated and hard. CNA 1 stated the next day on 7/26/2020 Resident 1's stomach was much harder. CNA 1 stated it felt as though there was a hard ball inside of the right side of Resident 1's stomach. CNA 1 stated if a resident does not have a bowel movement in two consecutive days, she was supposed to report to the charge nurse. CNA 1 stated she reported her findings about Resident 1 not having a bowel movement in two days and stomach being hard to the charge nurse but did not remember which charge nurse. CNA 1 also stated she was supposed to complete a Stop and Watch form (a tool the staff used to identify change of condition in a resident). CNA 1 stated she did not remember completing the Stop and Watch form for Resident 1. On 9/8/2020 at 3:51 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated she did not remember anyone reporting anything unusual to her regarding Resident 1's bowels the morning of 7/26/2020. LVN 1 stated CNAs were supposed to report to the charge nurse if a resident has not had a bowel movement for three days. LVN 1 stated some CNAs report to the charge nurse if there has not been a bowel movement for two days. LVN 1 stated Resident 1 has had constipation problems in the past. During a concurrent review of Resident 1's MAR for 7/2020, LVN 1 stated and acknowledged the prescribed [MEDICATION(S)] was not listed on the MAR. LVN 1 stated medications listed on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/8/2020 at 4 p.m., during an interview, Registered Nurse 1 (RN 1) stated [MEDICATION(S)] should have been on Resident 1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/18/2020 at 12:15 p.m., during an interview, the Director of Staff Development (DSD) stated if a resident was having bowel movements regularly daily and did not have a bowel movement one day, the CNA should have still reported to the charge nurse. A review of Resident 1's past Change of Condition (COC) Evaluations, dated 3/19/2020 and 6/13/2020 indicated the resident had identified signs and symptoms of constipation and/or fecal impaction. A review of Resident 1's COC Evaluation, dated 7/26/2020 and timed at 9:19 p.m. indicated Resident 1 had a COC that involved a distended abdomen and slow peristalsis (movements made that carries food away from the stomach and pushes food and waste through the body). The COC indicated the staff spoke to the physician recommending the need of KUB ([kidney, ureters, bladder]-x-ray of the abdomen) or use of laxatives. Resident 1's physician ordered to transfer the resident to a GACH. On 9/14/2020 at 10:39 a.m., during a telephone interview, RN 2 stated one of the staff members reported to her on 7/26/2020 of Resident 1's stomach being distended, and she assessed Resident 1's stomach and noted slow peristalsis. RN 2 stated she notified Resident 1's physician (Physician 1) and asked Physician 1 for an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN 2 stated she was informed by one of the nurses that Resident 1 used to have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's GACH Emergency Department (ED) note, dated 7/26/2020 and timed at 10:27 p.m. indicated Resident 1 was brought in by ambulance secondary to abdominal pain. The ED note indicated Resident 1 was last admitted to the GACH in 3/2020 secondary to severe constipation which was causing hydronephrosis (swelling of a kidney due to a back-up of urine). The ED note indicated due to Resident 1's severe pain, 911 was called and Resident 1 was brought in by ambulance. A review of Resident 1's GACH x-ray abdominal series (consisting of a series of x-ray on the abdomen) and the chest done on 7/26/2020 at 10:59 p.m., indicated paucity (a small amount) gas within the abdomen in a nonobstructive (not causing blockage) pattern related with constipation. A review of Resident 1's computed tomography ([CT] a type of medical imaging tool to see inside the body) of the abdomen/pelvis at the GACH indicated there was increased in size in the massive fecalith (a hard stony mass of feces) within the rectum and sigmoid colon (the last section of the bowel; part that attaches to the rectum) measuring up to 36 centimeters ([cm] unit of length). The CT results indicated this results in mass effect on the internal organs as well as the distal (the far end) ureters (tubes that carry urine from the kidneys [a pair of bean-shaped organs on either side of the spine, below your ribs and behind the abdomen; to filter blood] to the bladder [a membranous sac which urine is collected for excretion]) resulting in moderate to severe hydroureteronephrosis (a situation where the kidneys and ureters (ducts by which urine passes from the kidney to the bladder) swells due to an obstruction of urine flow in urinary tract towards the bladder was blocked). A review of Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Resident 1's H/P at the GACH, dated 7/29/2020 indicated Resident 1 had colonic dysmotility (the muscles do not work normally), massive stool impaction (40 cm fecalith) with a mass effect on internal organs and distal ureters, unresolving and intolerant to enemas (the injection of a fluid into the rectum to cause a bowel movement). The H/P indicated Resident 1 would need surgery of a partial versus total colectomy (surgical removal of all or part of the large intestine) and was planned to have an [CONDITION(S)] (the small intestine is diverted through an opening in the abdomen to carry feces out of the body) versus [CONDITION(S)] (the large intestine is diverted through an opening in the abdomen to carry feces out of the body). A review of Resident 1's GACH Post-Operative Documentation, dated 7/30/2020 and timed at 8:04 p.m. indicated Resident 1's total colon was removed. A review of Resident 1's GACH Pathology Report, dated 7/30/2020 indicated the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident 1's Nursing Progress Notes at the facility, dated 8/6/2020 and timed at 6:26 p.m. indicated Resident 1 was readmitted to the facility on [DATE] at 11 p.m., with staples on the stomach due to bowel obstruction with an [CONDITION(S)] bag (a special bag placed over the opening in the stomach to collect stool that usually pass through the colon and out of the body through the rectum and anus). On 9/17/2020 at 3:21 p.m., during a telephone interview, Physician 1 stated [MEDICATION(S)] was good for prevention of constipation but not strong enough on its own to get rid of fecal impaction. Physician 1 stated he was concerned that the facility did not notice Resident 1's constipation and should have been monitoring. Physician 1 stated as a result of the fecal impaction Resident 1 now has an [CONDITION(S)]. A review of the facility's P/P titled, Acute Condition Changes - Clinical Protocol, revised on December 2015 indicated direct care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident (for example, a decrease in food intake, increased agitation, changes in skin color or condition) and how to communicate these changes to the nurse. Nursing assistants are encouraged to use the Stop and Watch early warning tool to communicate subtle changes in the resident to the nurse. A review of the facility's P/P titled, Administering Medications, revised on December 2012 indicated medications must be administered in accordance with the physician's orders, including any required time frame.

Based on record review, observation, and interview, the facility failed to appropriately discharge one of three sample residents (Resident 1) by not ensuring Resident 1's physician evaluated Resident 1 before discharge and documented information about the basis for the discharge as indicated in the facility policy. For Resident 1, the resident's physician did not evaluate Resident 1 if he could be discharged to a lower level of care where non-skilled services were provided. As a result, Resident 1 was discharged on [DATE] (8 days later) to a board and care ((B and C) - group living arrangement that provides help with activities of daily living such as eating, bathing, and using the bathroom for people who cannot live on their own, but do not need nursing home services). On the same day at 7:36 p.m., Resident 1 was found unconscious (passed out) on the sidewalk, 2.5 miles away from the B and C. Resident 1 was transferred to General Acute Care Hospital (GACH) 2, where he required sutures (stitches holding together the edges of a surgical incision) to a chin laceration (deep cut). Findings: A review of Resident 1's Face Sheet (Admission Record) indicated Resident 1 was admitted to the facility on [DATE] from GACH 1 with [DIAGNOSES REDACTED]. A review of Resident 1's Interdisciplinary Team note (IDT-group of healthcare professionals from different fields who coordinate, collaborate, and plan the delivery of care for residents), dated 5/9/19, indicated Resident 1 required one-person physical assists for ambulation (ability to walk from place to place independently with or without assistive device), and used a wheelchair and front wheel walker (FWW) as his primary mode of locomotion (ability to move from one place to another). The IDT note indicated Resident 1 was appropriate for skilled nursing facility (SNF) care and there was no discharge plan to a lower level of care. A review of Resident 1's care plan developed for Resident 1's At Risk for Fall, dated 5/9/19, indicated the goal was to decrease the risk of falls and injuries. The interventions included educating the resident on functional mobility, placing the resident close to the Nursing Station, and providing physical therapy/occupational therapy assessment and training as indicated. A review of Resident 1's Physical Therapy (PT) Evaluation and Plan of Treatment, dated 5/9/19, indicated Resident 1's safety awareness was impaired due to the resident's cognition (inability to think reasonably). Resident 1 was able to ambulate 350 feet on level surfaces with the use of a FWW and with the assistance of the restorative nursing assistant (RNA - helps residents gain an improved quality of life by increasing their level of strength and mobility). The evaluation indicated due to Resident 1 was walking while leaning forward and decreased in step length, Resident 1 was at risk for compromised general health, further decline in function, falls and decreased participation with functional tasks. The physical therapist's impression was to place Resident 1 on RNA maintenance program for ambulation using a FWW. A review of Resident 1's Speech Therapy (ST) Evaluation and Plan of Treatment, dated 5/9/19, indicated Resident 1 required close supervision during eating due to difficulty to swallow and risk of aspiration (food enters the body's airways). The speech therapist recommended to provide close supervision for eating. A review of Resident 1's Order Summary dated 5/9/19, timed 2:03 p.m. indicated speech therapy order for dysphagia treatment three times per week for four weeks. A review of Resident 1's Licensed Nurse Notes, dated 5/11/19 at 10:10 a.m., indicated Resident 1 stated he lost his balance when he went to the bathroom. The physician was notified and the resident denied pain or any discomfort. A review of Resident 1's care plan developed for Resident 1's Altered Behavior Patterns Related to Opening Emergency Doors, dated 5/15/19, indicated the goal was to reduce the episodes of the behavior in 90 days. The interventions included approaching the resident calmly, attempting to reduce triggers, and providing reality awareness. A review of the unsigned Physician's telephone orders, dated 5/16/19, timed at 11:18 a.m., indicated discharge Resident 1 to the B and C with medications. A review of Resident 1's Social Service Progress Notes, dated 5/16/19, timed at 11:18 a.m., indicated Resident 1 was discharged to the B and C and transported by the B and C staff. The notes indicated at 11:42 a.m. on 5/16/19, Physician 1 was informed Resident 1 had been discharged to the B and C. A review of Resident 1's Notice of Transfer/Discharge, with a notification date of 5/16/19 and effective on 5/16/19, indicated Resident 1's discharge was appropriate when the resident's health had improved sufficiently so the required services provided by the facility was no longer needed. A review of Resident 1's Discharge Summary/Comprehensive Assessment, dated 5/16/19 indicated Resident 1 had weakness on both legs, required assistance with bathing, dressing, personal hygiene, transferring, toilet use, and bed mobility. The summary indicated no assistive device (wheelchair or FWW) was provided to the resident. A review of Resident 1's clinical record indicated there was no documentation by the resident's physician regarding the basis of Resident 1's discharge to a board and care facility on 5/16/19. There was no documentation by the licensed nurse and Social Service Designee to explain the sudden order to discharge Resident 1 to a lower level of care. A review of the CMS/Medicare, a Board and Care Facility is defined as group living arrangement that provides help with activities of daily living such as eating, bathing, and using the bathroom for people who cannot live on their own, but do not need nursing home services. http://www.medicare.gov/longtermcare/static/BoardCareHome.asp A review of a Paramedics Run Sheet, dated 5/16/19, indicated the paramedics found Resident 1, on 5/16/19 sat 7:36 p.m., sitting on the sidewalk after bystanders (person who is present at an event or incident but does not take part) witnessed Resident 1 tripped on the sidewalk and lost consciousness (state of being awake and aware of surroundings) after Resident 1 hit his chin on the ground. The run sheet indicated the resident had the SNF identification wristband. The paramedics took Resident 1 to GACH 2. A review of the maps indicated 2.5 miles walking distance from the B and C to the GACH's sidewalk, where Resident 1 was found. A review of Resident 1's GACH's Emergency Department (ED) report, dated 5/16/19, timed at 8:24 p.m., indicated Resident 1 tripped over a curb while walking. The ED assessment indicated the fall was witnessed by bystanders who called the paramedics. The report indicated Resident 1 had a four (4) centimeters (cm) inferior chin laceration that required a single layer of suture. The report indicated Resident 1 was discharged to the facility on [DATE] at 1:22 p.m. A review of Resident 1's Re-Admission Assessment, dated 5/17/19 and timed at 2:48 p.m., indicated Resident 1 was readmitted to the facility with a right cheek/eye bruising, right hand cut, left fingers (digit 2 and 3) with multiple cuts, right/left knee cuts and bruising, and left/right upper arm bruising. On 5/18/19 at 8:35 a.m., during a concurrent observation and interview, Resident 1 was in the dining room with multiple scrapes to the face with purple/yellowish discoloration and stiches to the chin, and bilateral (both) hands. When asked how he sustained the scrapes and discoloration, Resident 1 stated that he had a fall trying to go to the bathroom. On 5/18/19 at 11:07 a.m., during a concurrent interview and review of Resident 1's clinical record, the Medical Records Director (MDR) confirmed there was no documentation in Resident 1's clinical record that Physician 1 had evaluated Resident 1 prior to discharge. The MDR stated that Physician 1 did not conduct an initial assessment within 72 hours on Resident 1 as indicated on the facility's policy. On 5/18/19 at 12:15 p.m., during a concurrent interview and review of Resident 1's clinical record, the Assistant Director of Nurses (ADON) stated Resident 1 sustained a fall on 5/11/19 while trying to go to the bathroom and sustained an injury to the left side of the chest. The ADON stated the facility did not conduct a safe discharge and did not ensure Physician 1 had conducted Resident 1's initial and discharge assessment prior to the discharge on 5/16/19 to the B and C. On 5/18/19 at 12:58 p.m., during a concurrent interview and review of Resident 1's clinical record, the Social Services Director (SSD) confirmed Resident 1 was inappropriately discharged to the B and C. The SSD stated he did not assess the resident prior to the discharge. The SSD confirmed there was no documentation in Resident 1's record that the facility's IDT conducted discharge planning for Resident 1. The SSD stated the Administrator (ADM) approved Resident 1's discharge to the B and C without the physicians' discharge assessment. The SSD stated Resident 1 was not able to make medical decisions and did not have a responsible party/family member. On 5/18/19 at 1:45 p.m., during a concurrent interview and review of Resident 1's clinical record, the ADON stated and confirmed that Resident 1 was not a candidate to go to a B and C because of his elopement (ran away without being noticed) attempt on 5/15/19. On 5/18/19 at 2:26 p.m., during a telephone interview, Physician 1 stated he did not conduct the initial and discharge assessment for Resident 1. Physician 1 stated he did not visit Resident 1 to evaluate him during his stay at the facility and he did not remember giving an order to discharge Resident 1 to a B and C. Physician 1 stated that Resident 1's discharge was inappropriate if the resident needed the skilled services of the facility. Physician 1 stated that he was aware that he needed to see Resident 1 within three days of his admission. On 5/18/19 at 2:24 p.m., during a telephone interview with the facility's Medical Director (MD) and in the presence of the ADON, Registered Nurse (RN) and MRD, the MD stated the role of Physician 1 was to conduct an initial assessment of the residents and a discharge assessment prior to the discharge to assess the appropriateness of the transfer or discharge according to the residents' needs. The MD stated Physician 1 failed to conduct an initial assessment for Resident 1. On 5/18/19 at 3:25 p.m., during a concurrent interview and review of Resident 1's record, in the presence of the ADM, ADON, and the MRD, the ADM stated he approved Resident 1's discharge to the B and C. The ADM stated he was not aware that Physician 1 had not seen or assessed Resident 1, and not aware of the recommendations from PT and ST to continue skilled services and close supervision during eating. On 6/5/19 at 4:25 p.m., during a telephone interview, the B and C supervisor stated the B and C was not able to provide the care that Resident 1 needed because they had no licensed nurse and they only accepted independent residents. The B and C supervisor stated Resident 1 left the B and C on 5/16/19 two hours after his arrival. On 6/7/19 at 2:06 p.m., during a telephone interview, the PT stated that on 5/9/19 Resident 1's initial assessment was conducted and she had assessed the resident with difficulty walking, unsteady gait and requiring a FWW for ambulation. A review of the facility's policy dated 11/2017 titled, Physician Visit, indicated that within 72 hours of the resident admission, the physician was required to complete a History and Physical (H&P) examination of the resident. A review of the facility's policy and procedures, revised on 12/2016 and titled, Transfer or Discharge, indicated that when a resident is transferred or discharged , the details of the transfers or discharges would be documented in the medical records. The policy also indicated when the transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services of the facility, the resident's physician must document information regarding the basis for transfer and discharge.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services for two of 24 sampled residents (Residents 4 and 17) and two randomly selected residents (Residents 26 and 28). 1. For Resident 4, the facility failed to: (a) Accurately assess, develop a care plan , and notify the physician in a timely manner of Resident 4's left jaw/cheek pain that started on 12/10/14. The resident was evaluated by the dentist on 12/15/15, which was five days after the onset of the left jaw/cheek pain. (b) Accurately assess, develop a care plan and notify the physician timely on 12/11/14, when Resident 4 experienced severe left knee pain. The physician ordered diagnostic tests on 12/12/14, which was more than 24 hours after the onset of the pain. This deficient practice resulted in Resident 4 suffering severe pain from 12/10/14 to 12/17/14, a total of seven days. (c) Notify the physician of Resident 4's elevated blood sugar of more than 400 mg/dl (milligrams/deciliter) for a total of five times as indicated in the resident's record from 11/2/14 to 12/9/14. (d) Recheck Resident 4's blood sugar of more than 300 mg/dl 30 minutes after the initial reading, for a total of 16 times as stipulated in the facility's policy and procedure. (e) Monitor Resident 4's 6:30 a.m. blood sugar level for four days. These deficient practices resulted in Resident 4 having hyperglycemic (uncontrolled high blood sugar level) episodes that included nervousness, anxiety, and increased thirst. (2) The facility failed to ensure that blood sugar (BS) levels were consistently monitored for three of four residents (Resident 17, 26 and 28) with diabetes and who were on [MEDICAL TREATMENT] treatment (a medical procedure to remove waste and fluid from the blood): (a) Resident 17's 6:30 a.m. blood sugar (BS) levels were not taken for a total of 15 times from 11/1/14 to 12/11/14. (b) Resident 26's 11:30 am BS levels were not taken for a total of seven times from 12/1/14 to 12/16/14. (c) Resident 28, whose usual BS levels ranged from 250-460, did not have the BS levels taken at 11:30 a.m. for a total of 5 times from 11/3/14 to 11/21/14. (3) The facility failed to inform the physician of the discrepancy on the blood sugar monitoring schedule; failed to communicate with the [MEDICAL TREATMENT] Center of the need to monitor Resident 17, 26, and 28's blood sugar levels by finger-stick while the residents were in the [MEDICAL TREATMENT] Center. This deficient practice placed Residents 17, 26, and 28 at risk for hypoglycemic (abnormally low BS level) or [MEDICAL CONDITION] (abnormally high BS level) episodes that could result to coma or death. Findings: 1. a. A review of the admission Face Sheet indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 8/25/14, indicated that Resident 4 was able to make self-understood and understand others and required extensive assistance (weight bearing support) with two person physical assist in bed mobility, locomotion on the unit, dressing, toilet use and personal hygiene. On 12/10/14 at 8:05 a.m., Resident 4 was observed sitting in bed with her food tray in front of her. Resident 4 was grimacing and was holding her left cheek and complained of difficulty chewing due to left jaw and teeth pain, which she described as severe, 10/10 pain rating scale (0=no pain-10=severe pain). On 12/11/14 at 1:30 p.m., Resident 4 was observed sitting in her wheelchair inside her bedroom watching television (TV). During an interview, Resident 4 stated that her left knee had been painful. She stated that she had been given pain medication but it was not working. Resident 4 tried to lift her left leg and grimaced and stated, "I can't even lift my leg, it hurts." Resident 4 stated she had to hold her urine and delay toileting because of the left knee pain when she stands. During an interview on 12/11/14 at 1:35 p.m., LVN 6 stated that he was not aware of Resident 4's complaint of left knee pain, but stated he would give her pain medication. The review of Resident 4's clinical record on 12/11/14 indicated that there was no written plan of care for the management of the resident's jaw/teeth ache and left knee pain. A review of Resident 4's physician's orders [REDACTED]. The Pain Assessment Flow-sheet indicated that on 12/11/14, Resident 4 received [MEDICATION NAME] 5/325mg (a narcotic pain reliever), for three doses; on 12/12/14, four doses; on 12/13/14, three doses; on 12/14/14, four doses; and on 12/16/14, four doses. The Nursing Note dated 12/10/14, during the 7 a.m. to 3 p.m. shift, indicated Resident 4 complained of left side facial pain (tooth of a 10/10 pain rating) and the physician was notified. There was no documentation of the physician's response. During the 3 p.m. to 11 p.m. shift, Resident 4 continued to complain of pain of the left side of the face (teeth pain 8/10 pain rating). The Nursing Note dated 12/11/14, during the 7 a.m. to 3 p.m. shift indicated that, Resident 4 complained of left knee pain on a pain scale of 8/10 with left foot 3+ [MEDICAL CONDITION] (swelling). There was no documented evidence that the physician was notified of the new onset of severe left knee pain. During the 3 p.m. to 11 p.m. shift, Resident 4 complained of left knee pain on a pain scale of 8/10 and the physician was called but could not be reached. During the 11 p.m. to 7 a.m. shift, Resident 4 complained of left facial pain on a pain scale of 8/10. On 12/12/14, during the 7 a.m. to 3 p.m. shift, Resident 4 complained of left knee pain on a pain scale of 8/10 and was unable to lift left leg. There was no documented evidence the physician was informed of Resident 4's continued complaint of left facial pain and left knee pain. On 12/10/14 at 9 a.m., during an interview, LVN 6 stated that he notified the physician the morning of 12/10/14 about Resident 4's left side facial pain (tooth) 10/10 pain rating and was told to continue to give [MEDICATION NAME], a narcotic pain medication. On 12/11/14 at 8:05 a.m., during an interview, LVN 6 stated he did not follow up with the physician. LVN 6 stated he did not inform the social worker or the dentist regarding Resident 4's continued complaint of dental pain. On 12/12/14 at 9 a.m., during an interview, Resident 4 stated she continued to have left teeth pain on a pain scale of 8/10 and left knee pain on a pain scale of 8/10. Resident 4 stated, "They are giving me pain medication, it helps but it's painful again. It's difficult to chew. I was forced to swallow my food." On 12/12/14 at 9:10 a.m., LVN 6 was interviewed if the physician was notified of Resident 4's complaint of left knee pain and swelling to the left foot, LVN 6 stated, "Oh, I haven't called the doctor." LVN 6 went to the phone and called the physician. The Daily Licensed Nurses Notes dated 12/12/14, during the 3 p.m. to 11 p.m. shift, indicated that LVN 6 notified the physician of Resident 4's change of condition and an X-ray of the left knee was ordered. On 12/12/14 at 10:05 a.m., the assistant director of nursing (ADON) stated, "The dentist will be informed about Resident 4's complaint as soon as possible." On 12/15/14, five days after onset of left teeth pain, Resident 4 was seen by the dentist with the following documentation by the dentist, "Resident complained of pain from dentures, not teeth. Lower partial was adjusted due to sore spot. Recommended tooth extraction and consented for full lower denture." On 12/16/14 at 4 p.m., when asked about Resident 4's severe left knee pain on 12/11/14 on the 3 p.m. to 11 p.m. shift and the physician could not be reached, LVN 4 stated he did not report to the nursing supervisor but endorsed to the night shift to follow up with the physician. LVN 4 stated the night shift did not follow up with the physician. On 12/17/14 at 12:20 p.m., during an interview, Resident 4 stated, "The tooth ache has improved, I can eat better now. They adjusted my dentures." A review of the x-ray result done on 12/12/14 at 6:49 p.m. indicated "Suspicious for infection/osteo[DIAGNOSES REDACTED] (bone infection)." A review of the physician's orders [REDACTED].m, indicated to do CT scan (computed tomography scan is an imaging method that uses x-rays to create pictures of the body) to the left knee and to place a bandage on the left knee. [MEDICATION NAME] (medication use to prevent blood clot) 40 mg (milligrams) per injection was ordered. On 12/13/14 there was a physician's orders [REDACTED]. On 12/12/14 at 12 pm, during an interview and record review with the director of nursing and RN 1 regarding lack of care plan for pain management for Resident 4's left knee pain and left toothache, they stated they should have accurately assessed and developed care plans for Resident 4's pain. A review of the facility's policy and procedure titled, "Pain", dated 2/14/11, indicated that the facility was to assess resident's pain and to provide pain management as indicated in the physician's orders [REDACTED]. A review of the Nursing Note dated 12/16/14 indicated that Resident 4 continued to complain of severe (pain scale 8/10) left knee pain. Resident 4 was transferred to the hospital on [DATE]. 1b. On 12/9/14 at 11:50 a.m., during an interview, Resident 4 stated, "I was told by my nurse that my blood sugar had been high, almost 500. On Saturday (12/7/14), I told them (the nurses) to call my doctor, so he can give me more medication (insulin, a medication used to control high blood sugar levels). The nurse tried to call my doctor, but she could not get hold of him. She told me maybe because it was a weekend." Resident 4 stated, "They (the staff) did not check my (blood) sugar today (12/9/14 at 6:30 a.m.). I don't think they checked it yesterday (12/8/14 at 6:30 a.m.). I did not get any (insulin) injection today (12/9/14 at 6:30 a.m.). Sometimes they check my blood sugar, sometimes not." Resident 4 stated, "When my blood sugar is high, I feel nervous, like anxious and shaky. I asked them to give me anxiety pills, but they don't give it to me." The physician's orders [REDACTED].=1 units (u) subcutaneous (SQ) injection (a shot that is given into the layer of fat between the skin and the muscle), 200-249= 3 u SQ, 250-299=5 u SQ, 300-349=7 u SQ, 350-399=8 u SQ, >400 =10 u and call physician, or for BS < (less than) 60, call physician and do [MEDICAL CONDITION] /[DIAGNOSES REDACTED] protocol (a set of procedures to follow). A review of Resident 4's plan of care titled, "Risk for [DIAGNOSES REDACTED] and [MEDICAL CONDITION] related to diabetes", dated 12/9/14, indicated to monitor Resident 4 for [DIAGNOSES REDACTED] and [MEDICAL CONDITION]; check finger-stick blood sugar as ordered; and to initiate nursing measures for [DIAGNOSES REDACTED]/[MEDICAL CONDITION] immediately and to notify the physician promptly. During an interview and review of Resident 4's Medication Administration Record [REDACTED]. On 12/9/14 at 12:20 p.m., Resident 4's medical records were reviewed with the registered nurse supervisor (RN 1). The FS blood sugar record indicated Resident 4's blood sugar levels at 4:30 p.m. were as follows: 11/2/14=331 mg/d (milligram/deciliter), 11/4/14=429mg/dl, 11/7/14=373mg/dl, 11/10/14=327mg/dl, 11/12/14=368 mg/dl, 11/13=357mg/dl, 11/16/14=450mg/dl, 11/17/14=497mg/dl,11/20/14=390mg/dl, 11/30=358mg/dl 12/1/14=366mg/dl,12/2/14=380mg/dl, 12/3/14=390mg/dl, 12/4/14=431mg/dl, 12/7/14=418 mg/dl and 12/8/14=384 mg/dl (normal blood sugar reference range 70-130). On 12/4/14, 12/7/14, 12/8/14 and 12/9/14 at 6:30 a.m., Resident 4's blood sugar results were not documented. A review of Resident 4's Nursing Notes and physician progress notes [REDACTED].> 400 mg/dl according to the physician's orders [REDACTED]. There were no documented evidence that the blood sugar levels were rechecked 30 minutes after when the blood sugar was >300mg/dl, except on 12/7/14, 16 times from 11/2/14 to 12/8/14. On 12/9/14 at 12:30 a.m., in an interview, the registered nurse (RN 1) stated she was not aware that Resident 4's blood sugar was not being documented and physician was not being notified. RN 1 stated if there was a significant change in the resident's condition, it should be reported to the charge nurse or to the nursing supervisor, who reports the change of condition to the physician. On 12/10/14 at 6 a.m., LVN 5 stated he checked the blood sugar but did not document the result in the FS blood sugar record and medication reconciliation sheet because, "It was an oversight on my part." LVN 5 stated he did not document the result because of "Mental lapse. I'm not sure." He stated he was aware Resident 4's blood sugar had been high which may be due to dietary effect because Resident 4 tends to have a lot of outside food brought by family. On 12/16/14 at 7:15 a.m., during an interview with the nursing supervisor (RN2) regarding the facility's procedure on rechecking high blood sugar level, she stated the blood sugar was to be rechecked after one hour or so or depending on the physician's orders [REDACTED]. On 12/16/14 at 4:30 p.m., during an interview, LVN 4 stated he checked the blood sugar of Resident 4 on 12/4/14 at 4:30 p.m. and documented the result as 431 mg/dl. LVN 4 stated he forgot to inform the physician and did not document the result of the blood sugar after it was rechecked. LVN 4 stated he had not read or reviewed the facility's policy and procedure on Change of Condition, Physician Contact and [DIAGNOSES REDACTED]/[MEDICAL CONDITION]. The review of Resident 4's Nursing Progress Note dated 12/7/14 (Sunday), at 4p.m., indicated, "The resident was asking if her insulin can be adjusted. Explained to the resident, it is Sunday evening and the doctor is probably on two days off, and the issue will be followed up in the morning." There was no documentation that a physician was informed on 12/8/14, on a Monday. On 12/16/14 at 12:20 p.m., during an interview, Resident 4's primary physician stated he could not remember if he was informed about Resident 4's high blood sugar level results but he ordered insulin sliding scale for high blood sugar levels and the expectation was for the blood sugar to be rechecked after 30 minutes. If the blood sugar continues to be high, the physician should be informed. According to the facility's policy and procedure titled, "[DIAGNOSES REDACTED]/[MEDICAL CONDITION]", dated 3/31/06 indicated if increased thirst and dry mouth, complaints of aches and breathing and increased perspiration exist, a finger stick will be done by the licensed nurse to determine blood sugar level. If blood sugar level is high above 300, the following must be done; 1. Check physician's orders [REDACTED]. 2. Constantly monitor the patients for any changes, 3. Recheck blood sugar by finger stick every 30 minutes, 4. Notify family/responsible party of change in condition and update plan of care. According to the facility's policy and procedure titled, "Change of Condition, Physician Contact," dated 3/31/06, indicated to notify the attending physician of any significant change in resident's condition or to report an incident. On 12/16/14 at 5 p.m., during an interview, Resident 4 stated, "When my (blood) sugar is high I feel very thirsty, I asked my daughter for soda. I just wanted to eat, food or cookies." According to <http://nihseniorhealth.gov/diabetes>, (1/22/15) Diabetes is a chronic condition that causes [MEDICAL CONDITION] (high blood sugar). The common signs of diabetes includes: being thirsty, frequent urination, feeling hungry or tired and sores that heal slowly. According to <http://www.diabetes.org/living-with-diabetes/complications/kidney-disease-[MEDICAL CONDITION]>, (1/22/15) Patients with poorly controlled diabetes may be subject to acute complications of diabetes, including dehydration, poor wound healing, and coma. "Older Adults" Diabetes Care 2015; 38(suppl.1):567-569/DOI:10.2337/dc15-SO13. 2. a. On 12/11/14 at 12:40 p.m., Resident 17 was observed sitting at bedside getting ready for lunch. During an interview at the time, Resident 17 stated he just returned from the [MEDICAL TREATMENT] center. Resident 17 reported feeling hungry because he usually leaves the facility at around 4 a.m. and would not return until around 11 a.m. A review of the admission Face Sheet indicated that Resident 17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the MDS, dated [DATE], indicated Resident 17 was mentally intact, able to make self-understood and understand others, required extensive assistance with bed mobility, locomotion on and off unit, dressing, and personal hygiene. A review of Resident 17' Physician order [REDACTED].=2 units (u) subcutaneous (SQ), 201-250= 4 u SQ, 251-300=6 u SQ, 301-350=8 u SQ, 351-400=10 u SQ, call physician for BS <60 or >400. Administer [MEDICATION NAME] 70/30, 5 units SQ (combination of slow and fast acting medication to lower blood sugar) two times a day, hold if meals will be skipped. A review of the plan of care titled, "[MEDICAL TREATMENT]", dated 9/4/13, and another plan of care titled, "Risk for [DIAGNOSES REDACTED] and [MEDICAL CONDITION] related to diabetes mellitus" did not address Resident 17's need for blood sugar level monitoring at 6:30 a.m. while Resident 17 was in the [MEDICAL TREATMENT] center. A review of the "Nurses [MEDICAL TREATMENT] Communication Record," (a record utilized by the facility and the [MEDICAL TREATMENT] center to communicate the residents' care needs) dated 12/2, 12/6, 12/9, 12/14, 12/13 and 12/14/14 did not indicate Resident 17's blood sugar level at 6:30 a.m. while in the [MEDICAL TREATMENT] center. There was no documented evidence in the Nurses [MEDICAL TREATMENT] Communication Record that the facility communicated the need to have Resident 17's blood sugar level monitored at 6:30 a.m.) On 12/10/14 at 11:20 a.m., the Fingerstick record for the months of 11/14 and 12/14 for Resident 17 were reviewed with RN 1. There were no blood sugar level result at 6:30 a.m. on the following dates: 11/8/14, 11/13/14, 11/15/14, 11/18/14, 11/20/14, 11/22/14, 11/25/14, 11/27/14, 11/29/14, 12/2/14, 12/6/14, 12/9/14 and 12/11/14, a total of 13 times in one month. On 12/10/14 at 07:20 a.m., during an interview, RN 1 stated Resident 17's blood sugar levels were not taken at 6:30 a.m. because the resident was in the [MEDICAL TREATMENT] center. RN 1stated that Resident 17 usually leaves the facility around 4 a.m. and returns at around 11 a.m. RN 1 stated the care plan should address Resident 17's need to have the blood sugar level checked at 6:30 a.m. on the days he goes to [MEDICAL TREATMENT]. b. According to the admission Face Sheet, Resident 28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the MDS, dated [DATE], indicated Resident 28 was cognitively (mentally) intact, able to make self-understood and understand others, required extensive assistance with one person physical assist with bed mobility, dressing, personal hygiene and limited assistance with eating. According to Resident 28's physician's orders [REDACTED].=2 units (u) subcutaneous (SQ), 201-250= 4 u SQ, 251-300=6 u SQ, 301-350=8 u SQ, 351-400=10u SQ, >401=12 u SQ and call physician for BS <70 or >401. Administer [MEDICATION NAME] mix 70/30, 33 units every day before breakfast and [MEDICATION NAME] mix 70/30, 19 units every day at 5 p.m. before dinner. Another physician's orders [REDACTED]. A review of Resident 28's plans of care titled, "Risk for [DIAGNOSES REDACTED] and [MEDICAL CONDITION] related to diabetes mellitus", dated 10/23/14, and "[MEDICAL TREATMENT]", dated 10/23/14, did not address the need for blood sugar monitoring when Resident 28 leaves the facility to go to the [MEDICAL TREATMENT] Center for [MEDICAL TREATMENT] treatment at 11:30 a.m. A review of the "Nurses [MEDICAL TREATMENT] Communication Record," dated 12/3, 12/5, 12/8, 12/10, 12/12 and 12/15/14 did not indicate Resident 28's blood sugar levels at 11:30 a.m. nor the 11:30 a.m. blood sugar level monitoring ordered by the physician was communicated to the [MEDICAL TREATMENT] center via [MEDICAL TREATMENT] Communication Record. On 12/16/14 at 7:50 a.m., the Fingerstick records for the months of 11/14 and 12/14 were reviewed with RN 1. The review indicated that there were no blood sugar level results at 11:30 a.m. on the following dates: 11/3/14, 11/7/14, 11/14/14, 11/17/14, 11/21/14, 12/14/14, 12/8/14, 12/15/14, for a total of 8 times. On 12/16/14 at 7:50 a.m., during an interview, RN 1 stated Resident 28's blood sugar was not monitored because he leaves for [MEDICAL TREATMENT] at 11 a.m. The blood sugar was scheduled to be checked at 11:30 am. On 12/16/14 at 10:10 a.m., during an interview, the director of staff development (DSD) stated she had called the [MEDICAL TREATMENT] center and was informed by the staff that blood sugar monitoring by FS was not performed at the [MEDICAL TREATMENT] center. The DSD stated the [MEDICAL TREATMENT] Communication Record that the facility uses to communicate with the [MEDICAL TREATMENT] center does not have a place to put the latest blood sugar of the resident. On 12/16/14 at 10:55 a.m., during an interview, the assistant director of nursing (ADON) stated, "The communication record to the [MEDICAL TREATMENT] center does not have a space for blood sugar check or any medication given to resident prior to leaving the facility and the staff does not always call the [MEDICAL TREATMENT] center for patient report." c.A review of the admission Face Sheet indicated Resident 26 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the MDS, dated [DATE], indicated Resident 26's mental status was intact, required supervision to limited assistance (staff provided non-weight bearing assistance) with activities of daily living and was using a wheelchair as a mobility device. A review of the Physician Orders, dated 7/17/14, indicated fingerstick blood sugar before meals and at bedtime and to administer regular insulin per sliding scale. The Physician Orders, dated 9/8/14, indicated [MEDICAL TREATMENT] three times a week every Monday, Wednesday, and Friday at 11 am with pick up time at 10:30 am. A review of Resident 26's care plan, dated 5/31/14, for her risk for [DIAGNOSES REDACTED] and [MEDICAL CONDITION] related to diabetes indicated a goal for Resident 26 to be free from signs and symptoms of [DIAGNOSES REDACTED] and [MEDICAL CONDITION]. The approaches included to do fingerstick blood sugar checks as ordered and to administer insulin medication as ordered. A review of the Fingerstick for December 2014 indicated Resident 26's BS test results at 6:30 am, 11:30 am, 4:30 am, and 9 pm and insulin coverage given. The documentation did not indicate Resident 26's BS test results at 11:30 am on Mondays, Wednesdays, and Fridays. From 12/1/14 through 12/16/14, Resident 26's BS at 11:30 am were not taken, seven times. Review of the Fingerstick for November and October 2014 indicated Resident 26's BS test results at 11:30 am on Mondays, Wednesdays, and Fridays were not done. On 12/16/14 at 9:40 a.m., during an interview, regarding monitoring of blood sugar levels when residents were out to [MEDICAL TREATMENT] center, the director of staff developer (DSD) stated, "There is no way they (the licensed nursing staff) monitor the residents' blood sugar levels while they (the residents) are out ([MEDICAL TREATMENT] center)." For residents with 11:30 am blood sugar test, the DSD stated, "As soon as they (the residents) come back, they check the blood sugar at 4 pm." The DSD stated, "There should be a communication between the facility and the [MEDICAL TREATMENT] center." On 12/16/14 at 10:55 a.m., during an interview and review of Resident 26's Nurses [MEDICAL TREATMENT] Communication Record, the assistant director of nursing (ADON) stated, "Usually the [MEDICAL TREATMENT] center has a copy of the resident's list of medications/physician's orders [REDACTED]." The ADON stated, "It is important for them ([MEDICAL TREATMENT] center nursing staff) to know." On 12/16/14 at 3:50 p.m., during an interview and review of Resident 26's Nurses [MEDICAL TREATMENT] Communication Record, the director of nursing (DON) stated there was no communication with the [MEDICAL TREATMENT] center regarding Resident 26's blood sugar test and insulin administration coverage. The DON stated the communication record did not indicate if [MEDICAL TREATMENT] center staff took Resident 26's blood sugar levels at 11:30 a.m. while in the [MEDICAL TREATMENT] center. On 12/16/14 at 4:22 p.m., during an interview, the [MEDICAL TREATMENT] registered nurse (RN) stated, "Different facilities have different information in the communication sheet." "If there is no information in the communication sheet, we don't have anything to go by." "We don't do routine blood sugar fingersticks unless the resident was symptomatic."