Every finding on record at Rose Villa Health Care Center

Based on observation, interview, and record review, the facility failed to ensure three of nine sampled residents (Resident 28, Resident 45, and Resident 4) who complained of frequent pain, as indicated in Minimum Data Set (MDS-a resident assessment tool), received effective pain management, as evidenced by:a. Failing to obtain the physician ordered pain medication for moderate pain (pain level 4-6), to administer and document pain medication administration according to the prescribed parameters, and to implement and document non pharmacological interventions (uses physical, mental, and lifestyle therapies to reduce discomfort without relying on prescription or over-the-counter drugs) prior to administering pain medication, as required by the physician's orders for Resident 28.b. Failing to obtain the physician ordered pain medication for moderate pain, to administer and document pain medication administration according to the prescribed parameters, and to implement and document non pharmacological interventions prior to administering pain medication, as required by the physician's orders for Resident 45.c. Failing to follow the physician's orders when administering pain medication to Resident 4.This failure had the potential to result in insomnia (a sleep disorder involving difficulty falling asleep, staying asleep, or achieving restorative sleep) and negatively impacted the residents' quality of life due to unrelieved pain. Findings: a. During a review of Resident 28's admission Record (Face sheet- front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility admitted Resident 28 on 6/29/ 2026 with diagnoses included heart failure (condition in which the heart has difficulty pumping enough blood to keep up with demands of body), insomnia, and essential hypertension (high blood pressure that has no clear, single medical cause). During a review of Resident 28's History and Physical (H&P), dated 6/30/2026, the H&P indicated that Resident 28 had the capacity (ability) to understand and make decisions. During a review of Resident 28's Minimum Data Set (MDS – resident assessment tool), dated 6/30/2026, the MDS indicated that Resident 28 required maximal assistance (Helper does more than half the effort) from one staff for bed mobility, transfer, lower body dressing, shower, toilet hygiene, supervision or touching assistance (Helper provides verbal cues and/or ouching/steadying and/or contact guard assistance as resident completes activity) from one staff for upper body dressing, oral hygiene, and setup or clean-up assistance (Helper sets up or cleans up; resident completes activity) from one staff for eating. During an observation and interview on 8/3/2026 at 11:39 p.m. with Resident 28 in the hallway, Resident 28 was grimacing and holding her head with both hands while sitting in a wheelchair. Resident 28 stated that she had been suffering from a severe headache for the past few days and was experiencing five out of ten on the numeric pain scale (a series of numbers used to rate pain intensity: 0 no pain, 1–3 mild pain, 4–6 moderate pain, 7–10 severe pain). Resident 28 stated that she did not sleep well due to the headache and that pain medications were not always effective. During a concurrent interview and record review on 8/5/2026 at 1:29 p.m., with Registered Nurse Supervisor (RNS) 1, Resident 28's Order Summary Report (OSR), dated 8/5/2026 was reviewed. The OSR indicated that two tablets of acetaminophen (Tylenol – a common over the counter medication used to treat mild pain and reduce fever) 325 milligrams (mg) by mouth every six hours as needed for mild pain (pain level 1–3) was ordered on 6/29/2026. The OSR indicated that one tablet of hydrocodone acetaminophen (Norco – a prescription combination medication containing an opioid pain reliever and a non opioid pain reliever) by mouth every 12 hours for headache was ordered on 7/23/2026. The OSR indicated that one tablet of ibuprofen (a common nonsteroidal anti inflammatory drug used to reduce fever, ease mild to moderate pain, and decrease swelling or inflammation) 800 mg by mouth every eight hours as needed for mild to severe pain (pain level 1–10) was ordered on 7/2/2026. The OSR indicated implementation of non-pharmacological interventions as needed was ordered on 6/29/2026. RNS 1 stated that the parameters for administering pain medications were not correctly ordered. RNS 1 stated that ibuprofen could not appropriately cover the entire pain scale range (1–10), and Norco did not include any numeric pain level parameter. RNS 1 stated that Norco could have been used for severe pain, but there was no coverage for moderate pain (pain level 4–6). RNS 1 stated that non pharmacological interventions should have been implemented prior to administering pain medication. During a concurrent interview and record review on 8/6/2026 at 9:30 a.m. with the Director of Staff Development (DSD), Resident 28's Medication Administration Record (MAR), dated 7/2026, was reviewed. The MAR indicated that Tylenol, ordered for mild pain (pain level 1–3), was given on 7/10/2026 for a pain level of four out of ten (4/10) and on 7/27/2026 for a pain level of six out of ten (6/10) instead of ibuprofen, which was ordered for pain levels 1–10. The MAR indicated that ibuprofen was given on 7/6/2026 and 7/8/2026 for a pain level of zero out of ten (0/10). The MAR indicated that 7/6/2026 was the only date on which a non pharmacological intervention was documented. The DSD stated that pain medications should have clearly defined parameters and staff should not have administered medications outside of those parameters. The DSD stated that Tylenol was ordered for mild pain (pain level 1–3) and should not have been given for pain levels of four or six out of ten, which indicated moderate pain. The DSD stated that if the pain level was zero (no pain), ibuprofen should not have been given. The DSD stated that staff should have implemented and documented non pharmacological interventions before administering pain medications. b. During a review of Resident 45's admission Record, the admission Record indicated the facility initially admitted Resident 45 on 10/13/ 2024 and readmitted on [DATE] with diagnoses included chronic pain syndrome (CPS- a condition where physical pain lasts longer than three to six months, continuing past the normal healing time), history of malignant neoplasm of ovary (ovarian cancer), and fibromyalgia (chronic disorder characterized by widespread pain, fatigue, and tenderness in localized areas). During a review of Resident 45's H&P , dated 7/5/2026, the H&P indicated that Resident 45 had the capacity (ability) to understand and make decisions. During a review of Resident 45's MDS, dated [DATE], the MDS indicated that Resident 45 required maximal assistance (Helper does more than half the effort) from one staff for lower body dressing, shower, moderate assistance (Helper does LESS THAN HALF the effort) from one staff for toilet hygiene, upper body dressing, personal hygiene, bed mobility, transfer, and setup or clean-up assistance (Helper sets up or cleans up; resident completes activity) from one staff for eating, oral hygiene. During a concurrent observation and interview on 8/3/2026 at 10:04 a.m. with Resident 45 in the resident's room, Resident 45 was massaging the right arm with the left hand. Resident 45 stated that she had constant pain all over her body. Resident 45 stated that she was experiencing five out of ten pain scales on the right arm and right shoulder. Resident 45 stated that she recalled the nurse telling her that there was no pain medication coverage for moderate pain (pain level 4–6). Resident 45 stated that she did not sleep well during the night due to pain and took naps throughout the day. During a concurrent interview and record review on 8/5/2026 at 1:45 p.m. with RNS 1, Resident 45's Order Summary Report (OSR), dated 8/5/2026, was reviewed. The OSR indicated that two tablets of acetaminophen (Tylenol) 325 mg by mouth every six hours as needed for mild pain (pain level 1–3) were ordered on 7/3/2026. The OSR indicated that one tablet of Hydromorphone (Dilaudid – a powerful opioid (pain relieving drug) pain medication used to treat severe pain when other treatments do not work well enough) 4 mg by mouth every four hours as needed for severe pain (pain level 7–10) was ordered on 7/4/2026. The OSR indicated that there was no medication ordered for moderate pain (pain level 4–6). The OSR indicated implementation of non-pharmacological interventions as needed was ordered on 7/3/2026. RNS 1 stated that staff should have ensured that pain management orders covered all levels of pain. RNS 1 stated that the lack of coverage for moderate pain could lead to ineffective pain management. During a concurrent interview and record review on 8/6/2026 at 9:40 a.m., with the DSD, Resident 45's MAR, dated 7/2026, was reviewed. The MAR indicated that hydromorphone four mg was administered as follows: 7/6/2026 for a pain level of zero out of ten (0/10), 7/7/2026 for 0/10, 7/8/2026 for 0/10, 7/9/2026 for 0/10, and 7/29/2026 for a pain level of three out of ten (3/10). The MAR indicated that there was no administration documentation for Tylenol. The MAR indicated that non pharmacological interventions for pain were documented twice on 7/5/2026 and once on 7/18/2026. The DSD stated that hydromorphone, which was ordered for severe pain, should not have been given for a pain level of zero out of ten, and stated that doing so could have led to overdose. The DSD stated that staff should have given Tylenol instead of hydromorphone for the pain level of three out of ten (3/10) on 7/29/2026. The DSD stated that staff should have implemented and documented non pharmacological interventions prior to administering pain medication. During an interview on 8/7/2026 at 9:51 a.m., with the Director of Nursing (DON), the DON stated that all levels of pain should have been covered by different pain medications for effective pain management. The DON stated that staff should have administered pain medications as ordered and not outside of their parameters. The DON stated that non pharmacological interventions should have been tried before administering pain medications to avoid giving medication unnecessarily. The DON stated that effective pain management was important to improve and maintain residents' quality of life because pain affected all aspects of their lives. During a review of the facility's P&P titled, Pain Recognition and Management, revised 12/2023, the P&P indicated, Procedure: 2. Pain will be identified and documented in the electronic health record (EHR). a. Using a scale of 1 -10 is most common . 3. Management : b. Medication(s) received, refused and response to medication will be documented on the Electronic Medication Administration Record (e-MAR) .4. Monitoring: b. Monitor for effectiveness of interventions and/or adverse consequences (e.g., constipation, sedation). c. Consult physician for additional interventions if pain is not relieved by current orders. d. The interdisciplinary care plan will reflect the location and type of pain, pharmacological, and non­pharmacological interventions, with evaluation and revision as indicated. During a review of the facility's P&P titled, Medication Administration-General Guidelines, reviewed 2025, the P&P indicated, Administration: Medications are administered in accordance with written orders of the prescriber. c. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility 6/23/2026 with diagnoses of chronic pain syndrome (a condition where physical pain lasts longer than three to six months) and chronic migraine (having headaches on 15 or more days a month). During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4 was cognitively intact (healthy brain function) and was receiving opioids. During a review of Resident 4's Order Summary Report for 8/2026, the Order Summary Report indicated there was a physician's order placed for Acetaminophen (pain reliever) Oral Tablet 325 milligrams (mg, a unit of measurement) give two tabs by mouth every four hours as needed for mild pain (1-3 [numeric pain scale runs from 0 to 10. A score of 0 means no pain. A score of 10 means the worst pain you can imagine]) and tramadol (pain reliever) HCl Oral Tablet 50 mg give two tablets by mouth every six hours as needed for mild to moderate pain (1-6). During an interview and concurrent record review on 8/7/2026 at 9:12 a.m., with the the DON, Resident 4's MAR for the month of August 2026 were reviewed. The DON stated she reviewed Resident 4's MAR for the month of August 2026 and there were five instances (8/3/2026, 8/4/2026, 8/5/2026,8/6/2026 and 8/7/2026) where nursing staff (unknown) gave tramadol for a pain scale of 0 (no pain) and 1 instance on 8/2/2026 where the nursing staff (unknown) gave tramadol for a pain scale of 7 (severe pain). The DON stated that Acetaminophen was given for a pain scale of 0 on 8/2/2026, 8/3/2026, 8/4/2026, 8/5/2026, 8/6/2026, and 8/7/2026. The DON stated nursing staff (unknown) did not follow the physician's orders for pain medication administration regarding the pain scale. The DON stated it was important to follow the pain scale to ensure the resident's pain was accurately managed. During a review of the facility's P&P titled Pain Recognition and Management revised 12/2023, the P/P indicated pain would be identified and documented in the medical record using a pain scale of 1-10.

Based on observation, interview and record review, the facility failed to:a. Ensure rectal hydrocortisone was available for administration on 8/4/2026 and 8/5/2026 for one of six observed sampled residents during medication administration (Resident 64).b. Follow the facility's policy and ensure the registered nurse witness signed with the pharmacist on the controlled substance (medications with a high potential for abuse) destruction log for destroyed controlled medications on 8/2/2026 for two of two sampled controlled drug records (formal log used to track the receipt, use, waste, and current balance of regulated medications and controlled substances).These failures had the potential to result in continued rectal pain and discomfort for Resident 64 and risk for missing controlled substances or diversion (transfer of a medication from a legal to an illegal use).Findings:a. During a review of Resident 64's admission Record, the admission Record indicated the facility admitted Resident 64 on 7/23/2026 with diagnoses including end stage renal disease ( ESRD - chronic kidney disease that causes gradual loss of kidney function), dependence on dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and depression (persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities).During a review of Resident 64's History and Physical (H&P), dated 7/25/2026, the H&P indicated Resident 64 did have the capacity to understand and make decisions.During a review of Resident 64's Minimum Data Set (MDS - a resident assessment tool), dated 7/27/2026, the MDS indicated Resident 64's cognition (ability to learn, reason, remember, understand, and make decisions) was intact, required moderate assistance (helper does less than half the effort) for eating, oral hygiene, and personal hygiene, required maximal assistance (helper does more than half the effort) for upper body dressing, and was dependent (helper does all the effort) for toileting hygiene, bathing, and lower body dressing. During a concurrent observation and interview on 8/5/2026 at 9:40 a.m. outside Resident 64's room, Licensed Vocational Nurse (LVN) 1 prepared Resident 64's medication. LVN 1 stated Resident 64's rectal hydrocortisone was not available in the medication cart.During a review on 8/5/2026 at 10:34 a.m., Resident 64's Physician Order Summary, dated 8/7/2026, indicated an order for Rectal 1% Hydrocortisone to be applied to external rectal area topically (on the surface of the body) two times a day for hemorrhoid symptom relief.During a review on 8/5/2026 at 1:07 p.m., Resident 64's electronic medication administration record (EMAR) for August 2026 was reviewed. Resident 64's EMAR indicated the rectal hydrocortisone was pending a delivery from the pharmacy on 8/4/2026 and 8/5/2026.During a concurrent interview and record review on 8/5/2026 at 3:49 p.m. with LVN 1, Resident 64's order summary and August 2026 EMAR were reviewed. LVN 1 stated the rectal hydrocortisone had not arrived. LVN 1 stated the facility is waiting for the pharmacy to deliver Resident 64's rectal hydrocortisone. LVN 1 stated Resident 64 did not receive the rectal hydrocortisone on 8/4/2026 and 8/5/2026.During an interview on 8/7/2026 at 12:34 p.m. with the Director of Nursing (DON), the DON stated the residents should receive medication as ordered. The DON stated the medications should have been available for the resident. The DON stated not receiving the rectal hydrocortisone may result in continued pain or discomfort in Resident 64's rectal area.b. During a concurrent interview and record review on 8/7/2026 at 12:10 p.m. in the DON office with the DON, the Controlled substance destruction log was reviewed. Two Controlled drug records dated 8/2/2026 indicated a pharmacy signature at the date and time of destruction. The DON stated there is no RN signature on the date of destruction. The DON stated they (DON) are present for the destruction of the controlled substances. The DON stated it is important for an RN or DON to witness and sign the controlled drug records at the time of destruction to ensure medications are accounted for and prevent diversion.During a review of the facility's policy and procedure (P&P), titled Preparation and General Guidelines: Medication Administration, dated May 2022, the P&P indicated Medications are administered in accordance with written orders of the prescriber.During a review of the facility's P&P, titled Disposal of Medications and Medication-Related Supplies, dated May 2022, the P&P indicated When controlled medications are destroyed at the facility licensed staff as allowed by state law will witness the destruction and ensure that the following information is entered on the individual controlled substance accountability record/book:1. Date of destruction2. Resident's name3. Name and strength of medication4. Prescription number5. Amount of medication destroyed6. Signatures of witnesses7. And any additional information required by state regulatory agencies.

Based on observation, interview and record review, the facility failed to follow the facility's recipe instructions documented on Cooks Spreadsheet: Summer Menus, when parsley was not placed on the breakfast plate on 8/4/2026 for 32 of 45 residents receiving a regular texture diet.This failure had the potential to result in residents not finding the food appealing or appetizing and resulting in decreased intake and nutrition.Findings:During a record review of the Cooks spreadsheet: Summer Menus for 8/4/2026, the Cooks spreadsheet indicated regular texture diets should have received a parsley sprig garnish.During an observation on 8/4/2026 at 7:20 a.m., in the kitchen during breakfast service preparation, there was no parsley present on the food assembly line (Trayline). [NAME] 1 did not place parsley on any plate.During a concurrent interview and record review on 8/4/2026 at 7:45 a.m. in the kitchen with [NAME] 1, the Cooks spreadsheet: Summer menu for 8/4/2026 breakfast recipe instructions were reviewed. [NAME] 1 stated the regular textured diets should have received parsley garnish. [NAME] 1 stated they (Cook 1) forgot to prepare the parsley garnish.During a interview on 8/5/2026 at 2:56 p.m. with the Dietary Supervisor (DS), the DS stated it is important to follow the recipe instructions as stated on the Cooks spreadsheet. The DS stated the Cooks spreadsheet are designed to ensure residents receive proper nutrition. The DS stated parsley is included to make the resident's plate more appealing and appetizing.During an interview on 8/7/2026 at 12:41 p.m. with the Director of Nursing (DON), the DON stated the kitchen should follow the recipe instructions when preparing meals. The DON stated the parsley is important because it helps with palatability (how tasty, pleasant, or acceptable a food or drink is). During a review of the facility's policy and procedure (P&P), titled Menu Planning, dated 2023, the P&P indicated the menus are planned to meet nutritional needs of residents in accordance with established national guidelines, and physician orders.Standardized recipes adjusted to appropriate yield shall be maintained and used in food preparation.During a review of the facility's P&P, titled Food and Nutrition Services, dated 2023, the P&P indicated the food service department, which is organized, staffed, and equipped to assure that the food service to residents is safe, appetizing, and provides for their nutritional needs.

Based on observation, interview and record review, the facility failed to follow the Juice Shelf Life policy to dispose of pineapple blend juice after one month of opening affecting 42 of 45 residents receiving thin liquids (drinks that pour and flow quickly).This failure had the potential to result in residents experiencing stomach discomfort or not receiving adequate nutritional needs.Findings:During a concurrent observation and interview on 8/3/2026 at 8:25 a.m. in the kitchen with dietary aide (DA) 1, the juice machine and boxes were inspected. DA 1 stated the juice bag-in-the boxes are used for one month after connecting the juice bag. DA 1 stated the pineapple juice blend had an open date of 6/4/2026. DA 1 stated the pineapple juice should have been changed to a new bag.During a concurrent interview and record review on 8/5/2026 at 3:40 p.m. in the kitchen with the Dietary Supervisor (DS), the facility's policy and procedure (P&P), titled Juice Shelf Life, undated, was reviewed. The P&P indicated, Once the bag-in-box has been connected, product is best if used within one month. The DS stated if the pineapple juice blend bag-in-box was opened on 6/4/2026, it was good until 7/4/2026. The DS stated if a resident receives juice past the expiration date or best by date, the juice might not be good or the juice concentrate could be expired.During an interview on 8/7/2026 at 12:45 p.m. with the Director of Nursing (DON), the DON stated if a resident received expired juice, the resident might not receive appropriate nutritional needs or may have stomach discomfort.During a review of the facility's policy and procedure (P&P), titled Food and Nutrition Services, dated 2023, the P&P indicated the food service department, which is organized, staffed, and equipped to assure that the food service to residents is safe, appetizing, and provides for their nutritional needs.

Based on interview and record review, the facility failed to update care plan and interventions when Resident 5 experienced a repeat fall on 5/4/2026 and 6/10/2026 for one of two sampled residents reviewed for falls (Resident 5).These failures resulted in Resident 5 experiencing repeated falls on 6/10/2026 and 7/17/2026 and had a potential to result in Resident 5 experiencing continued falls and possible injury.Findings:During a review of Resident 5's admission Record, the admission Record indicated the facility admitted Resident 5 on 1/13/2026 and readmitted on [DATE] with diagnoses including atrial fibrillation (an irregular, rapid heart rate that may cause symptoms like heart palpitations), 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 5's History and Physical (H&P), dated 7/22/2026, the H&P indicated Resident 5 did not have the capacity to understand and make decisions.During a review of Resident 5's Minimum Data Set (MDS - a resident assessment tool), dated 7/17/2026, the MDS indicated Resident 5 had severe cognitive (ability to learn, reason, remember, understand, and make decisions) impairment, required moderate assistance (helper does less than half the effort) for eating, oral hygiene, and personal hygiene, required maximal assistance (helper does more than half the effort) for upper body dressing, and was dependent (helper does all the effort) for toileting hygiene, bathing, and lower body dressing. During a review of Resident 5's Fall Risk Evaluation, dated 4/18/2026, the Fall Risk Evaluation indicated Resident 5 was considered at risk for falls. The Fall Risk Evaluation indicated Resident 5's risk factors for falls included history of falls in the past three months, had decreased muscular coordination, and required use of assistive devices such as canes, wheelchairs, or walker.During a review of Resident 5's change of condition documentation, titled Situation-Background-Assessment-Recommendation (SBAR) Communication form dated 4/18/2026, the SBAR Communication form indicated Resident 5 had a fall on 4/18/2026.During a review of Resident 5's change of condition documentation, titled SBAR Communication form dated 5/4/2026, the SBAR Communication form indicated Resident 5 fell on 5/4/2026.During a review of Resident 5's change of condition documentation, titled SBAR Communication form dated 6/10/2026, the SBAR Communication form indicated Resident 5 fell on 6/10/2026.During a review of Resident 5's change of condition documentation, titled SBAR Communication form dated 7/17/2026, the SBAR Communication form indicated Resident 5 fell on 7/17/2026.During a concurrent interview and record review on 8/7/2026 at 1:01 p.m. ,with the Director of Nursing (DON), Resident 5's SBAR Communication forms dated 4/18/2026, 5/4/2026, 6/10/2026, and 7/17/2026 and care plans were reviewed. The DON stated Resident 5 had fallen on 4/18/2026, 5/4/2026, 6/10/2026, and 7/17/2026. The DON stated Resident 5's fall care plan was not revised and did not implement new interventions after Resident 5 fell on 5/4/2026 and 6/10/2026. The DON stated Resident 5's fall care plan should have been revised and updated with new interventions after every fall incident.During a review of the facility's policy and procedure (P&P), titled Fall Management System, revised April 2025, the P&P indicated after a fall incident, the resident's care plan will be updated.

Based on interview and record review, the facility failed to provide diabetic care (maintain target glucose [sugar] levels) for one of one sampled diabetic residents who was refusing blood glucose checks and insulin (medication that controls the level of sugar in the body) when: a. Resident 4's physician (MD 1) was not notified Resident 4's had been refusing blood glucose monitoring and insulin. b. A care plan for Resident 4's refusals of insulin and glucose monitoring was not created or implemented. This deficient practice had the potential for a delay in care for Resident 4 and abnormal glucose levels to go unnoticed. Findings:During a review of Resident 4's admission Record (face sheet), the admission Record indicated Resident 4 was admitted to the facility 6/23/2026 with diagnoses of Type 2 Diabetes (a chronic medical condition where your body resists insulin or does not make enough of it) and morbid obesity (overweight). During a review of Resident 4's Minimum Data Set (MDS, a resident assessment tool) dated 5/1/2026, the MDS indicated Resident 4 was cognitively intact (healthy brain function) and had diabetes. During a review of Resident 4's current care plans as of 8/2026, there were no care plans implemented for Resident 4's refusals of insulin and blood glucose checks. During a review of Resident 4's Order Summary Report for 8/2026, the Order Summary Report indicated there was a physician's order placed 7/9/2026 for Insulin Lispro Injection Solution 100 UNIT/milliliter (mL) inject as per sliding scale: if blood sugar is less than 70 GIVE 8 ounces of juice if the resident was awake and alert and if the blood sugar was more than 350 give 6 units of insulin then notify the physician one time a day for diabetes. During an interview and concurrent record review on 8/7/2026 at 9:12 a.m., with the Director of Nursing (DON), Resident 4's Medication Administration Record (MAR0 for the months of July and August 2026, Care Plans, and Electronic Medical Records (EMR) were reviewed. The DON stated she reviewed Resident 4's MAR for the months of July (15 occurrences) and August (three occurrences) 2026 and there were multiple days where nursing staff put refused for insulin administration and NA (not applicable) for the blood glucose result. The DON stated she reviewed Resident 4's care plans and there was no care plan related to Resident 4 refusing insulin or blood glucose monitoring. The DON stated she reviewed Resident 4's EMR including nurses progress notes and change of condition (COC) evaluations but could not find any entries stating the nursing staff made MD 1 aware Resident 4 was refusing insulin and blood glucose checks. The DON stated there should have been documentation indicating MD 1 was informed regarding Resident 4's refusal of insulin and blood glucose checks. The DON stated not checking Resident 4's blood glucose level could lead to unidentified hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar). The DON stated it was very important to let MD 1 know about the refusal of insulin and blood sugar checks because it could affect the health of Resident 4 and MD 1 should have been made aware so he could implement different interventions to safely manage Resident 4's diabetes. The DON stated a care plan for Resident 4's refusals of blood sugar checks and insulin was important because it gave guidance to the nurses to accurately manage Resident 4's diabetes. During a review of the facility's policy and procedure (P/P) titled Resident Rights- Medications and Treatments, Refusal of undated, the P/P indicated if a resident refused medication or treatment documentation in the medical record was to include the date and time the physician was notified as well as the physician's response. During a review of the facility's P/P titled Comprehensive Person-Centered Care Planning revised 4/2025, the P/P indicated the resident could refuse treatment but if the refusal posed a risk to residents' health and safety, the comprehensive care plan would identify the care or service declined.

Based on interview and record review, the facility failed to attempt a gradual dose reduction [GDR - an attempt to decrease or discontinue psychotropic (capable of affecting the mind, emotions, and behavior) medication after no more than three months after starting on the psychotropic medication, unless clinically contraindicated) for Aripiprazole [medication used to treat schizophrenia (a mental illness that is characterized by disturbances in thought), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and major depression (persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities)] and Sertraline (medication used to treat depression) for one of three sampled residents reviewed for psychotropic medication use Resident 9.These failures had the potential to result in use of unnecessary psychotropic medication for Resident 9 and can lead to side effects and adverse consequences such as a decline in quality of life and functional capacity.Findings:During a review of Resident 9's admission Record, the admission Record indicated the facility admitted Resident 9 on 3/7/2024 and readmitted on [DATE] with diagnoses including major depressive disorder, bipolar disorder, schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and Alzheimer's disease (a disease characterized by a progressive decline in mental abilities).During a review of Resident 9's History and Physical (H&P), dated 3/17/2026, the H&P indicated Resident 9 had the capacity to understand and make decisions.During a review of Resident 9's Minimum Data Set (MDS - a resident assessment tool), dated 6/8/2026, the MDS indicated Resident 9's cognition (ability to learn, reason, remember, understand, and make decisions) was intact, was independent when eating, required setup assistance for oral hygiene, required supervision for personal hygiene, required moderate assistance (helper does less than half the effort) for upper body dressing, required maximal assistance (helper does more than half the effort) for toileting hygiene, bathing, and lower body dressing. During a review of Resident 9's Physician Order Summary dated 8/7/2026, the Order Summary indicated orders for:a. Aripiprazole oral tablet 15 milligrams (MG - metric unit of measurement, used for medication dosage and/or amount) - give one tablet by mouth one time a day for bipolar disorder manifested by (M/B) sudden mood changed.b. Sertraline Hydrocholoride (HCL) oral tablet 25 MG - give one tablet by mouth one time a day for major depressive disorder M/B verbalization of feeling sad.During a review of Resident 9's July 2026 Medication Administration Record (MAR) and August 2026 MAR, the July 2026 MAR and August 2026 MAR indicated Resident 9 received the Aripiprazole and Sertraline daily as ordered.During a concurrent interview and record review on 8/7/2026 at 12:48 p.m. with the Director of Nursing (DON), May 2026 Medication Regimen Review (MRR), June 2026 MRR, and Resident 9's Psychiatry Notes dated 8/4/2025, 9/8/2025, 9/22/2025, 10/6/2025, 11/2/2025, 11/24/2025, 12/14/2025, 12/29/2025, 1/9/2026, 2/19/2026, 3/5/2026, 4/2/2026, 4/16/2026, 5/7/2026, and 6/18/2026 were reviewed. The May 2026 MRR indicated the facility had not attempted a previous GDR for Resident 9's Aripiprazole and Sertraline. The May 2026 MRR indicated Resident 9's Aripiprazole and Sertraline's next GDR consideration was 8/15/2026. The June 2026 MRR indicated the facility had not attempted a previous GDR for Resident 9's Aripiprazole and Sertraline. The June 2026 MRR indicated Resident 9's Aripiprazole and Sertraline's next GDR consideration date was 10/12/2026. The DON stated the Psychiatry Notes did not indicate when Resident 9's the facility attempted a GDR for Aripiprazole and Sertraline. The DON stated Resident 9's last attempted GDR's are unknown. The DON stated the facility relies on the pharmacy MRR's recommended GDR consideration dates to attempt a GDR for psychotropic medication. The DON stated it is important to know the facility's last attempted GDR for psychotropic medications to ensure residents do not receive unnecessary psychotropic medications.During a review of the facility's policy and procedure (P&P), titled Psychotropic Medications, Revised date February 2024, the P&P indicated the facility will ensure that Residents who use psychotropic drugs receive a gradual dose reductions (GDR), and behavioral interventions, unless clinically contraindicate, in an effort to discontinue these drugs.

Based on interview, and record review, the facility failed to ensure one of one sampled resident (Resident 64), who received hemodialysis (HD-process of mechanically removing waste products and excess fluid from the body) treatment, received care in accordance with standards of practice as evidenced by:a. Failing to monitor and document urine output as physician ordered.b. Failing to implement the prescribed fluid restriction of 1000 milliliters(ml) per day as physician ordered.c. Failing to measure and document weekly weight as physician ordered.This failure resulted in Resident 64 suffering from complications such as fluid overload (too much fluid build up in the body, causing swelling).Findings:During a review of Resident 64's admission Record (Face sheet- front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility admitted Resident 64 on 7/23/ 2026 with diagnoses included End Stage Renal Disease (ESRD-irreversible kidney failure) on HD, Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and essential hypertension (a type of high blood pressure that has no clearly identifiable cause).During a review of Resident 64's History and Physical (H&P), dated 7/26/2026, the H&P indicated that Resident 64 had the ability to understand and make decisions.During a review of Resident 64's Minimum Data Set (MDS - resident assessment tool), dated 7/27/2026, the MDS indicated that Resident 64 required dependent assistance (Helper does all of the effort) from two or more staff for transfer, shower, toilet hygiene, lower body dressing, maximal assistance (Helper does more than half the effort) from one staff for upper body dressing, bed mobility, and moderate assistance (Helper does less than half the effort) from one staff for eating, oral hygiene.a. During a concurrent interview and record review on 8/5/2026 at 1:29 p.m., with Registered Nurse Supervisor (RNS) 1, Resident 64's Order Summary Report (OSR), dated 8/5/2026 was reviewed. The OSR indicated staff were required to document total intake and output every shift, document the weekly average intake and output, and complete a weekly evaluation of Resident 64's intake and output were ordered on 7/24/2026. RNS 1 stated that staff should record intake and output in measurable units (ml) each shift and assess whether Resident 64's intake and output was balanced. RNS 1 stated that the amount of output should be close to the amount of intake. RNS 1 stated that monitoring intake and output was essential for evaluating kidney function, particularly for residents receiving HD treatment.During a concurrent interview and record review on 8/6/2026 at 9:10 a.m., with the Director of Staff Development (DSD), Resident 64's Medication Administration Record (MAR), dated from 7/24/2026 to 8/2/2026 was reviewed. The MAR indicated that urine output was documented using frequency rather than measurable units. The MAR indicated there was no documentation of the weekly intake and output evaluation or the weekly average intake and output. The DSD stated that monitoring a resident's fluid status was crucial for residents receiving hemodialysis (HD) to prevent fluid overload, which can cause difficulty breathing and heart failure (a condition in which the heart cannot pump enough blood to meet the body's needs). The DSD stated that staff should have measured urine output in measurable units and documented the weekly intake and output evaluation and weekly average. The DSD stated it would be impossible to determine kidney function without this critical information.b. During a concurrent interview and record review on 8/5/2026 at 1:35 p.m., with Registered Nurse Supervisor (RNS) 1, Resident 64's Order Summary Report (OSR), dated 8/5/2026 was reviewed. The OSR indicated a fluid restriction of 1000 ml in 24 hours: Nursing 7-3 shift for 240 ml, 3-11 shift for 240 ml, and 11-7 shift for 160 ml. Dietary intake of 120 ml for breakfast, 120 ml for lunch, and 120 ml for dinner was ordered on 7/27/2026. RNS 1 stated total intake should have been less than 1000 ml in 24 hours per the physician's order. RNS 1 stated staff should have followed the fluid restriction as ordered, but she believed staff did not follow the order. RNS 1 stated not following the fluid restriction order increased the risk of fluid overload.During a concurrent interview and record review on 8/6/2026 at 9:20 a.m. with the DSD, Resident 64's Medication Administration Record (MAR), dated 7/27/2026 to 8/2/2026 was reviewed. The MAR indicated total intake in 24 hours as follows: 7/27/2026 (1600 ml), 7/28/2026 (1250 ml), 7/29/2026 (1600 ml), 7/30/2026 (1000 ml), 7/31/2026 (1600 ml), 8/1/2026 (1850 ml), and 8/2/2026 (1330 ml). The DSD stated there was only one day (7/30/2026) when total intake was implemented as the physician ordered. The DSD stated the staff failed to implement the fluid restriction order, which increased the risk of fluid overload.c. During a concurrent interview and record review on 8/6/2026 at 8:32 a.m. with Restorative Nurse Assistant (RNA) 1, Resident 64's RNA Weekly Weight Report, dated 7/2026, was reviewed. The RNA Weekly Weight Report indicated Resident 64 was admitted on [DATE] and there was no weight measurement. The report indicated Resident 64's weight was 176 pounds (lbs) on 7/25/2026 and 172 lbs on 8/1/2026 per the dialysis record. RNA 1 stated she did not measure Resident 64's weight herself and converted the weight from kilograms (kg) to pounds (lbs) based on the values received from the hemodialysis (HD) center. RNA 1 stated she converted weight into kilograms by multiplying by two to obtain pounds. RNA 1 stated Resident 64 was the only resident who received HD treatment.During a concurrent interview and record review on 8/6/2026 at 9:15 a.m., with the DSD, Resident 64's Order Summary Report (OSR), dated 8/5/2026 was reviewed. The OSR indicated that weekly weights were ordered on 7/23/2026, to be measured every Wednesday for four weeks. The DSD stated that Resident 64's weight should have been measured and documented on the following dates: 7/23/2026 (admission date), 7/29/2026 (Wednesday), and 8/5/2026 (Wednesday). The DSD stated no admission weight was documented for 7/23/2026. The DSD stated that the correct weight conversion formula is kilograms multiplied by 2.2. The DSD stated that RNA 1 used an incorrect conversion method. The DSD stated the weight obtained from the HD center on two occasions was converted incorrectly. The DSD stated 80.3 kg, which should convert to 176.7 lbs, was incorrectly documented as 176 lbs on 7/25/2026. The DSD 78.6 kg, which should convert to 172.9 lbs, was incorrectly documented as 172 lbs on 8/1/2026. The DSD stated that accurately measuring and converting weight is essential for correctly evaluating a resident's fluid status, particularly for individuals receiving hemodialysis treatment. The DSD stated that RNA 1 should have measured Resident 64's weight as ordered, rather than relying on the HD center's records.During a concurrent interview and record review on 8/7/2026 at 9:41 a.m., with the Director of Nursing (DON), Resident 64's Care Plan (CP) titled, Resident 64 needs Hemodialysis related to ESRD, dated 7/27/2026 was ordered. The CP goal indicated that Resident 64 would have no signs or symptoms of complications from dialysis through the target date of 10/21/2026. The CP interventions included monitoring intake and output, restricting fluids to 1000 ml per day, and obtaining weight as ordered. The DON stated that the most common complication experienced by residents receiving hemodialysis was fluid overload. The DON stated that monitoring and documenting intake and output, restricting fluids as ordered, and measuring weight are essential interventions to prevent fluid overload, which could lead to shortness of breath and heart failure.During a review of the facility's Policy and Procedure(P&P) titled, Intake & Output Documentation, revised 1/2015, the P&P indicated, Procedures: 2. The intake and output (I &O) information is to be recorded at the end of each shift by a licensed nurse. The 24-hour total is to be entered. 3. Weekly evaluations are to be written and shall include the following: a. Average l&O for the past week. b. Adequacy of the I&O for the individual resident and hydration status. c. Resident's response and progress toward goal(s) established on the care plan. d. Characteristics of the urine. e. Problem identification, assessment, and interventions taken.During a review of the facility's Policy and Procedure(P&P) titled, Nutrition Care Management, revised 7/21/2021, the P&P indicated, Procedure: 2. Each resident is to be weighed and height measured upon admission. Weekly weights for four (4) weeks and monthly weight thereafter will be conducted. The weight will be entered into PCC in the weights and vitals tab.

Based on observation, interview and record review, the facility failed to maintain a medication error rate of less than five percent (%) observed during medication administration (medication pass) as evidenced by the identification of two medication errors out of 30 opportunities to yield a facility medication error rate of 18% affecting for one of six sampled residents (Resident 64). The facility failed to:Ensure Resident 64 received the physician ordered renal (related to the kidneys) multivitamin oral tablet 0.8 milligrams (mg- unit of measurement) instead of the offered renal therapeutic nutrition shake on 8/5/2026.Administer rectal hydrocortisone (medication used to lower swelling, redness, and/or itching to the rectum) to Resident 64 on 8/5/2026.These failures had the potential to result in Resident 64's inadequate renal nutritional support and rectal pain or discomfort.Findings:During a review of Resident 64's admission Record, the admission Record indicated the facility admitted Resident 64 on 7/23/2026 with diagnoses including end stage renal disease (ESRD - chronic kidney disease that causes gradual loss of kidney function), dependence on dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and depression (persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities).During a review of Resident 64's History and Physical (H&P), dated 7/25/2026, the H&P indicated Resident 64 did have the capacity to understand and make decisions.During a review of Resident 64's Minimum Data Set (MDS - a resident assessment tool), dated 7/27/2026, the MDS indicated Resident 64's cognition (ability to learn, reason, remember, understand, and make decisions) was intact, required moderate assistance (helper does less than half the effort) for eating, oral hygiene, and personal hygiene, required maximal assistance (helper does more than half the effort) for upper body dressing, and was dependent (helper does all the effort) for toileting hygiene, bathing, and lower body dressing. During a concurrent observation and interview on 8/5/2026 at 9:40 a.m. outside Resident 64's room, Licensed Vocational Nurse (LVN) 1 prepared Resident 64's medication. LVN 1 prepared nine medications and one bottle of a renal therapeutic nutrition shake. LVN 1 did not prepare Resident 64's Renal Multivitamin oral tablet 0.8 MG (B-Complex with C & Folic Acid). LVN 1 stated Resident 64's rectal hydrocortisone was not available in the medication cart.During a concurrent observation and interview on 8/5/2026 at 10:03 a.m. inside Resident 64's room, LVN 1 administered nine medications to Resident 64. LVN 1 provided Resident 64 with a bottle of the renal therapeutic nutrition shake. Resident 64 stated the shake will hurt their (Resident 64's) stomach or cause vomiting.During a review on 8/5/2026 at 10:34 a.m., Resident 64's Physician Order Summary, dated 8/7/2026, indicated orders for:Renal Multivitamin oral tablet 0.8 MG (B-Complex with C & Folic Acid) to be given one tablet by mouth one time a day for supplements Rectal 1% Hydrocortisone to be applied to external rectal area topically (on the surface of the body) two times a day for hemorrhoid symptom relief.The order summary did not indicate an order for a renal therapeutic nutrition shake.During a review on 8/5/2026 at 1:07 p.m., Resident 64's electronic medication administration record (EMAR) for August 2026 was reviewed. Resident 64's EMAR indicated LVN 1 documented Resident 64 received the Renal Multivitamin oral tablet 0.8 MG (B-Complex with C & Folic Acid) on 8/5/2026. Resident 64's EMAR indicated the rectal hydrocortisone was pending a delivery from the pharmacy.During a concurrent interview and record review on 8/5/2026 at 3:49 p.m. with LVN 1, Resident 64's order summary and August 2026 EMAR were reviewed. LVN 1 stated they thought the Renal Multivitamin oral tablet 0.8 MG (B-Complex with C & Folic Acid) order was the renal therapeutic nutrition shake and offered it to Resident 64. LVN 1 stated the Renal Multivitamin oral tablet 0.8 MG (B-Complex with C & Folic Acid) was not available in the medication cart. LVN 1 stated the rectal hydrocortisone had not arrived. LVN 1 stated the facility is waiting for the pharmacy to deliver Resident 64's rectal hydrocortisone.During an interview on 8/7/2026 at 12:34 p.m., with the Director of Nursing (DON), the DON stated the residents should receive medication as ordered. The DON stated the medications should have been available for the resident. The DON stated not receiving the renal multivitamin 0.8 MG placed Resident 64 at risk for inadequate nutrition or supplements to the kidneys. The DON stated not receiving the rectal hydrocortisone may result in continued pain or discomfort in Resident 64's rectal area.During a review of the facility's policy and procedure (P&P), titled Preparation and General Guidelines: Medication Administration, dated May 2022, the P&P indicated Five rights - right resident, right drug, right dose, right route and right time are applied for each medication being administered. A triple check of these 5 Rights is recommended.Medications are administered in accordance with written orders of the prescriber.

Based on observation, interview and record review, the facility failed to store Resident 25's rectal medications separately from inhalation and nasal spray medications for four of 22 residents whose medications are dispensed from the Station 2 medication cart (Resident 12, 28, 40, and 45).This failure had the potential to result in medication errors for the incorrect route of administration.Findings:During a concurrent observation and interview of 8/5/2026 at 3:49 p.m. at the Station 2 medication cart with Licensed Vocational Nurse (LVN 1), Resident 25's rectal lidocaine anorectal cream (a prescribed cream applied to the rectum used to reduce pain, burning, and/or itching caused by hemorrhoids) was stored in the same bin with Resident 40's Fluticasone Propionate Nasal Spray (a medication sprayed inside the nose to stop allergy symptoms such as sneezing, runny nose, and itchy nose) , Resident 12's Advair Diskus [a medication used to control and prevent breathing problems from asthma or chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing)] for oral inhalation, Resident 45's nasal decongestion spray (a liquid medication sprayed into the nose to clear a stuffy nose), and Resident 28's albuterol inhaler (a fast-acting rescue medication used to quickly open the airways in the lungs during wheezing, coughing, and chest tightness).During an interview on 8/7/2026 at 12:41 p.m. with the Director of Nursing (DON), the DON stated rectal route medication should be stored separately from inhaled or ingested route medications to prevent potential medication errors.During a review of the facility's policy and procedure (P&P), titled Storage of Medications, dated May 2022, the P&P indicated Orally administered medications are kept separate from externally used medications and treatments such as suppositories, ointments, creams, vaginal products, etc.

Based on record review and interview, the facility staff failed to document the accurate intake and output (I&O) for one of three sampled residents (Resident 1), who was admitted to the facility with an indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) . This deficient practice resulted in the inability of the facility to accurately gauge the amount urine output and quality of urine for Resident 1 and had the potential for urinary inconsistencies to be unrecognized.Findings: During a review of Resident 1's admission Record (Face Sheet) the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had a diagnosis of urinary retention (inability to fully empty your bladder). During a review of Resident 1's History and Physical (H&P), the H&P indicated Resident 1 did not have the capacity to understand and make decisions and her compacity to understand fluctuated. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 1/7/2026, the MDS indicated Resident 1 required supervision with toilet hygiene. During a record review of Resident 1's Care Plan dated 1/7/2026, the Care Plan indicated Resident 1 had an indwelling urinary catheter due to a diagnosis of urinary retention. The Care Plan's goal was for Resident 1 to remain free form catheter related trauma and will show no s/s of urinary tract infection. The Care Plan's interventions were to monitor and document Resident 1's I&Os and to monitor for signs and symptoms (s/s) of discomfort and frequency on urination. During a review of Resident 1's Medication Administration Record ([MAR] a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 1/3/2026, the MAR indicated Resident 1's I&Os were documented as follows: Day Shift1/4/2026 - 1/16/2026 Resident 1's I&O was documented as x2 Evening Shift1/4/2026 - 1/16/2026 Resident 1's I&O was documented as x2 Night Shift1/4/2026 - 1/8/2026 and 1/10/2026 - 1/16/2026 Resident 1's I&O was documented as x2 During an interview on 2/13/2026 at 3:49 p.m., Registered Nurse (RN) 2 stated when a resident is admitted to the facility with an indwelling urinary catheter we monitor the I&O to make sure the resident is not retaining urine. RN 2 stated the indwelling urinary bag collects the resident's urine and is emptied and measured, documenting x2 is not how the urine output should be measured. During an interview on 1/13/2026 at 1:30 p.m., the Director of Nursing (DON) stated after each shift the CNAs empty the residents' urinary bag and report the amount of urine collected to the licensed Nurse assigned to the resident. The DON stated the Licensed Nurses document on the MAR the amount of urine output in CCs and should not document the urine output as x1, x2. During a review the facility's Policy and Procedure (P&P, titled, Intake and Output Documentation revised 1/2015, the P&P indicated it is the policy of this facility that fluid intake and output shall be recorded for each resident with an indwelling catheter The intake and output information is to be recorded at the end of each shift by a licensed nurse.

Based on observation, interview, and record review, the facility failed to ensure for one of three sampled residents (Resident 2), who was continent of bowel and bladder functions, that he was not made to wear an adult brief (diaper) and not asked to urinate in it. This deficient practice resulted in Resident 2's inability to use the restroom and feeling like a child when made to wear diapers. This deficient practice had the potential for Resident 1's ability to use the restroom to diminish over time. Findings: During a review of Resident 2's admission Record (Face Sheet) the Face Sheet indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses included essential primary hypertension ([HTN] high blood pressure), spinal stenosis (narrowing spaces in the spine causing pain and numbness) and type 2 diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing) without complications. During a review of Resident 2's History and Physical (H&P), the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool) dated 1/1/2026, the MDS indicated Resident 2 required substantial /maximal assistant (helper dose more than half the effort) with sit to lying and he was dependent (helper does all the effort) with toilet transfer, tub/ shower transfers and sit to stand. During a review of Resident 2's Bowel and Bladder Evaluation dated 1/28/2026, the Bowel and Bladder Evaluation indicated Resident 2 was continent (ability to control your bladder). During a review of Resident 2's Care Plan dated 1/30/2026/, the Care Plan indicated Resident 2 had a deficit in performing his activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily)) related to spinal stenosis. XXXX The Care Plan's interventions indicated Resident 2 needed two-persons to assist him with toilet transfers and to encourage him to participate to the fullest extent possible with each interaction. During an observation of Resident in his room and a concurrent interview on 2/11/2026 at 11:13 a.m., Resident 2 was observed pulling on an adult brief he was wearing, and stated he was placed in this adult brief and told to use the rest room in it. Resident 2 stated a nurse told him if he had to use the restroom just go in your adult brief. Resident 2 stated they could have given him a bedpan or a bedside commode to use and wearing an adult brief made it difficult for him to urinate, like his body was shutting down and he felt like a baby wearing adult briefs. During an interview on 2/11/2026 at 3:10 p.m., Certified Nursing Assistant (CNA) 1 stated she put an adult brief on Resident 2 because when he uses a urinal (a plastic container males use to urinate in) he urinates everywhere. CNA 1 stated she puts adult briefs on all her residents unless she is told not to do so. During an interview on 2/11/2026 at 3:35 p.m., Registered Nurse (RN ) 1 stated Resident 2 was continent of bowel and bladder and did not need to wear adult briefs. RN 1 stated Resident 2 should be allowed to use a bedside commode if that was what he wanted to do. During an interview on 2/12/2026 at 4 p.m., the Director of Staff Development (DSD) stated continent residents should be made to wear adult briefs. The DSD stated staff were not instructed to tell residents to go in their diaper by placing diapers on continent residents, they could possibly lose the urge to control their bladder and become incontinent. During an interview on 2/13/2026 at 1:30 p.m., the Director of Nursing (DON) stated if a resident does not want to wear adult briefs they should not be made to wear them. During a review of the facility's Policy and Procedure (P&P) dated 11/2021 titled, Residents Rights the P&P indicated it was the policy of this facility that all residents be treated with kindness dignity and respect.

Based on observation, interview, and record review, the facility failed to ensure medications were administered as prescribed by the physician and not left unattended on the bedside table of one of three sampled residents (Resident 4). This deficient practice resulted in Resident 4 not receiving his prescribed medication and had the potential for the unattended medication to be taken and/or ingested by other residents causing unnecessary medication administration and/or harm.Findings: During a review of Resident 4's admission Record (Face Sheet) the Face Sheet indicated Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including essential primary hypertension ([HTN] high blood pressure), unspecified atrial fibrillation ([a-Fib] irregular heart rhythm) , and anemia (low red blood cell count). During a review of Resident 4's Minimum Data Set ([MDS] a resident assessment tool) dated 6/27/2025, the MDS indicated Resident 4 required supervision with toilet hygiene, shower /bathe self and independent with eating and oral hygiene. During a review of Resident 4's Medication Administration Record ([MAR] a daily documentation record used by licensed nurse to document medications and treatments given to a resident) dated 2/2026, the MAR indicated the following medications were administered to Resident 4 on 2/11/2026 at 9:00 a.m. 1. Chlorthalidone oral tablet 50 milligram ([mg] a metric unit of measurement, used for medication dosage and/or amount) give 1/2 tablet daily for congestive heart failure ([CHF] a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). 2. Ferrous Sulfate (Iron) 325 mg one tablet daily as a supplement. 3. Memantine HCL 5 mg one tablet daily for Alzheimer's disease, unspecified. 4. Multi -Vitamin one tablet daily as a supplement. 5. Docusate Sodium 100 mg one capsule two times for bowel management. 6. Hydrochlorothiazide 50 mg tablet daily for edema (swelling). During an observation on 2/11/2026 at 9:45 a.m., Licensed Vocational Nurse (LVN ) 1 entered Resident 4's room with a medication cup then left the room. At 10 a.m., and a subsequent observation at 11:29 a.m., a medication cup with 6 pills in it was observed on Resident 4's bedside table. During an interview on 2/11/2026 at 12:21p.m., LVN 1 stated she placed the medication cup with pills in it, on Resident 4's bedside table and left the room, because she was called to help another resident. LVN 1 stated it was not her usual practice to leave medication unattended on a resident's bedside table because another resident could ingest it, but she got busy. During an interview on 2/12/2026 at 4:15 p.m., the Director of Nursing (DON) stated licensed nurses should not to leave medication unattended at the resident's bedside because another resident could be harmed if they took it. During a review of the facility's Policy and Procedure (P&P) dated 9/2010 titled, Medication Administration the P&P indicated for residents not in their room or otherwise unavailable to receive medication on the pass, the MAR is flagged (e.g., tags colored plastic strips or paper clip). After completing the medication pass, the nurse returns to the missed resident to administer the medication. The resident is always observed after administration to ensure the dose was completely ingested. If only a partial dose is ingested, this is noted on the MAR, and action is taken as appropriate.

Based on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 1 accurately documented the medication administration for one of three sampled residents (Resident 4). This deficient practice resulted in Resident 4 not receiving medication as prescribed to him, but his clinical records indicating it was. This deficient practice had the potential to negatively impact Resident 4's health, mismanagement of his medication regimen and result in non-continuity of care.Findings: During a review of Resident 4's admission Record (Face Sheet) the Face Sheet indicated Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including essential primary hypertension ([HTN] high blood pressure), unspecified atrial fibrillation ([a-Fib] irregular heart rhythm) , and anemia (low red blood cell count). During a review of Resident 4's Minimum Data Set ([MDS] a resident assessment tool) dated 6/27/2025, the MDS indicated Resident 4 required supervision with toilet hygiene, shower /bathe self and independent with eating and oral hygiene. During a review of Resident 4's Medication Administration Record ([MAR] a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 2/2026, the MAR indicated the following medications were administered to Resident 4 on 2/11/2026 at 9:00 a.m. 1. Chlorthalidone oral tablet 50 milligram ([mg] a metric unit of measurement, used for medication dosage and/or amount) give 1/2 tablet daily for congestive heart failure ([CHF] a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). 2. Ferrous Sulfate (Iron) 325 mg one tablet daily as a supplement. 3. Memantine HCL 5 mg one tablet daily for Alzheimer's disease, unspecified. 4. Multi -Vitamin one tablet daily as a supplement. 5. Docusate Sodium 100 mg one capsule two times for bowel management. 6. Hydrochlorothiazide 50 mg tablet daily for edema (swelling). During an observation on 2/11/2026 at 9:45 a.m., Licensed Vocational Nurse 1 (LVN) 1 entered Resident 4's room with a medication cup then left the room. At 10 a.m., and a subsequent observation at 11:29 a.m., a medication cup with six pills in it was observed sitting on resident 4's bedside table. During an interview on 2/11/2026 at 12:21 p.m., and a concurrent review of Resident 4's MAR dated 2/2026, the MAR indicated Chlorthalidone 50 mg, Ferrous Sulfate 325 mg, Memantine HCL 5 mg, Docusate Sodium 100 mg, and hydrochlorothiazide 50 mg were documented as given at 9:55 a.m. LVN 1 stated she placed the medication cup with pills in it on Resident 4's bedside table and left the room, because she was called to help another resident. LVN 1 stated it was not her usual practice to leave medication unattended at a resident's bedside because another resident could ingest it, but she got busy. LVN 1 stated she should not have signed Resident 4's MAR indicating he received his medication when he did not receive it During an interview on 2/12/2026 at 4:15 p.m., the Director of Nursing (DON) stated the correct way to pass medications is to is to pour the medication, pass the medication and sign the MAR. Signing the MAR before the medications are administered is false documentation. During a review of the facility's Policy and Procedure (P&P) dated 9/2010, titled, Medication Administration the P&P indicated s for residents not in their room or otherwise unavailable to receive medication on the pass, the MAR is flagged (e.g., tags colored plastic strips or paper clip). After completing the medication pass, the nurse returns to the missed resident to administer the medication. The individual that administers the medication dose records the administration on the resident's MAR directly after the medication is given. Pour- Pass -Chart is the acceptable method for medication preparation, administration and documentation.

During interview and record review, the facility failed to ensure two of three sampled residents (Resident's 1 and 2), who were assessed at a high fall risk, and had previous falls, and were cognitively (the ability to think and reason) impaired, were capable of following Care Plan interventions which included using the call light for assistance. The facility failed to investigate and review causal factors per Resident 2's Care Plan interventions after Resident 2 fell on [DATE].These deficient practices resulted in Resident's 1 and 2 getting up unassisted without the knowledge of staff resulting in Resident 1 falling on 10/28/2025, and Resident 2 falling 11/22/2025. These failures increased the risk of future falls, potential injuries, and unnecessary hospitalizations for Resident's 1 and 2. Findings:a. During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing), speech and language deficits, repeated falls, hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and hemiparesis (weakness or loss of strength on one side of the body, affecting the arm, leg, and sometimes the face, making everyday tasks difficult) following a cerebral infarction ([stroke] loss of blood flow to a part of the brain) affecting the right dominant side.During a review of Resident 1's Minimum Data Set ([MDS] a federally mandated resident assessment tool), dated 10/9/2025, the MDS indicated Resident 1 had severe cognitive impairment. The MDS indicated Resident 1 was dependent on staff for toileting hygiene, required moderate assistance (helper does less than half the effort) for personal hygiene, and required maximum assistance (helper does more than half the effort) for walking up to 10 feet.During a review of Resident 1's Fall Risk assessment dated [DATE], the Fall Risk Assessment indicated Resident 1 was at a high risk for falls.During a review of Resident 1's At Risk for Falls Care Plan dated 10/5/2025, the Care Plan indicated Resident 1 was at risk for falls related to poor balance and gait (walking). The Care Plan goal indicated Resident 1 to be free from falls and had interventions which included making sure Resident 1's call light is within reach, and for staff to encourage Resident 1 to use the call light for assistance as needed.During a review of Resident 1's Situation, Background, Assessment, Recommendation ([SBAR] a communication tool used by healthcare workers when there is a change of condition among the residents), dated 10/13/2025, and timed at 4:10 p.m., the SBAR indicated Resident 1 fell in the restroom on 10/13/2025 at 4:10 p.m. During a review of Resident 1's Post-Event Interdisciplinary Team ([IDT] a group of medical professionals from different disciplines who work together to help a resident achieve their goals) Review, dated 10/13/2025, the Post-Event IDT Review indicated Resident 1 was found on the restroom floor and stated when he used the restroom his foot got stuck between the wheelchair when trying to wash his hands, then lost his balance and fell. The Post-Event IDT review indicated Resident 1 stated did not want to use the call light to bother anyone since he thought he could do it himself.During a review of Resident 1's Actual Fall Care Plan dated 10/13/2025, the Care Plan indicated Resident 1 had a fall due to poor balance. The Care Plan goal indicated Resident 1 will resume usual activities without further incident and interventions including educating Resident 1 to call for assistance when needed.During a review of Resident 1's SBAR, dated 10/28/2025 and timed at 4:10 a.m., the SBAR indicated Resident 1 was found sitting on the floor mat (a cushioned pad placed on the floor next to a resident's bed or chair to reduce the severity of injuries if the resident falls) and Resident 1 stated he fell from the left side of bed while turning.During an interview on 1/15/1026 at 10:29 a.m., Certified Nursing Assistant (CNA) 1 stated Resident 1 was able to walk but with assistance and always needed someone to help him. CNA 1 stated Resident 1 was confused sometimes, used a cane and a wheelchair, had a right arm splint (a strip of right material used for supporting and immobilizing a body part) and he had never used the call light. CNA 1 stated that Resident 1 never used the call light when he needed something she would make rounds at least once an hour if she could see if he needed anything.During an interview on 1/15/2026 at 11:16 a.m., Registered Nurse (RN) 1 stated Resident 1 was a high fall risk and would get up unassisted all the time even if they encouraged him to use the call light. RN 1 stated sometimes he was confused but sometimes he preferred to be independent. RN 1 stated when someone falls, they initiate an investigation and will interview the residents and witnesses to determine what happened and prevent future falls.b. During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition), dementia (a progressive state of decline in mental), altered mental status (a sudden change in brain function, causing confusion, disorientation, poor attention, unusual behavior, or unresponsiveness), and unspecified fall.During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had severe cognitive impairment. The MDS indicated Resident 2 required moderate assistance (helper does less than half the effort, by either lifting, holding, or supporting trunk or limbs) with ambulating up to 10 feet.During a review of Resident 2's Fall Risk assessment dated [DATE], the Fall Risk Assessment indicated Resident 2 was assessed as a high fall risk. During a review of Resident 2's At Risk for Falls Care Plan dated 11/13/2025, the Care Plan indicated Resident 2 was at risk for falls related to his dementia, right eye cataract (a medical condition in which the lens of the eye becomes progressively opaque, resulting in blurred vision), and history of falls. The Care Plan goal indicated to minimize the risk of injury for Resident 2 and interventions including to be sure the Resident 2's call light was within reach and for staff to encourage Resident 2 to use it to call for assistance as needed.During a review of Resident 2's Physical Therapy (PT) Treatment Encounter Note, dated 11/21/2025, the PT Treatment Encounter Note indicated Resident 2 needed Contract Guard Assistance ([CGA] a caregiver or therapist keeps one or two hands on a person during movement, like walking or transferring, to provide balance support and prevent falls, but doesn't do the work for them).During a review of Resident 2's Nursing Note, dated 11/22/2025, and timed at 10:45 a.m., the Nursing Note indicated on 11/22/2025 at 10:15 a.m., Resident 2 had an unwitnessed fall and was found sitting on the floor in his room. The Nursing Note indicated Resident 2 stated he fell on his butt when attempting to sit down.During a review of Resident 2's Actual Fall Care Plan dated 11/22/2025, the Care Plan indicated Resident 2 had an actual fall, and the Care Plan goal was for Resident 2 to resume usual activities without further incident. The Care Plan interventions included determining and addressing the causative factors of the fall.During an interview on 1/15/2026 at 11:04 a.m., Certified Nursing Assistant (CNA) 2 stated Resident 1 liked to be independent, would ambulate in his room, and would go to the bathroom by himself. CNA 1 stated due to a past fall he had they were instructed to keep an eye on him, which although it was not specified, she would check on him at least once an hour. CNA 2 stated Resident 2 was able to ambulate on his own and required assistance to the restroom only. During an interview on 1/15/2026 at 12:13 p.m., the Director of Rehabilitation (DOR) stated Resident 2 was not allowed to walk alone and needed someone within arm's reach when ambulating because he was at a high fall risk due to his cognition, multiple history of falls, and required moderate assistance from staff when ambulating. The DOR stated that after a resident falls, the rehabilitation (rehab) department will evaluate the residents within three days of the fall to determine if there was an injury and to determine the cause of the fall for safety reasons. The DOR stated during the evaluation, the rehab department will interview the resident and the nurses to determine what happened and discuss it with the team in order to minimize the risk of future falls. The DOR stated rehab did not evaluate Resident 1 after this second fall on 10/28/2025, and because of that they had not discussed this with the IDT team. The DOR stated rehab services, and an IDT meeting should have occurred after Resident 1's fall on 10/28/2025, to prevent any potential future falls.During an interview on 1/16/2026 at 12:37 p.m., the Director of Nursing (DON) stated Resident 1 had cognitive impairment and was not sure if he was assessed for his ability to understand and follow instructions on using the call light. The DON stated Resident 2 also had cognitive impairment and she was not sure about his ability to learn to use the call light. The DON stated that because Resident 1 and Resident 2 had not used the call light when needing help, the intervention was ineffective, and other interventions should have been in place like more frequent rounds and monitoring at least once every 2 hours. The DON stated that after every fall the facility will investigate the fall and the team will have a meeting and write their investigation in the conclusion in the Post-Event IDT note, however they did not do a Post-Event IDT note after Resident 1's second fall on 10/28/2025 or Resident 2's first fall on 11/22/2025. The DON stated the reason why they investigate the fall is to find the cause and update the care plan to prevent more falls, and that not investigating the fall 10/28/2025 and 11/22/2025 could have led to another fall for Resident 1 and Resident 2. The DON stated they communicate fall risk residents during rounds and report, and that all staff should be aware of the high risk for fall residents and what interventions should be done. The DON stated she was not sure why some of the staff believed it was appropriate for Resident 2 to ambulate without assistance, but this could cause him to fall again if staff are unaware that he needs assistance for all ambulating activities. The DON stated they did not investigate the fall for Resident 2 because he was hospitalized the next day and at the time they anticipated his return.During a review of facility's policy and procedure (P&P) titled Comprehensive Person-Centered Care Planning, dated 1/2022, the P&P indicated the IDT shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. The P&P indicated interventions are measurable; able to be evaluated or quantified.During a review of facility's P&P titled Fall Management System, dated 1/2022, the P&P indicated the facility will provide each resident with appropriate assessment and interventions to prevent falls and minimize complications if a fall occurs. The P&P indicated the care plan interventions will be developed to prevent falls by addressing the risk factors and will consider the particular elements of the evaluation that put the resident at risk. The P&P indicated review of the fall incident will include investigation to determine probably causal factors and will be reviewed by the IDT.

Based on interview and record review, the facility failed to ensure Licensed Vocational Nurses (LVNs) 2 and 3 administered 9 a.m. medications in a timely manner, for one of three sampled residents (Resident 4).These deficient practices resulted in Resident 4 not receiving his scheduled 9 a.m. medications on time on 11/15/2025 and 11/16/2025. These deficient practices had the potential of causing increased risk of harm to Resident 4 due to potential underdosing or overdosing, which could lead to unstable blood pressure, heart complications, and unnecessary discomfort.Findings:During a review of Resident 4's admission Record (Face Sheet), the Face Sheet indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included type 2 Diabetes Mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing) congestive heart failure ([CHF]heart disorder that causes the heart to not pump the blood effectively, sometimes resulting in leg swelling) and atrial fibrillation (an abnormal heart rhythm) .During a review of Resident 4's Minimum Data Set ([MDS] a resident assessment tool), dated 10/30/2025, the MDS indicated Resident 4's cognition (ability to think and reason) was moderately impaired and had the ability to understand and be understood by others.During a review of Resident 4's Physician's Orders, dated 11/26/2025, indicated Resident 4 was to receive the following medications:1. Valproic Acid (medication used to stabilize mood) Oral Solution 250 milligrams ([mg] unit of measurement)/5 milliliters ([ml] unit of measurement) 5 ml by mouth one time a day for mood disorder, ordered on 8/15/2025.2. Metoprolol Tartrate (medication used to lower heart rate and lower blood pressure) 12.5 mg by mouth two times a day for hypertension (high blood pressure), hold if systolic blood pressure ([SBP] measures the pressure in the arteries when the heart beats and pumps blood to the rest of the body) is less an 110 or heart rate less than 60 beats per minute, ordered on 8/14/2025.3. Potassium Chloride (supplement) Extended Release (designed to dissolve and release gradually in the body) 10 milliequivalent ([mEQ] unit of measurement) two tablets by mouth one time a day for supplement, ordered on 8/14/2025.4. Prednisone (medication, also called a steroid that works to control inflammation in the body) tablet 10 mg by mouth one time a day for chronic obstructive pulmonary disease ([COPD] a chronic lung disease causing difficulty in breathing) exacerbation, ordered on 8/14/2025.5. Hydroxychloroquine Sulfate (medication that works by calming an overactive immune system) 200 mg by mouth one time a day for arthritis, ordered on 8/14/2025.6. Docusate Sodium (stool softener) 100 mg one capsule by mouth two times a day for bowel management, ordered on 8/14/2025.7. Furosemide (medication acts to rid body of extra salt and water by causing an increase in urination), one tablet by mouth two times a day for CHF, ordered on 8/14/2025.8. Apixaban (medication that works to prevent harmful blood clots from forming in the blood) 5 mg two times a day for cerebrovascular accident ([CVA] stroke, loss of blood flow to a part of the brain) prophylaxis, ordered on 8/14/2025.9. Cyanocobalamin (Vitamin B-12, supplement) 1000 micrograms ([mcg] unit of measurement) by mouth one time a day for supplements, ordered on 8/14/2025.10. Gabapentin (medication used to calm overactive nerves, helping to treat nerve pain and control certain types of seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]) 100 mg, by mouth one time a day for neuropathy (nerve damage that can cause pain, tingling, numbness or weakness), ordered on 8/14/2025.11. Calcitonin (Salmon) (medication used to treat weakened bones (osteoporosis) in women who have gone through menopause Nasal Solution 200 unit/ACT 1 spray alternative nostrils once a day for osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D), ordered on 8/14/2025.During a review of Resident 4's Medication Administration Audit Report (a document indicating the exact time medications were documented and administered), dated 11/26/2025, indicated Resident 4 was to receive the following medications on 11/15/2025:1. Valproic Acid was scheduled to be administered at 9 a.m., however, the report indicated LVN 2 documented she administered Valproic Acid at 10:38 a.m. (over one hour after the scheduled dose). 2. Metoprolol Tartrate was scheduled to be administered at 9 a.m., however, the report indicated LVN 2 documented she administered Metoprolol at 10:42 a.m. (over one hour after the scheduled dose). 3. Potassium Chloride was scheduled to be administered at 9 a.m., however, the report indicated LVN 2 documented she administered Potassium at 10:43 a.m. (over one hour after the scheduled dose).4. Prednisone was scheduled to be administered at 9 a.m., however, the report indicated LVN 2 documented she administered Prednisone at 10:43 a.m. (over one hour after the scheduled dose). 5. Hydroxychloroquine Sulfate was scheduled to be administered at 9 a.m., however, the report indicated LVN 2 documented she administered Hydroxychloroquine at 10:42 a.m. (over one hour after the scheduled dose). 6. Docusate Sodium was scheduled to be administered at 9 a.m., however, the report indicated LVN 2 documented she administered Docusate at 10:42 a.m. (over one hour after the scheduled dose) 7. Furosemide was scheduled to be administered at 9 a.m., however, the report indicated that LVN 2 documented that she administered Furosemide at 10:42 a.m. (over one hour after the scheduled dose). 8. Apixaban was scheduled to be administered at 9 a.m., however, the report indicated LVN 2 documented she administered Apixaban at 10:42 a.m. (over one hour after the scheduled dose). 9. Cyanocobalamin was scheduled to be administered at 9 a.m., however, the report indicated LVN 2 documented she administered Cyanocobalamin at 10:42 a.m. (over one hour after the scheduled dose). 10. Gabapentin was scheduled to be administered at 9 a.m., however, the report indicated LVN 2 documented she administered Gabapentin at 10:42 a.m. (over one hour after the scheduled dose). 11. Calcitonin was scheduled to be administered at 9 a.m., however, the report indicated LVN 2 documented that she administered Calcitonin at 10:44 a.m. (over one hour after the scheduled dose). During a subsequent review of Resident 4's Medication Administration Audit Report (a document indicating the exact time medications were documented and administered) dated 11/26/2025, Resident 4 was to receive the following medications on 11/19/2025:1. Apixaban was scheduled to be administered at 9 a.m., however, the report indicated LVN 3 documented she administered Apixaban at 11:56 a.m. (almost three hours after the scheduled dose). 2. Cyanocobalamin was scheduled to be administered at 9 a.m., however, the report indicated LVN 3 documented she administered Cyanocobalamin at 11:56 a.m. (almost three hours after the scheduled dose).3. Gabapentin was scheduled to be administered at 9 a.m., however, the report indicated LVN 3 documented she administered Gabapentin at 11:56 a.m. (almost three hours after the scheduled dose). 4. Calcitonin was scheduled to be administered at 9 a.m., however, the report indicated LVN 3 documented she administered Calcitonin at 11:57 a.m. (almost three hours after the scheduled dose).5. Furosemide was scheduled to be administered at 9 a.m., however, the report indicated LVN 3 documented that she administered Furosemide at 11:56 a.m. (almost three hours after the scheduled dose). 6. Hydroxychloroquine was scheduled to be administered at 9 a.m., however, the report indicated LVN 3 documented she administered Hydroxychloroquine at 11:56 a.m. (almost three hours after the scheduled dose). 7. Valproic Acid was scheduled to be administered at 9 a.m., however, the report indicated LVN 3 documented that she administered Valproic Acid at 11:55 a.m. (almost three hours after the scheduled dose). 8. Metoprolol was scheduled to be administered at 9 a.m., however, the report indicated LVN 3 documented she administered Metoprolol at 11:55 a.m. (almost three hours after the scheduled dose). 9. Potassium Chloride was scheduled to be administered at 9 a.m., however, the report indicated LVN 3 documented that she administered Potassium at 11:55 a.m. (almost three hours after the scheduled dose).10. Prednisone was scheduled to be administered at 9 a.m., however, the report indicated LVN 3 documented she administered Prednisone at 11:55 a.m. (almost three hours after the scheduled dose).11. Docusate was scheduled to be administered at 9 a.m., however, the report indicated LVN 3 documented she administered Docusate at 12:03 p.m. (three hours after the scheduled dose). During an interview on 11/26/2025, at 3:50 p.m. LVN 2 stated on 11/15/2025 she administered Resident 4's 9 am scheduled medications late due to the facility being short staffed that day. LVN 2 stated the facility policy states medications can be given up to one hour before or one hour after the scheduled time. LVN 2 stated administered medications after the scheduled time leads to potential risk of overdosage or underdosage of medication.During an interview on 11/26/2025, at 4:05 p.m. LVN 3 stated on 11/19/2025 she administered Resident 4's 9 a.m. scheduled medications about three hours late due to being busy with other residents. LVN 3 stated she did not ask for help from her coworkers because everyone seemed busy.During an interview on 11/26/2025, at 4 p.m., the DON stated when residents do not receive their medications on time as prescribed and scheduled, the resident is at risk for underdosage or overdosage if the medications are given too close together. The DON stated that administering certain medications late that directly affect the heart rate and blood pressure can cause harm to the resident. The DON stated, the although the licensed nurses are instructed to ask for help when they anticipate they are falling behind on administering medications, they often choose not to ask for assistance. The DON stated that the facility will call in additional nurses to work to cover shifts that are short staffed. The DON stated she was not aware of any short staffing on 11/15/2025 or 11/19/2025.During a review of the facility's Policy and Procedure (P&P) titled, Medications Administration, revised 2012, the P&P indicated medications are administered within 60 minutes of scheduled time, except before or after meals orders, which are administered based on mealtimes.

49130 Based on observation, interview and record review the facility failed to ensure four out of five sampled residents' (Resident 14 and Resident 21, Resdent 28 amd 12)'s Minimum Data Set ([MDS], a resident assessment tool) was coded appropriately when: a.Resident 14's MDS was not coded correctly in the bladder and bowel portion. b.Resident 21's MDS was not coded correctly in the active diagnosis portion. c. Resident 28's MDS was not coded correctly to reflect Resident 28 had Bed sensor alarm (a safety device a pressure sensitive pad use to detect when a resident leaves their bed) and chair sensor alarm( a safety device a pressure sensitive pad use to detect when a resident leaves their bed). d.Resident 12's MDS was not coded correctly to reflect a diagnosis of bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) The deficient practice resulted in an inaccurate depiction of Resident 14, Resident 21, Resident 28, and Resident 12's current health status. Findings: a.During a review of Resident 14's Admission Record, the Admission Record indicated Resident 14 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including asthma (a chronic respiratory disease characterized by inflammation and narrowing of the airways, making breathing difficult), hypertension ([HTN], high blood pressure), atrial fibrillation ([A-Fib], (a condition that causes irregular and fast heartbeat in the heart), and hyperlipidemia (too much fat particles in the blood). During a review of Resident 14's history and physical (H/P) dated 4/6/2025, the H/P indicated Resident 14 had the capacity to understand and make decisions. During a review of Resident 14's MDS dated [DATE], the MDS indicated Resident 14 had intact cognitive (thinking process) skills and was independent (resident completes the activity by themselves with no assistance from a helper) with self-care abilities such as eating, required supervision (helper provides verbal cues as resident completes the task) with oral hygiene, personal hygiene, and upper body dressing, required moderate assistance (helper does less than half the effort completing task) with toileting hygiene, lower body dressing, and putting on/taking off footwear and maximal assistance (helper does more than half the effort) with shower/bathe. The MDS indicated Resident 14 required supervision during mobility such as rolling left and right, sit to lying position, and lying to sitting on side of bed, required moderate assistance with sit to stand position, bed to chair transfer, toilet transfers, shower transfers, and walking 10 to 50 feet. The MDS indicated Resident 14 was always incontinent with urinary continence (loss of voluntary control of urination) and occasionally incontinent with bowel continence (loss of voluntary control of bowl movements). During a review of Resident 14's Bowel and Bladder Evaluation dated 2/15/2025, the Bowel and Bladder evaluation indicated Resident 14 as incontinent. During a concurrent observation and interview on 2/4/2025 at 10:23 a.m., with Resident 14 in her room, Resident 14 was resting in bed watching television. Resident 14 stated she was not incontinent. Resident 14 stated she could not ambulate to the bathroom without assistance because she just had surgery on her right hip. During a concurrent interview and record review on 4/23/2025 at 4:03 p.m., with the MDS Coordinator (MDSC), the MDS dated [DATE] and the Bowel and Bladder Evaluation dated 2/15/2025 was reviewed. The MDSC nurse stated the resident was alert and oriented and could tell staff if she needed to go to the restroom, so she was not incontinent. The MDSC nurse stated the MDS should have been coded as always continent because the resident was alert and oriented and knows when she needed to go to the restroom. The MDSC nurse stated the MDS assessment was coded incorrectly. The MDSC nurse stated if the MDS was not coded correctly, the plan of care for the resident would not be appropriate for the resident. b.During a review of Resident 21's Admission Record, the Admission Record indicated Resident 21 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including HTN, high blood pressure), hyperlipidemia (too much fat particles in the blood), diabetes mellitus ([DM]-a disorder characterized by difficulty in blood sugar control and poor wound healing), and glaucoma (a group of eye diseases that damage the optic nerve, which connects the eye to the brain, leading to vision loss). During a review of Resident 21's H/P dated 2/27/2025, the H/P indicated Resident 21 had the capacity to understand and make decisions. During a review of Resident 21's MDS dated [DATE], the MDS indicated Resident 21 had moderate cognitive impairment and required assistance with set up or clean up (helper sets up or cleans up while resident completes the activity), required moderate assistance (helper does less than half the effort while resident completes the task) with self-care abilities such as eating and required maximal assistance (helper does more than half the effort completing task) with oral hygiene, and personal hygiene, as dependent (helper does all of the effort while resident does none of the effort to complete the task) with upper body dressing, with toileting hygiene, shower/bathe, lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 21 required maximal assistance with mobility such as rolling left and right, sit to lying position, lying to sitting on side of bed, and bed to chair transfers, was dependent on sit to stand position, toilet transfers, and shower transfers. The MDS indicated Resident 21 was taking an antidepressant medication (medications used to treat depression [a persistent mood disorder characterized by feelings of sadness, loss of interest, and a range of physical and cognitive symptoms that significantly interfere with daily life]). Resident 21 did not have a mood disorder diagnosis in the active diagnoses portion of the MDS. During a review of Resident 21's psychiatric (relating to mental illness or its treatment) consult note dated 3/3/2025, the psychiatric consultation note indicated Resident 21 had a documented history of major depressive disorder, and continued to exhibit symptoms of major depressive disorder. The psychiatric consultation notes also indicated diagnoses of adjustment disorder (a mental health condition characterized by an excessive emotional or behavioral reaction to a specific stressful event or life change). During a review of Resident 21's psychologist consultation note dated 3/6/2025, the psychologist consultation note indicated that Resident 21 was diagnosis with adjustment disorder with depressed mood as evidence by reported emotional and behavioral response to medical conditions, functional limitations, increased need for assistance and rehab placement. During a review of Resident 21's Order Summary Report, the Order Summary Report indicated sertraline (medication used to treat depression) oral tablet (pill) 100 milligram ([mg], unit of measurement) give one tablet by mouth one time a day for depression manifested by verbalization of feeling depressed, informed consent obtained by medical doctor from Resident 21 ordered on 2/26/2025. During a concurrent interview and record review on 4/23/2025 at 3:18 p.m. with MDS Coordinator (MDSC), the MDS dated [DATE] and psychologist consultation note dated 3/6/2025 was reviewed. The MDSC nurse stated MDS assessment should have been coded to indicate that Resident 21 had a depressed mood disorder because she was seen by psychology and psychiatry consult that stated resident was diagnose with adjustment disorder with depressed mood and was taking an antidepressant medication. The MDSC stated the importance of ensuring the MDS assessment was accurate was to make sure Resident 21's care plans were based on an accurate MDS that reflected the diagnoses of the resident. During a concurrent interview and record review on 4/24/2025 at 4:15 p.m., with the Director of Nursing (DON), the MDS assessment dated [DATE] for Resident 14, Bowel and Bladder evaluation dated 2/15/2025, the MDS assessment dated [DATE] for Resident 21, the psychologist consultation note dated 3/6/2025 for Resident 21 were reviewed. The DON stated the MDS assessment for Resident 14 was inaccurate because Resident 14 was continent and stated the MDS assessment was coded that Resident 14 was incontinent. The DON stated the importance of accurate assessment of the MDS was to meet the needs of the residents, to provide the proper care needed for the residents, and to maintain their functioning status. The DON stated the MDS assessment for Resident 21 was also not accurate as the MDS assessment for active diagnosis section, there should have been a diagnosis of mood disorder because Resident 21 was taking an antidepressant medication for depress mood. The DON stated the psychologist consultation note indicated that the resident had a diagnosis of adjustment disorder with depressed mood and the MDS assessment should have indicated that Resident 21 had some type of depressed mood disorder. The DON stated the MDS assessment needed to be accurate to reflect Resident 14's and Resident 21's diagnoses and health status so the facility can give person centered care. c.Based on observation, interview, and record review, the facility failed to ensure the assessment entries on the Minimum Data Set (MDS- an assessment and care screening tool) related to Bed sensor alarm ( a safety device a pressure sensitive pad use to detect when a resident leaves their bed) and chair sensor alarm( a safety device a pressure sensitive pad use to detect when a resident leaves their bed ) was accurately documented for one of three randomly selected residents (Resident 28) This deficient practice had the potential to negatively affect Resident 28's plan of care and delivery of necessary care and services. Findings: During a review of Resident 28's Admission Record, the Admission Record indicated, Resident 28 was initially admitted to the facility on ,d+[DATE]/ 2021 and last admission was on 3/27/2025 with diagnoses including hemiplegia and hemiparesis (muscle weakness or partial paralysis not being able to move a body part) following cerebral infarction (brain tissue dies due to lack of blood flow) affecting the right dominant side. HTN and abnormalities in gait (walking) and mobility ( (moving). During a review of Resident 28's MDS dated [DATE], the MDS indicated Resident 28 had significant cognitive impairment. The MDS indicated Resident 28 required partial moderate assistance (helper lifts or holds trunk or supports trunk or limbs but provides less than half the effort) with eating, oral hygiene, upper body dressing, personal hygiene and needs help on indoor mobility. During a record review of Resident 28's Order Summary Report (OSR), as of 3/27/2025 the OSR indicated an order for sensor pad alarm on bed to alert staff when trying to get out of bed unassisted and on 3/27/2025 an order for sensor alarm pad in wheelchair to alert staff when trying to get out of wheelchair unassisted. During a concurrent interview and record review on 4/23/2025 at 3:31 p.m., with the MDSC nurse, the MDSC nurse stated Resident 28 had a sensor bed pad alarm and a sensor bed alarm. The MDSC nurse stated she did not document the sensor pad alarm and the sensor bed alarm in Resident 28's MDS. The MDSC nurse stated the sensor bed alarm and sensor chair alarm was a form of restraint (when a patient avoids moving or repositioning themselves in a chair of bed due to fear of triggering the alarm). The MDSC nurse stated documenting sensor pad alarms helps in making sure it is used appropriately. During an interview on 4/24/2025 at 3:00 p.m., with the DON, the DON stated bed sensor alarms and chair sensor alarms should be documented in section P of the MDS. The DON stated if the assessment is not correct it does not reflect what the resident is getting, and the facility was not keeping Resident 28 safe. The DON stated if the chair and bed alarm is not documented or monitored it may not serve its purpose and the resident may still fall. d.During a review of Resident 12's Admission Record (a document containing demographic and diagnostic information), dated 4/22/2025, the admission record indicated Resident 12 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to, schizophrenia (a mental illness that is characterized by disturbances in thought) and depression (a mood disorder characterized by persistent sadness and loss of interest in activities). During a review of Resident 12's Minimum Data Set MDS (MDS - a federally mandated resident assessment tool), dated 3/31/2025, the MDS indicated Resident 12's cognition was intact. The MDS indicated Resident 12 was independent for Activities of Daily Living (ADLs) such as eating, needed supervision level assistance from the facility staff for oral hygiene, upper body dressing, lower body dressing and personal hygiene, moderate assistance for toileting, showering and putting on/taking off footwear. The MDS did not indicate a medical diagnosis for bipolar disorder. During a review of Resident 12's Order Summary Report (a list of all currently active medical orders), dated 4/22/2025, the order summary report indicated the following physician order: Aripiprazole (a medication used to treat mental conditions such as depression and bipolar disorder) Oral Tablet 15 milligrams ([mg] a unit of measurement for mass), give 1 tablet by mouth one time a day for bipolar disorder manifested by (m/b) sudden mood change, order date 9/24/2024, start date 9/25/2024. During a review of Resident 12's psychiatry initial evaluation and consultation notes, dated 1/10/2025, 3/3/2025 and 2/5/2025, the documents respectively indicated, The patient, with a documented history of major depressive disorder and bipolar disorder, underwent an initial 45-minute, and 16-minute psychiatry evaluations. The documents indicated diagnoses of Major Depressive Disorder (MDD) and bipolar disorder, and no diagnosis of schizophrenia was documented. During a review of Resident 12's Medication Administration Record ([MAR] - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 4/1/2025 to 4/22/2025, 3/1/2025 to 3/31/2025 and 2/1/2025 to 2/28/2025, the MAR indicated aripiprazole 15 mg was documented as administered every day for bipolar disorder. During an interview on 4/23/2025 at 3:30 p.m. with the Minimum Data Set Coordinator (MDSC), the MDSC stated Resident 12's MDS indicated diagnoses of schizophrenia and depression. MDSC stated facility staff would look at the psychiatry evaluation to verify the accuracy of the diagnoses in MDS, but she was not sure how the diagnoses were entered for Resident 12 because MDSC was not at the facility when they were entered. MDSC stated there was an inaccuracy of assessments and there was a possibility that the care plans would not be according to what was necessary for the resident's care. MDSC stated there could be side effects from unnecessary use of psychotropic medications for elderly residents which could cause unwanted side effects, such as cognitive impairment and increased risk for falls. MDSC stated the medications should have been prescribed only if there was a valid diagnosis. During a phone interview on 4/24/2025 at 10:40 a.m. with the psychiatry nurse practitioner (NP) 1, NP 1 stated Resident 12 had medical diagnoses of bipolar disorder and depression based on her evaluation of the resident. NP 1 stated Resident 12 did not have a diagnosis of schizophrenia. NP 1 stated, I do not believe that the MDS stating schizophrenia is accurate. During an interview on 4/24/2025 at 12:20 p.m. with the Director of Nursing (DON), DON stated when she checked Skilled Nursing Facility (SNF) 1's records, Resident 12's admitting diagnoses were bipolar disorder, depression and anxiety. DON stated the hospital's admission records, dated 09/2024 and 03/2024, did not have any diagnoses. DON stated there was an inaccuracy in diagnoses in Resident 12's MDS because MDS indicated diagnoses of schizophrenia and no bipolar disorder, whereas psychiatry evaluation indicated bipolar disorder and no schizophrenia. DON stated the inaccurate record of medical diagnoses would affect resident's treatment plan. DON stated the resident might not be getting treatment with the right medications causing negative impact on resident's cognition and behaviors. During a review of the facility's policy and procedure (P/P) titled Resident Assessment and Associated Processes, dated 12/2023, indicated it is the policy of this facility that resident's will be assessed and the findings documented in their clinical health record. These will be comprehensive, accurate, standardized reproducible assessment of each resident and will be conducted initially and periodically as part of an ongoing process through which each resident's preferences and goals of care, functional and health status, and strengths and needs will be identified comprehensive assessment includes the completion of the MDS MDS data is signed/stored electronically in the clinical health record and is readily and easily accessible to all professionals who need to review the information in order to provide care to the resident. 49573

49573 Based on observation, interview and record review the facility failed to develop a care plan for two of three sampled residents (Resident 28 and Resident 29) when : a. Resident 28 had an order for a bed sensor alarm (a safety device a pressure sensitive pad use to detect when a resident leaves their bed) and a chair sensor alarm (a safety device a pressure sensitive pad used to detect when a resident tries to get up from the chair) b. Resident 29 refusing to get out of bed and attend activities for three days . Findings: During a review of Resident 28's Admission Record, the Admission Record indicated Resident 28 was originally admitted on [DATE] with a re-admitted on 3/22/2025 with diagnoses including chronic obstructive pulmonary disease ([COPD], a chronic lung disease causing difficulty in breathing), hypertension ([HTN], high blood pressure), dementia (a progressive state of decline in mental abilities), and atrial fibrillation ([A-Fib], (a condition that causes irregular and fast heartbeat in the heart). During a review of Resident 28's History and Physical (H/P) dated 3/25/2025, the H/P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 28's Minimum Data Set ([MDS], a resident assessment tool) dated 3/26/2025, the MDS indicated Resident 28 was severely cognitivly (ability to make decisions of daily living) impaired, and required moderate assistance (helper does less than half the effort) on self-care abilities such as eating, required maximal assistance (helper does more than half the effort to complete the task) with oral hygiene, toileting hygiene, shower/bathe, upper and lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 28 required maximal assistance with mobility such as rolling left and right, sitting to lying position, lying to sitting on side of bed, bed to chair transfers, and toilet transfers. During a review of Resident 28's Order Summary Report, the Order Summary Report indicated; sensor pad alarm (a device, typically a pressure-sensitive pad, used to alert facility staff when a resident moves or leaves their bed or chair unassisted) in bed to alert staff when Resident 28 was trying to get out of bed unassisted, informed consent obtained by medical doctor from responsible party ordered on 3/22/2025. The Order Summary Report indicated sensor pad alarm in wheelchair to alert staff when trying to get out of wheelchair unassisted informed consent obtained by medical doctor from responsible party ordered on 3/22/2025. During a review of Resident 28's comprehensive care plan dated 3/13/2025, the comprehensive care plan did not indicate a care plan addressing Resident 26's use of bed and chair sensor alarm pads in place. During an observation on 4/21/2025 at 10:47 a.m., in Resident 28's room, Resident 28 was resting in bed with eyes closed. There was a box attached to the bed with a wire attached to the box underneath Resident 28. During a concurrent interview and record review on 4/23/2025 at 2:59 p.m. with the MDS Coordinator (MDSC), Resident 28's the Order Summary Report and comprehensive care plan dated 3/13/2025 were reviewed. The MDSC stated sensor alarm pads should have been care planned, to monitor the effectiveness of the sensor alarm pads. The MDSC stated there should have been interventions in place to make sure the sensor alarm pads were effective in alerting staff and keeping Resident 28 safe from falling. The MDSC stated if the interventions in the care plan were not effective, the interventions could be reassessed, and new interventions would be added. The MDSC stated a comprehensive care plan should be a focused individualized care plan, and how staff should be caring for the residents based on the interventions being done on the floor. The MDSC stated the comprehensive care plan did not have a focus for the sensor alarm pads and to guide staff on how to care for Resident 28's pad alarms. During a concurrent interview and record review on 4/24/2025 at 3:20 p.m. with the Director of Nursing (DON), Resident 28's comprehensive care plan dated 3/13/2025 was reviewed. The DON stated sensor alarm pads should have been care planned. The DON stated the importance of having a comprehensive care plan was that it was a plan of care on how facility staff will be providing care to the residents. The DON stated there should have been a separate care plan for sensor alarm pads to monitor the effectiveness of the sensor alarm pads and its functioning purpose. DON stated the comprehensive care plan should make sure the residents still have a need for the sensor alarm pads. b.During a review of Resident 29's Admission Record, the Admission Record indicated, Resident 29 was initially admitted to the facility on [DATE] and last admission was on 1/29/2025 with diagnoses including cerebral infarction (brain tissue dies due to lack of blood flow) due to blockage of a blood vessel in the brain, essential (primary) Hypertension ( high blood pressure) and muscle weakness ( generalized). During a record review of Resident 29's H&P, the H&P indicated Resident 29 did not have the capacity to understand and make decisions. During a review of Resident 29's MDS dated [DATE] , the MDS indicated, Resident 29 was dependent (resident does none of the effort to complete the activity. Or the assistance of two or more helpers is required for the resident to complete the activity) with shower/ bath, toilet hygiene, eating , lower body dressing, putting on and taking off footwear and substantial/ maximum assistance ( helper lifts or holds trunk or limbs and provides more than half the effort) with chair/ bed -to chair transfer. During a record review of Resident 29's Order Summary Report (OSR), as of 3/27/2025 the OSR indicated an order dated 3/26/2025 for skilled physical therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function) every day, 5 times per week for 4 weeks. PT may include therapeutic exercises, therapeutic activities, neuromuscular (relating to nerves and muscles) re-education ,wheelchair management, gait training , manual therapy and patient caregiver education and training. During a review of resident 29's care plan dated 1/30/2025 the care plan indicated Resident 29 had a pressure ulcer (injury to skin and underlying tissue due to unrelieved pressure) or potential for pressure ulcer development, theinterventions were for Resident 29 to get out of bed unless contraindicated. During an interview on 4/23/2025 at 10:30 a.m., with Certified Nurse Assistant 2 (CNA 2), CNA 2 stated Resident 29 had refused to get up for the past three days , CNA 2 stated resident 29 never get out of bed. CNA 2 stated when a resident refuses to get out of bed she reports the refusal to her charge nurse. CNA 2 stated it is important to get the resident out of bed to prevent beds sores. During an interview on 4/23/2025 at 10:36 a.m., with Licensed Vocational Nurse (LVN 1) , LVN 1 stated he was aware Resident 29 did not want to get out of bed and when a resident refuses multiple times a plan of correction is done, and the doctor is called. LVN 1 stated there must be a care plan so the nurses can focus on the resident's problem. During an interview on 4/ 24/2025 at 3:00 p.m., with the Director of nursing (DON), the DON stated the bed sensor alarm and wheelchair sensor alarm for Resident 28 should have a separate sectionin the care plan so staff can focus where nurses can monitor the placement of the sensor alarm and if it is functioning. The DON stated CNA's notify the LVN when Resident 29 refuses to get out of bed and the LVN charts it and notifies the doctor and family, and then care plan it. The DON stated it was important to do a care plan for Resident 29 refusing to get out of bed and must be reflective to meet the residents needs so that we can refer them to the right DON stated it is important the resident gets out of bed to improve their sensory stimulation. During a review of the facility's policy and procedure (P/P) titled, Comprehensive Person-Centered Care Plan, dated 12/2023, indicated the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person- centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment the facility IDT will develop and implement a comprehensive person-centered, culturally-competent, and trauma-informed care plan for each resident within seven (7) days of completion of the Resident Minimum Data Set (MDS) and will include resident's needs identified in the comprehensive assessment, any specialized services as a result of PASARR recommendation, and resident's goals and desired outcomes, preferences for future discharge and discharge plan.

Based on interview and record review, the facility failed to implement the antibiotic stewardship program (the effort to ensure that [antibiotics - medicines that fight bacterial infections in people and animals] are used only when necessary and appropriate) for two of four sampled residents (Resident 148 and Resident 14) as evidenced by: A. Failing to identify the indication of use and assess Infection Surveillance (an active reassessment of an antimicrobial prescription 48-72 hours after first administration) of Zosyn (a prescription drug that's used to treat or prevent certain infections intravenously) for Resident 148. B. Failing to implement Infection Surviellance of daptomycin (medication used to treat infection) for Resident 14. This deficient practice had the potential for resident to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use. Findings: A. During a review of Resident 148's Admission Record, the Admission Record indicated, Resident 148 was admitted to the facility on [DATE] with diagnoses including pneumonia (an infection/inflammation in the lungs), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia (a progressive state of decline in mental abilities). During a review of Resident 148's History and Physical (H&P), dated 4/21/2025, the H&P indicated, Resident 148 had fluctuating ability to make medical decisions. During a review of Resident 148's Minimum Data Set (MDS - a resident assessment tool), dated 4/25/2025, the MDS indicated Resident 148 required moderate assistance (Helper does less than half the effort) from one staff for oral hygiene, toileting hygiene, shower/bathe self, dressing, personal hygiene, bed mobility, transfer, and supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and /or contact guard assistance as resident completes activity) from one staff for eating. During a review of Resident 148's Order Summary Report (OSR), dated 4/24/2025, the OSR indicated, give Zosyn intravenous solution 4-0.5 milligram (mg)/100 milliliter (ml) every eight hours for pneumonia for two days was ordered on 4/21/2025 and completed on 4/23/2025. During a review of Resident148's Care Plan (CP), initiated and revised on 4/21/2025, the CP Focus indicated, Resident 148 had community acquired pneumonia. The CP Interventions indicated, give medications as ordered and monitor/document for side effects and effectiveness. During a concurrent interview and record review on 4/24/2025, at 9:36 a.m., with the IPN, Resident 148's Infection Surveillance, dated 4/21/2025 was reviewed. The Infection Surveillance indicated, there was no documentation and was left blank. The IPN stated, Resident 148 received Zosyn (mediction used to treat infection) through Intravenous (IV) therapy from the General Acute Care Hospital (GACH) prior to admission to the facility and Resident 148 continued to receive the Zosyn at the facility.The IPN stated, she did not do Infection Surveillance (equivalent to Antibiotic Time Out) assessment. The IPN stated, she was not sure if Zosyn antibiotic administration for Resident 148 met McGeer's Criteria (criteria used to determine appropriate use of antibiotics). The IPN stated, Zosyn administration for Resident 148 was completed yesterday, and she (IPN) should have done Infection Surveillance assessment to see if Zosyn was indicated because unnecessary use of antibiotics could lead to develop antibiotic resistance. During a concurrent interview and record review on 4/24/2025, at 4:21 p.m., with the Director of Nursing (DON), Resident 148's Infection surveillance, dated 4/24/2025 was reviewed. The Infection Surveillance indicated, McGeer's Criteria was not met for Zosyn. The DON stated, she completed the Infection Surveillance assessment and realized Resident 148's condition did not meet McGeer's criteria for recieving Zosyn, but the Zosyn was given already. The DON stated, all antibiotics should be assessed, monitored, and evaluated for the indication and duration of the therapy to prevent unnecessary use of antibiotics that could develop resistance, and unnecessarily suffer from adverse reaction and side effects. B. During a review of Resident 14's Admission Record, the Admission Record indicated Resident 14 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including asthma (a chronic respiratory disease characterized by inflammation and narrowing of the airways, making breathing difficult), hypertension ([HTN], high blood pressure), atrial fibrillation ([A-Fib], (a condition that causes irregular and fast heartbeat in the heart), and hyperlipidemia (too much fat particles in the blood). During a review of Resident 14's H&P dated 4/6/2025, the H&P indicated has the capacity to understand and make decisions. During a review of Resident 14's MDS dated [DATE], the MDS indicated Resident 14 had intact cognitive skills and was independent (resident completes the activity by themselves with no assistance from a helper) with self-care abilities such as eating, required supervision (helper provides verbal cues as resident completes the task) with oral hygiene, personal hygiene, and upper body dressing, required moderate assistance (helper does less than half the effort completing task) with toileting hygiene, lower body dressing, and putting on/taking off footwear and maximal assistance (helper does more than half the effort) with shower/bathe. The MDS indicated Resident 14 required supervision mobility such as rolling left and right, sitting to lying position, and lying to sitting on side of bed, required moderate assistance with sit to stand position, bed to chair transfer, toilet transfers, shower transfers, and walking 10 to 50 feet. During a review of Resident 14's Order Summary Report, the Order Summary Report indicated daptomycin intravenous ([IV], existing or taking place within, or administered into, a vein or veins) solution reconstitute 850 milligram ([mg], unit of measurement) intravenously one time a day for right hip wound MRSA ([Methicillin-resistant Staphylococcus aureus], infection caused by a type of bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infections) infection for 35 days ordered on 4/4/2025. During a review of Resident 14's Infection Surveillance dated 4/4/2025, the Infection Surveillance indicated the surveillance by body system indicated other infections such as right hip surgical wound infection with antibiotic treatment daptomycin 850 mg IV one time a day started on 4/5/2025 and that infection preventionist note meets criteria for infection. The Infection Surveillance also indicated infection preventionist note that Resident 14 was currently on daptomycin 850 mg IV one time a day. During a review of the Antibiotics Stewardship binder, the Antibiotic Stewardship binder indicated a list of all the residents in the facility that were receiving antibiotics with the reason for antibiotic use, the start date, the end date and the signs and symptoms or testing residents had done. Resident 14 was not on the list of residents who were receiving antibiotics in the facility. During a review of Resident 14's care plan dated 4/6/2025, the care plan indicated interventions such as monitor/document/report to medical doctor as needed for signs and symptoms of infection at the site such as drainage, inflammation, swelling, redness and warmth. The care plan also indicated to give medication as ordered and monitor/document for effectiveness, side effects, monitor/document/report to medical doctor as needed for signs and symptoms of MRSA infection such as inflammation around the wound sites, drainage, lethargy, headache, increased heart rate, urinary tract infections, and toxic shock syndrome. During an observation on 2/4/25 at 10:23 a.m., of Resident 14 in her room, Resident 14 was resting in bed watching television. Resident 14 stated she had revision surgery on her right hip replacement on 3/25/2025. Resident 14 stated she was getting antibiotics through her PICC (peripherally inserted central catheter, a long, thin tube inserted into a vein in the arm and threaded up to a larger vein near the heart) line on right upper arm. During a concurrent interview and record review on 4/24/2025 at 11:33 a.m., with the IPN, the Order Summary Report, antibiotics stewardship binder, and Infection Surveillance dated 4/4/2025 were reviewed. The IPN stated Resident 14 was started on daptomycin 850 mg intravenously one time a day for right hip wound MRSA infection for 35 days. The IPN stated she was aware that Resident 14 was on IV antibiotics, but that Resident 14 was not monitored in the antibiotics stewardship binder for residents who are on antibiotics. The IPN stated residents that are not being monitored while receiving antibiotics may experience adverse effects, the medication might not be affective anymore and residents might get another infection.The IPN stated the Infection Surveillance was done when Resident 14 was started on the antibiotic, but another assessment was not done after to see if the medication was effective, if it needed to be continued and no monitoring was done. During a concurrent interview and record review on 4/24/2025 at 4:50 p.m. with the DON, the Infection Surveillance dated 4/4/2025 was reviewed. The DON stated there was no monitoring done for Resident 14 while the on antibiotic. The DON stated Resident 14 was first assessed on 4/4/2025 when the antibiotic was ordered but there have been no other assessments done after to see if the antibiotic was still required. The DON stated there was no monitoring in place to see if there was still a need for the antibiotic. The DON stated the importance of monitoring residents on antibiotics was to see if the antibiotics were working, and to monitor any signs or symptoms if the antibiotics was still needed. The DON stated the IPN should have followed up with the doctor for prolonged use of the antibiotic because the resident can develop resistance to the antibiotic. During a review of the facility's policy and procedure (P/P) titled, Antibiotic Stewardship, dated 12/2023, indicated is the policy of this facility to implement an Antibiotic Stewardship Program (ASP) that is incorporated in the overall Infection Prevention and Control Program which will promote appropriate use of antibiotics while optimizing the treatment of infections, at the same time reducing the possible adverse events associated with antibiotic use . review data, monitor and summarize antibiotic use from pharmacy data, such as the rate of new starts, types of antibiotics prescribed summarize antibiotic resistance patterns based on laboratory data incorporate monitoring of antibiotic use, including the frequency of monitoring/review, report on number of antibiotics prescribed and the number of residents treated each month, assess residents for any infection using McGeer's criteria, require antibiotic orders to include the indication, dose, and duration . facility may consider antibiotic time-out (TO) practices. A time-out can be considered a stop order of an antibiotic when a diagnostic test or symptoms of resident do not support the diagnosis of infection. These practices include improving the evaluation and communication of clinical signs and symptoms when a resident is first suspected of having an infection, optimizing the use of diagnostic testing, and implementing an antibiotic review process, also known as an antibiotic time-out, for all antibiotics prescribed in the facility . IP or designee will be responsible for infection surveillance and [NAME] tracking. IP or designee will collect and review data. During a review of the facility's Policy and Procedure (P&P) titled, Antibiotic Stewardship, revised 12/2023, the P&P indicated, Policy :It is the policy of this facility to implement an Antibiotic Stewardship Program (ASP) that is incorporated in the overall Infection Prevention and Control Program which will promote appropriate use of antibiotics while optimizing the treatment of infections, at the same time reducing the possible adverse events associated with antibiotic use. This policy has the potential to limit antibiotic resistance in the post-acute care setting, while improving treatment efficacy and resident safety, and reducing treatment-related costs. This policy will include basic elements about antibiotic resistance and opportunities for improvement. Procedure: 1. Leadership: a. The team may consist of the Medical Director, Administrator, Director of Nursing, Infection Preventionist, Pharmacy Consultant and Laboratory Representative. b. The team will: o Review data, monitor and summarize antibiotic use from pharmacy data, such as the rate of new starts, types of antibiotics prescribed, or days of antibiotic treatment per 1,000 resident days o Summarize antibiotic resistance patterns based on laboratory data, for example, the last 18 months; and/or o Track measures of outcome surveillance related to antibiotic use (e.g. C. difficile, MRSA, and/or CRE) o Incorporate monitoring of antibiotic use, including the frequency of monitoring/review o Report on number of antibiotics prescribed and the number of residents treated each month o Assess residents for any infection using McGeer's criteria. o Require antibiotic orders to include the indication, dose, and duration . 4. Action: a. Facility may consider antibiotic time-out (TO) practices. o A time-out can be considered a stop order of an antibiotic when a diagnostic test or symptoms of resident do not support the diagnosis of infection. oThese practices include improving the evaluation and communication of clinical signs and symptoms when a resident is first suspected of having an infection, optimizing the use of diagnostic testing, and implementing an antibiotic review process, also known as an antibiotic time-out, for all antibiotics prescribed in the facility. Antibiotic reviews provide clinicians with an opportunity to reassess the ongoing need for and choice of an antibiotic when the clinical picture is clearer and more information available. 5. Tracking: a. IP or designee will be responsible for infection surveillance and [NAME] tracking. b. IP or designee will collect and review data. B. [NAME] Resident 14 49573

Based on observation, interview and record review, the facility failed to develop and implement a policy for use of, sensor alarm pads (a device that alerts staff when a resident moves or leaves their bed or chair) and to ensure consistent monitoring of the use of the sensor alarm pads for the bed and chair, for one of three sampled residents (Resident 26) while the sensor alarm pads were utilized. This deficient practice had the potential to place Resident 26 at risk for decline in physical functioning, reduced mobility, and loss of dignity due to the unmonitored use of sensor alarm pads. Findings: During a review of Resident 26's Admission Record, the Admission Record indicated Resident 26 was originally admitted on [DATE] with a re-admitted on 3/22/2025 with diagnoses of chronic obstructive pulmonary disease ([COPD], a chronic lung disease causing difficulty in breathing), hypertension ([HTN], high blood pressure), dementia (a progressive state of decline in mental abilities), and atrial fibrillation ([A-Fib], (a condition that causes irregular and fast heartbeat in the heart). During a review of Resident 26's History and Physical (H/P) dated 3/25/2025, the H/P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 26's Minimum Data Set ([MDS], a resident assessment tool) dated 3/26/2025, the MDS indicated Resident 26 was severely cognitively (ability to make decisions of daily living) impaired and required moderate assistance (helper does less than half the effort) on self-care abilities such as eating, required maximal assistance (helper does more than half the effort to complete the task) with oral hygiene, toileting hygiene, shower/bathe, upper and lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 26 required maximal assistance with mobility such as rolling left and right, sitting to lying position, lying to sitting on side of bed, bed to chair transfers, and toilet transfers. During a review of Resident 26's Order Summary Report, the Order Summary Report indicated, sensor pad alarm while in bed to alert staff when Resident 26 is trying to get out of bed unassisted, informed consent obtained by medical doctor from responsible party, ordered on 3/22/2025. The Order Summary Report indicated sensor pad alarm in wheelchair to alert staff when Resident 26 is trying to get out of wheelchair unassisted informed consent obtained by medical doctor from responsible party ordered on 3/22/2025. During a review of Resident 26's Medication Administration Record ([MAR], used to document medications taken by the resident) for April 2025, there was missing documentation for April 5th during the nocturnal shift, April 14th during night shift, April 21st during night and nocturnal shift to monitor the resident when the sensor alarm pads were in use. During an observation on 4/21/2025 at 10:47 a.m., in Resident 26's room, Resident 26 was resting in bed with eyes closed. There was a box attached to the bed with a wire attached to the box connect to the alarm pad underneath Resident 26 who as resting in bed. During a concurrent interview and record review on 4/23/2025 at 2:59 p.m., with the MDS Coordinator (MDSC), Resident 26's MAR for April 2025 was reviewed. The MDSC stated staff should be monitoring the residents and the sensor alarm pads every shift to make sure the sensor alarms pads were still there and if the sensor alarm pads were working properly. The MDSC stated if the monitoring was not done every shift or as needed, the residents could be at risk for falls. The MDSC stated monitoring should be done every shift to make sure residents are safe and it should have been documented in the MAR. The MDSC stated if it was not documented, the monitoring was not done. The MDSC stated not aware if there was a policy for sensor alarm pads being utilized. During an interview on 4/24/2025 at 3:20 p.m. with the Director of Nursing (DON), the DON stated sensor alarm pads should be monitored every shift. The DON stated the importance of monitoring the residents and the sensor alarm pads was to make sure the sensor alarm pads were functioning and in place. The DON stated monitoring of the sensor alarm pads should be done every shift and documented to make sure the sensor alarm pads were serving their purpose of alerting staff [NAME] Resident 26 tried to get up unassisted. The DON stated high fall risk residents will fall if monitoring was not done every shift or as needed. The DON stated there was no policy and/or procedure for the bed and chair sensor alarm pads being utilized for residents and that there should be a policy for bed and chair sensor alarm pads since it was an intervention being used for fall risk residents. The DON stated a policy, and procedure was how the facility would monitor and document interventions being done with residents and if the interventions are effective. The facility did not have a policy regarding use of bed and chair alarms.

Based on observation, interview, and record review the facility's staff failed to address pain and discomfort for three of three sampled residents (Resident 1, 2, and 3) by failing to: a. Ensure timely ordering of [MEDICATION(S)] (medication used to treat severe pain) for Resident 1. Resident 1 had chronic pain but did not receive her pain medication for three days. b. Ensure Resident 3 who was complaining of leg pain, was referred to the orthopedic doctor as ordered by the physician. c. Ensure Resident 2 who had a vaginal itching was assessed timely and provided prompt care. These deficient practices caused Residents 1, 2, 3 to suffer unnecessary pain, discomfort, and stress. Findings: a. A review of Resident 1's Pain Management Review dated 1/20/21, indicated Resident 1 was prescribed [MEDICATION(S)] (a narcotic classified as a controlled substance, used to treatment severe pain) and [MEDICATION(S)] (a combination of 2 medications, which is Oxycodone and acetaminophen, to relieve moderate to severe pain), 10 milligrams ([mg] unit of measurement) of Oxycodone and 325mg of acetaminophen. The record also indicated; Resident 1 had pain for the past five days. A review of Resident 1's, Pain Management Review record dated 8/4/21, indicated Resident 1 was prescribed routine [MEDICATION(S)] and oxycodone as needed with complaints of pain (has chronic pain syndrome, watches the clock for her pain medications). The pain management review record also indicated; Resident 1 had current pain. According to this record, Resident 1 also had pain within the past five days. The pain management record indicated the resident's pain was worse in the late evenings and affected Resident 1's concentration, emotions. According to the record, feeling anxious made the resident's pain worse. A review of the Resident 1 's Admission Records indicated the resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's History and Physical (H/P) record dated 2/22/2020, indicated the resident had the capacity to understand and make decisions. A review of Resident 1's Minimal Data Set ([MDS] a standardized assessment and care screening tool) dated 7/23/21, indicated the resident was able to understand and be understood. The MDS indicated Resident 1 required extensive one person assistance with bed mobility, transfer, dressing, toilet, and personal hygiene. A review of Resident 1's care plan for Alteration in Musculoskeletal status revised on 8/4/21 indicated, the resident's goal was to remain free from complications. The care plan interventions included to give analgesics (pain medicine) as ordered by the physician and to plan activities during optimal times when pain and stiffness was less. A review of Resident 1's care plan for Opioid for Chronic Pain Syndrome revised on 8/4/21, indicated the goal for Resident 1 was to remain free from pain or at a level of discomfort acceptable to the resident. The care plan intervention included to administer opioid as prescribed to reduce acute /chronic pain conditions. A review of Resident 1's Restorative Nursing Assistant (RNA) record dated 8/2021 indicated, Resident 1 refused RNA activities on 8/11/21 and 8/12/21. A review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . It also indicated with the exception of August 12-13, 2021. Resident received [MEDICATION(S)] 10-325 mg on from August 21 through 8/31/21, in which four (4) to six (6) doses were documented as administered, with the exception of 8/11/21, in which only two (2) doses were administered. The record also indicated on 8/12/21 and 8/13/21, Resident 1 did not receive any [MEDICATION(S)]. According to the MAR, on 8/26/21 Resident 1 did not receive [MEDICATION(S)] in the evening. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] During a concurrent observation and interview on 8/31/21 at 12:41 p.m., Resident 1 stated she had chronic pain and did not receive her pain medication for two to three days. Resident 1 stated, when she asked the staff about her pain medication they would walk away. Resident 1 stated, around six different times the facility delayed ordering the [MEDICATION(S)] and that I had to suffer in pain for three to four days until the medication arrived. Resident 1 repeated that she needed her pain medication to treat her chronic pain, and that she felt stressed when the nurses would tell her she only had eight pills left and she worried, she would be in pain again without the medication. Resident 1 stated, the days she did not receive her pain medication she was in pain and did not want to do anything. Resident 1 cried as she stated, I am so glad you are here! A review of Resident 1's updated [MEDICATION(S)] card and narcotic count sheet indicated when the label was generated at the facility's dispensing pharmacy on 8/27/21. A review of the narcotic count sheet titled Controlled Drug Record indicated, an inventory of 60 tablets on 8/27/21 to 38 tablets on 9/1/21. The narcotic count sheet indicated a gap between 8/11/21 to 8/14/21, in which no doses were documented as administered on 8/12/21 and 8/13/21. During an interview on 9/1/21 at 1:22 p.m., Certified Nurse Assistant 4 (CNA) stated, the resident often complained she was in pain on her legs and feet and requested her pain medication. CNA 4 stated, when the resident was in pain, she refused therapy. During an interview on 9/1/21 at 2:55 p.m., the Licensed Vocational Nurse 1 (LVN 1) stated Resident 1's [MEDICATION(S)] was usually ordered when 7 or 10 tablets were remaining. LVN 1 stated physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 9/1/21at 3:25 p.m., with the Director of Nursing (DON) regarding the process of reordering controlled medications, she stated, I always tell the nurses not to wait because the pharmacy is not going to dispense if the narcotics were not signed by the physician. The DON stated as soon as an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Regarding the delay in reordering [MEDICATION(S)] and the three days it took to receive Resident 1's [MEDICATION(S)], the DON stated, If the narcotic is not signed, the pharmacy will not deliver. Don't wait, because the patients use a lot of narcotics. According to the DON, it was hard getting signatures for narcotics and nurses had to communicate with the doctor to sign narcotic orders for fast delivery. During an interview on 9/2/21 at 2:58 p.m., the pharmacy manager, (Pharm 1) stated the order was faxed to the pharmacy on 8/24/21 and the physician signed the form on 8/27/21. Pharm 1 also stated Sometimes it's hard to reach the physician. According to Pharm 1, pharmacy staff e-mailed and faxed Resident 1's physician. The facility needs at least two (2) days for authorization. I don't know where the physician was, I can get someone to find out. During an interview on 9/1/21, at 4:07 p.m., Resident 1 stated her pain was worse each time she did not receive pain medication. The resident also stated when in pain, she would not have any appetite, would have a headache, nausea, unable to sleep or participate in her therapy. According to Resident 1 it was too painful. During a concurrent interview and record review on 9/2/21, at 11:45 a.m., the DON stated Resident 1 received [MEDICATION(S)] for the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During a concurrent interview and record review on 9/2/21 at 12:44 p.m., Restorative Nurse Assistant 1 (RNA) stated Resident 1 refused RNA services on 8/11/21 and on 8/12/21. The RNA 1 stated he did not document the reason why Resident 1 refused RNA services. During an interview on 9/13/21 at 4:06 p.m., LVN 1 stated Resident 1 received [MEDICATION(S)], every four hours, as needed, for generalized pain. LVN 1 stated, Resident 1 had pain even after taking the pain medication. LVN 1 also stated, Resident 1 had a phone alarm that would go off every four hours as a reminder for pain management. According to LVN 1, Resident 1 knew when she was out of the [MEDICATION(S)] and had agreed not to ask for the [MEDICATION(S)] when the facility was running low on [MEDICATION(S)] supply. LVN 1 stated, Resident 1did not say her pain was ok without the [MEDICATION(S)] medication and that she kept on asking the staff to follow up on the medication. During an interview on 9/13/21 at 5:11 p.m., LVN 2 stated Resident 1 suffered from pain daily and non-pharmacological interventions did not work for the resident's pain. LVN 2 stated, Resident 1 needed her pain medications all the time for generalized body pain. LVN 2 stated, the resident refused therapy each time she was in pain, and Resident 1 suffered from pain and anxiety when she didn't take [MEDICATION(S)]. According to LVN 2, without [MEDICATION(S)] the resident's pain may increase. A review of the facility's policy titled Pain Management/ Assessment revised on 5/2019 indicated the facility assisted each resident with pain to maintain or achieve the highest practicable level of well-being and functioning by screening to determine if the resident had been or experienced pain, comprehensively assessed the pain, identified circumstances when pain could be anticipated, developed and implemented a plan to manage the pain and or try to prevent the pain consistent with the resident's goals. The policy indicated pain findings, responses, and interventions were documented in the nursing notes. A review of the facility's undated Licensed Vocational Nursing job description indicated the LVN would report any complaints and grievances made by the resident regarding their medical care to the Director of Nursing, keep a written record of the resident's complaint with a notation of actions taken. B. A review of Resident 3's Admission Record indicated, the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE]. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident 3's H/P record dated 11/8/20, indicated Resident 3 had the capacity to understand and make decisions. A review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 3's MDS a standardized assessment and care screening tool) dated 8/12/2021 indicated, Resident 3 was able to understand and be understood. The MDS indicated Resident 3 required extensive one person assistance with bed mobility, dressing, toileting, and personal hygiene. A review of Resident 3's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of another note dated 6/7/21, indicated Resident 3 continued to have the same pain complains. A review of Resident 3's Pain Management Review record dated 5/6/2021 and timed at 1:52 p.m. indicated, Resident 3 was taking [MEDICATION(S)] 5mg/acetaminophen (medication to relieve mild to chronic pain and fever), 325 mg ([[MEDICATION(S)] 5-325 mg] pain medication) and 50mg [MEDICATION(S)] (medication to treat moderate to severe pain). The assessment record also indicated Resident 3 was not experiencing any pain. A review of Resident 3's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 3's care plan for Potential for Pain revised on 5/27/21 indicated, the resident's goal for this plan was to verbalize adequate pain relief or ability to cope with incomplete relief of pain and voicing a level of comfort. The care plan's interventions included to, anticipate Resident 1's need for pain relief and respond immediately, monitor and document probable causes of each pain episode, the quality, anatomical location, onset, aggravating, and relieving factors of the pain. A review of Resident 3's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MAR pain assessment record, the resident complained of pain only for 8 days in August. The record however did not indicate the location of Resident 3's pain. During an interview on 8/31/21 at 1:04 p.m., Resident 3 stated, she had pain in her legs and was supposed to see the orthopedic doctor for pain management, but the facility did not follow up on her appointment. According to Resident 3, she was given pain medication for leg pain, but she continued to have pain and the staff did not assess her pain level after giving her pain medication. During an interview on 9/1/21 at 3:46 p.m., the Social Services Director (SSD) stated nurses were supposed to notify the SSD when the physician ordered a referral for any resident. The SSD stated Resident 3's nurses did not notify the SSD of the resident's order for an orthopedic referral. The SSD also stated that she did not set up any appointment for Resident 3 because she was not aware the resident had an order. During a concurrent interview and record review on 9/2/21 at 11:45 a.m. the DON stated, Resident 3 had an orthopedic referral order dated 4/5/21. The DON stated, the orthopedic referral order was communicated to the nurses, who had to find out who the orthopedic doctor was. The DON stated, the order should have been followed as soon as received, to ensure Resident 3 was seen by the doctor for pain. A review of the facility's undated Licensed Vocational Nursing (LVN) job description indicated the LVN duties and responsibilities included initiating request for consultation and referral. A review of the facility's undated Social Services Director job description indicated the SSD functions included arranging transportation to other facilities when necessary, meeting with nursing staff and other departments in planning service programs and activities, ensuring daily social services were performed without interruptions, making daily rounds for appropriate social services procedures as well as ensure residents' care plans and nurses noted were reviewed and carried out. c. A review of the Resident 2's Admission Records indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 2's Minimum Data Det ([MDS] a care plan and assessment screening tool) dated 8/12/2021 indicated, Resident 2 was able to understand and be understood. The MDS further indicated, the resident required extensive one person assistance with bed mobility, transfer, locomotion on and off the unit, dressing, toilet, and personal hygiene. A review of Resident 2's history and physical examination [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 2's Situation, Background, Assessment, and Recommendation ([SBAR] internal communication tool) Communication form dated 8/31/21, indicated Resident 2 complained of vaginal itching. During an interview on 8/31/21 at 12:22 p.m., Resident 2 stated she had vaginal itch, and notified the CNAs and the Treatment Nurse 1 (TN) two months ago. The resident further stated the staff did not take any actions to address her vaginal itch. Resident 1 who was next to Resident 2 confirmed that Resident 2 notified the Tx nurse about her vaginal itching two weeks ago and stated the treatment nurse did not assessed Resident 2. During an interview on 8/31/21 at 1:24 p.m., CNA 2 stated Resident 2 usually complained of a vaginal itching and CNA 2 notified the Tx nurse each time that Resident 2 complained the resident's vaginal was itch. During an interview on 8/31/21 at 1:57 p.m., the TN 1 stated had just heard about Resident 2's complaint of a vaginal itch. TN 1 denied being notified about Resident 2's vaginal itch and stated, the facility's process is when a resident complains of a vaginal itch, licensed staff are supposed to assess the resident, call the doctor, the resident's representative and carry out any new orders. During an interview on 9/1/21 at 11:30 a.m. Resident 2 stated, when she was left soiled for about three hours on 8/31/21, her vaginal itch increased. During an interview on 9/1/21 at 12:10 p.m., the TN 1 stated on 8/31/21 the resident's family member mentioned to her that the Resident 2 had a vaginal irritation. TN 1 stated, she notified the physician who ordered [MEDICATION(S)] (a medication used to treat fungal infection) 150 milligrams ([mg] unit of measure) daily, for three days, for vaginal itch. The treatment nurse stated, the physician did not assessed Resident 2. During an interview on 9/1/21 at 1:10 p.m., the DON stated she did not know what was reported to the physician about Resident 2 to prompt him to order [MEDICATION(S)] 150 mg. The DON stated, TN 1 received the medication ordered and administered the medication. The DON stated, the TN 1 should have communicated the order to the DON for review. A review of the facility's undated policy titled Change of Condition indicated any changes in a resident's condition would be communicated to the physician and the responsible party. The policy indicated, the change of condition and response would be documented in a change of condition electronic form, and the progress note. It also indicated the resident would be monitored for 72 hours. A review of the facility's undated Certified Nursing Assistant job description, indicated the CNA would report changes in the resident's condition and report all complaints and grievances made by the resident to the nurse supervisor /charge nurse as soon as practical. A review of the facility's undated Licensed Vocational Nursing job description, indicated the LVN would report any complaints and grievances made by the resident regarding their medical care to the DON, keep a written record of the resident's complaint with a notation of actions taken. The LVN duties and responsibilities included exam the resident and distinguish between normal and abnormal to recognize early stages of serious physical, emotional, or mental problems and notify findings to the physician.

Based on observation, interview, and record review, the facility's staff failed to ensure one of five sampled residents (Resident 1), who had a history of [REDACTED]. [REDACTED]. These deficient practices resulted in Resident 1 being found in the surrounding neighborhood, by a passerby, sitting on the sidewalk with a [MEDICAL CONDITION] (deep cut). The Fire Department was called, and the paramedics transferred Resident 1 to the general acute care hospital (GACH), and the resident was diagnosed with [REDACTED]. The facility had a system failure in providing supervision for a resident who was at risk for elopement due to unsupervised wandering (traveling aimlessly from place to place) behaviors. Resident 1, who was identified on a care plan as being at risk for harm related to the resident's episodes of going out of the facility unaccompanied, wandering (traveling aimlessly from place to place) and elopement behaviors. On 3/19/2020 at 5:25 p.m., the Administrator (ADM) and the Director of Nursing (DON), were notified an Immediate Jeopardy ((IJ), a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident), which was declared under F689. The facility's Administrator (ADMIN) and Director of Nursing (DON) were notified of the immediacy and seriousness to the resident's health and safety being threatened. On 3/20/2020 at 3:21 p.m., the facility submitted an acceptable Plan of Action (POA). The IJ was lifted on 3/20/2020 at 3:40 p.m., after the team verified and confirmed, while onsite, the POA was implemented through observation, interview and record review as follows: a. Staff in-service was conducted on 3/19/2020. All staff to be in-serviced by 3/21/2020. The in-service training included management of confused residents and residents with dementia at high risk for elopement/wandering and monitoring of functionality of Sensor Alarms and Tab Alarms. b. The DON/Designee will conduct an elopement drill for each shift on 3/20/2020. c. The facility initiated a binder at the receptionist desk that included photos, face sheets, and descriptions for each of the high-risk residents for staff awareness. d. The DON/Designee will conduct elopement drills every six months and the results will be taken to their monthly Quality Assurance (QA) Committee meetings for trending and recommendations. e. Ongoing education will continue with random testing on elopement procedures with focus on monitoring and supervision of residents that are at risk for elopement and unsafe wandering and the coordination of care amongst all staff providing care to facility residents. f. The DON/Designee will review all new resident admissions within 24 hours to identify any risk factors for elopement or unsafe wandering to ensure that all interventions to mitigate those risk factors have been care-planned and communicated to the staff. g. All residents will be assessed for elopement upon admission and assessed quarterly. h. The DON/Designee will ensure employees receive education related to elopement risk and management of high-risk residents upon hire and annually. i. The Maintenance Supervisor/Designee will check the Wander Guard (bracelet placed on residents that will alarm s when the resident is near an exit door) and door sensor functionality every week. j. The Licensed Nurses will monitor placement and function of each Wander Guard bracelet every shift and document on the treatment administration record (TAR). k. The Licensed Nurses will monitor placement and function of each Sensor and Tab Alarm every shift and document on the TAR. l. The Administrator will present a summary of all elopement related interventions to the QA Committee for review and recommendations monthly. Findings: A review of Resident 1's Admission Record indicated the resident was initially admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Elopement/Wandering Evaluation, dated 1/6/2020 and timed at 6:56 p.m. indicated Resident 1's predisposing disease of dementia indicated Resident 1 had episodes of intermittent confusion. A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 1/13/2020 indicated the resident had moderate cognitive impairment. A review of Resident 1's History and Physical, dated 1/7/2020 indicated Resident 1 did not have the capacity to understand and make decisions and was diagnosed with [REDACTED]. A review of Resident 1's care plan, dated 1/6/2020 and titled, At Risk for falls related to dementia and difficulty in walking with episodes of going out of the facility unaccompanied. The staff's interventions included to anticipate the resident's need; keep call light in reach and encourage resident to use for assistance as needed; maintain the bed in the lowest position and use an alarm device in the resident's bed and wheelchair. A review of Resident 1's Physician Orders, dated 2/29/2020 and timed at 3:13 p.m., indicated an order for [REDACTED]. A review of the facility's undated investigation report indicated Resident 1 had an elopement incident on 3/18/2020 approximately at breakfast time (7:20 a.m.) and at 8:20 a.m., a Fireman came to the facility and asked the charge Nurse did he know Resident 1. The Fireman informed the charge nurse that Resident 1 was transferred to the general acute care hospital (GACH). A review of Resident 1's Prehospital Care Report (Fire department/paramedics report) indicated on 3/18/2020 at 7:55 a.m., they were dispatched and arrived at the scene at 8:01 a.m. The report indicated Resident 1 was found by a passerby sitting on the sidewalk with a laceration over the left eye and was transported to the nearest trauma center. The chief complaint was documented as [MEDICATION NAME] traumatic injury and the resident's vital signs (blood pressure, heart rate, respirations) were within normal limits (WNLs). A review of Resident 1's GACH Emergency Department (ED) notes dated 3/18/2020 and timed at 8:49 a.m. indicated Resident 1 was admitted to ED with [MEDICATION NAME] head trauma ((BHT) head injury) with a left [MEDICAL CONDITION] with pain radiating to the head. The history and physical (H/P) indicated Resident 1 was found down near a convalescent facility with confusion but was able to follow simple commands. Resident 1 had a Computed Tomography Scan ((CT)) use of combination of x-rays and computer images to see inside the body) performed at the GACH, which showed a left-sided scalp and forehead skin swelling and hematoma (a localized swelling filled with blood caused by a break in the wall of a blood vessel) and a left frontal cortical hemorrhagic contusion (area of bleeding on surface of the brain). The H/P indicated Resident 1's scalp laceration was repaired, and wound closure done in the ED. A review of Resident 1's Nurse's Progress Note, dated 3/18/2020 and timed at 12:32 p.m., indicated Licensed Vocational Nurse (LVN 1) documented at 8:25 a.m., a fireman (F1) rang the facility's doorbell and notified LVN 1, Resident 1 was found in the street with a wound to his head. LVN 1 documented F1 informed LVN 1, Resident 1 was transported to a GACH's emergency room and Resident 1's family member was notified. On 3/19/2020 at 11:27 a.m., during a concurrent observation and interview, the facility's Maintenance Supervisor (MS) stated the facility's front door alarm does not activate when exiting the facility. On observation, the MS exited the facility's door and the door alarm did not activate. On 3/19/2020 at 11:52 a.m., during a telephone interview, Resident 1's family member (FM 1) stated she received a telephone call from LVN 1 on 3/18/2020 at 8:25 a.m. informing her that Resident 1 had eloped from the facility and was found a couple of blocks away from the facility and was taken to a GACH. FM 1 stated during her initial meeting with the facility on 1/8/2020, she informed the DON and the Social Service Director (SSD) of Resident 1's history of eloping from their residence on several occasions. FM 1 stated she visited Resident 1 every day and his sensor pad bed alarm only worked intermittently (sometimes) and there was no sensor pad alarm on Resident 1's wheelchair. On 3/19/2020 at 11:42 a.m., during an interview, the DON stated Resident 1 does not have orders for a Wander Guard (an electronic device that will activate near a door with the sensor). The DON stated the facility's front door alarm would only be activated by residents wearing a Wander Guard and the front door alarm will not activate for regular traffic. A review of the facility's video surveillance dated 3/18/2020 and timed at 7:47 a.m., with the SSD, Resident 1 was observed exiting the facility through the facility's front door unsupervised. There was no receptionist observed at the front desk located next to the facility's front door. The SSD stated Someone is supposed to be at the receptionist desk at all times. I'm not sure why no one was there. On 3/19/2020 at 12:55 p.m., during an interview, the facility's receptionist stated, I start at 9:30 a.m. and there is no one at this desk from 7 a.m. to 9 a.m. The front door is locked from the outside and the nurses monitor the front door from the nurse's station during that period. On 3/19/2020 at 1:10 p.m., during an interview, Certified Nursing Assistant 1 (CNA1) stated Resident 1 was confused at times and had to be redirected. CNA1 stated Resident 1 had orders for a sensor pad bed alarm and a sensor pad wheelchair alarm. CNA1 stated she and the charge nurse were responsible for ensuring the bed alarms were turned on and functioning. CNA1 stated Resident 1's bed alarm was not turned on at the beginning of the shift. CNA1 stated she forgot to check Resident 1's bed alarm because she was in a rush and there was so much going on. CNA1 stated she noticed Resident 1 was not in his room at 7:45 a.m. on 3/18/2020 and she notified LVN 1 at that time. On 3/19/2020 at 3:47 p.m., during a concurrent observation and interview, LVN 2 stated Resident 1 had dementia, was confused and forgetful, and needed reorientation many times. LVN 2 stated residents who had dementia and are confused should be monitored for elopement. LVN 2 stated Resident 1 was not monitored for elopement. LVN 2 stated the receptionist desk located at the front door was not staffed after 5 p.m. daily until the next morning. LVN 2 stated, We monitor the front door from the nursing stations. LVN 2 went to Nursing Stations 1 and 2 to demonstrate how she could view the front door. LVN 2 acknowledged she could not see the front door from Nursing Station 1 or 2. On 3/19/2020 at 4:20 p.m., during an interview, the SSD stated she participated in the initial meeting with FM 1, the DON, and the Case Manager (CM). The SSD stated FM 1 May have mentioned the resident (Resident 1) leaving FM 1's house and FM 1 is concerned with Resident 1 being at home. The SSD stated Resident 1 had dementia and had episodes of confusion and forgetfulness. On 3/23/2020 at 1:36 p.m., during an interview, LVN 1 stated Resident 1 had orders for sensor bed pad and wheelchair alarms. LVN 1 stated he assumed Resident 1's bed alarm was turned on and he did not check the alarms when he started his shift at 7 a.m. on 3/18/2020 (the day of elopement). LVN 1 acknowledged Resident 1's bed alarm was not turned on at 7:42 a.m. on 3/18/20. LVN 1 stated he was notified by a fireman on 3/18/2020 at 8:25 a.m. that Resident 1 was found in the street and was taken to a GACH. A review of the facility's undated Policy titled, Elopement-Policy and Assessment/Prevention, under procedures indicated Assessment and Identification of Wandering Residents and the importance of obtaining the history of behaviors, including wandering; will be obtained prior to admission. This can be accomplished during the pre-admission inquiry from family, hospital records, or physician's history.

Based on observation, interview, and record review, the facility's staff failed to properly supervise one of five sampled residents (Resident 1) resulting in an elopement (an act or instance of leaving a safe area or safe premises) from the facility. As a result of this deficient practice, Resident 1 eloped into the surrounding neighborhood unsupervised, and sustained a laceration to the forehead and a subarachnoid hemorrhage((SAH)bleeding in the space between the brain and the surrounding tissues that cover the brain) after a fall. As a result of this deficient practice, the facility did not meet Resident 1's physical, mental, and psychosocial needs. Findings: A review of Resident 1's Admission Record indicated the resident was initially admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 1/13/20, indicated the resident had moderate cognitive (ability to process thoughts) impairment. A review of Resident 1's History and Physical, dated 1/7/20, indicated Resident 1 did not have the capacity to understand and make decisions and is diagnosed with [REDACTED]. During a telephone interview on 3/19/20 at 11:52 a.m., Resident 1's family member (FAM1) stated she received a telephone call from Licensed Vocational Nurse (LVN1) on 3/18/20 at 8:25 a.m FAM1 stated LVN1 informed her that Resident 1 had eloped from the facility, was found a couple of blocks away, and was taken to General Acute Care Hospital (GACH). FAM1 stated that during the initial meeting with the facility on 1/8/2020, she informed the Director of Nursing (DON) and the Social Service Director (SSD) of Resident 1's history of eloping from their residence on several occasions. During a telephone interview on 3/19/20 at 12:15 a.m., FAM1 stated she visits Resident 1 everyday and his sensor pad bed alarm only works intermittently. FAM1 stated there was no sensor pad alarm on Resident 1's wheelchair. During a concurrent observation and interview on 3/19/20 at 11:27 a.m., Maintenance Supervisor (MS1) stated the facility's front door alarm does not activate when exiting the facility. MS1 exited the facility and the door alarm did not activate. During an interview on 3/19/20 at 11:42 a.m., the DON stated Resident 1 does not have orders for a Wanderguard. DON stated the facility's front door alarm is only activated by Residents wearing a Wanderguard and the front door alarm will not activate for regular traffic. During a review of a video surveillance tape dated 3/18/20 and timed at 7:47 a.m. with Social Service Director (SSD), Resident 1 was observed exiting the facility through the facility's front door unsupervised. No receptionist was observed at the front desk located next to the facility's front door. SSD stated Someone is supposed to be at the receptionist desk at all times. I'm not sure why no one was there. During an interview on 3/19/20 at 12:55 p.m., the Receptionist (REC1) stated I start at 9:30 a.m. and there is no one at this desk from 7:00 a.m. to 9:00 a.m The front door is locked from the outside and the nurses monitor the front door from the nurse's station during this period. During an interview on 3/19/20 at 1:10 p.m., Certified Nursing Assistant (CNA1) stated Resident 1 is confused at times and must be redirected. CNA1 stated Resident 1 has orders for a sensor pad bed alarm and a sensor pad wheelchair alarm. CNA1 stated the charge nurse and herself are responsible for ensuring the bed alarms are turned on and functioning. CNA1 stated Resident1's bed alarm was not turned on at the beginning of her shift. CNA1 stated she forgot to check Resident 1's bed alarm because she was in a rush and there was so much going on. CNA1 stated she noticed Resident 1 not in his room at 7:45. CNA1 stated she notified LVN1 at this time. During a concurrent observation and interview on 3/19/20 at 3:47 p.m., LVN2 stated that Resident 1 had Dementia, was confused and forgetful, and needed reorientation many times. LVN2 stated Residents who have Dementia and are confused should be monitored for elopement. LVN2 stated Resident 1 was not monitored for elopement. LVN2 stated that the receptionist desk located at the front door is not staffed from 5:00 p.m. through 9:00 a.m LVN2 stated we monitor the front door from the nursing stations. LVN2 was escorted to nursing station 1 and nursing station 2 to demonstrate front door observation. LVN2 acknowledged she could not see the front door from nursing station 1 or nursing station 2. During an interview on 3/19/20 at 4:20 p.m., SSD stated she was in a meeting with FAM1, the DON, and the Case Manager (CM). SSD stated FAM1 may have mentioned Resident 1 leaving FAM1's house and FAM1 is concerned with Resident 1 being at home. SSD stated Resident 1 has Dementia and has episodes of confusion and forgetfulness. During a telephone interview on 3/23/20 at 1:36 p.m., LVN1 states Resident 1 had orders for sensor pad bed and wheelchair alarms. LVN1 states that he assumed Resident 1's bed alarm was turned on and he did not check the alarms when he started his shift at 7:00a.m. on 3/18/20. LVN1 acknowledged that Resident 1's bed alarm was not turned on at 7:42 a.m. on 3/18/20. LVN1 stated he was notified by F1 on 3/18/20 at 8:25 a.m. that Resident 1 was found in the street and was taken to GACH. A review of Resident 1's Elopement/Wandering Evaluation dated 1/6/20, timed at 6:56 p.m., indicated Resident 1's predisposing disease as Dementia (a condition characterized by decline in memory, problem solving skills, and other thinking skills that affect a person's ability to perform everyday activities) and indicated Resident1 has episodes of intermittent confusion. A review of Resident 1's Physician Orders, dated 2/29/20 and timed at 3:13 p.m., indicated an order for [REDACTED].>A review of Resident 1's Progress Note, dated 3/18/20, and timed at 12:32 p.m., indicated Licensed Vocational Nurse (LVN)1 documented at 8:25 a.m., F1 rang the facility doorbell and notified LVN1 that Resident 1 was found walking in the street with a wound to his head. F1 informed LVN1 he transported Resident 1 to GACH emergency room and notified Resident 1's daughter. A review of FD1 Prehospital Case Report indicated on 3/18/20 at 8:01 a.m., Resident one was found sitting on the sidewalk with a laceration to his head. The Prehospital Case Report indicated Resident one was transported to GACH. A review of Resident 1's GACH Emergency Department (ED) notes dated 3/18/20 at 8:49 a.m. indicated Resident 1 was admitted to ED with [MEDICATION NAME] head trauma (head injury) and left [MEDICAL CONDITION] (wound produced by tearing of soft tissue). A review of Resident 1's Computed Tomography Scan (CT) performed by GACH, indicated a left frontal cortical hemorrhagic contusion (area of bleeding on surface of the brain). A review of the facility's Policy and Procedure (P & P) titled, Resident Rights. Abuse: Prevention of and Prohibition Against, revised 11/28/2017, indicated the policy defines neglect as the failure of the Facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

Based on observation, interview, and record review, the facility failed to report one of five-sampled residents (Resident 1) elopement to the Department of Public Health (DPH) within two (2) hours from the time the incident occurred. This deficient practice had the potential to place Residents 2, 3, 4 and 5, at risk for harm related to the resident's unsupervised wandering (traveling aimlessly from place to place) and/or elopement behavior(s). Findings: A review of Resident 1's Admission Record indicated the resident was initially admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 1/13/20, indicated the resident had moderate cognitive (ability to process thoughts) impairment. A review of Resident 1's History and Physical, dated 1/7/20, indicated Resident 1 did not have the capacity to understand and make decisions and is diagnosed with [REDACTED]. During a telephone interview on 3/19/20 at 11:52 a.m., Resident 1's family member (FAM1) stated she received a telephone call from Licensed Vocational Nurse (LVN1) on 3/18/20 at 8:25 a.m FAM1 stated LVN1 informed her that Resident 1 had eloped from the facility, was found a couple of blocks away, and was taken to General Acute Care Hospital (GACH). FAM1 stated that during the initial meeting with the facility on 1/8/2020, she informed the Director of Nursing (DON) and the Social Service Director (SSD) of Resident 1's history of eloping from their residence on several occasions. During a concurrent observation and interview on 3/19/20 at 11:27 a.m., Maintenance Supervisor (MS1) stated the facility's front door alarm does not activate when exiting the facility. MS1 exited the facility and the door alarm did not activate. During an interview on 3/19/20 at 11:42 a.m., the DON stated Resident 1 does not have orders for a Wanderguard. DON stated the facility's front door alarm is only activated by Residents wearing a Wanderguard and the front door alarm will not activate for regular traffic. During a review of a video surveillance tape dated 3/18/20 and timed at 7:47 a.m. with Social Service Director (SSD), Resident 1 was observed exiting the facility through the facility's front door unsupervised. No receptionist was observed at the front desk located next to the facility's front door. SSD stated Someone is supposed to be at the receptionist desk at all times. I'm not sure why no one was there. During an interview on 3/19/20 at 12:55 p.m., the Receptionist (REC1) stated I start at 9:30 a.m. and there is no one at this desk from 7:00 a.m. to 9:00 a.m The front door is locked from the outside and the nurses monitor the front door from the nurse's station during this period. During an interview on 3/19/20 at 1:10 p.m., Certified Nursing Assistant (CNA1) stated Resident 1 is confused at times and must be redirected. CNA1 stated she noticed Resident 1 not in his room at 7:45. CNA1 stated she notified LVN1 at this time. CNA1 stated If we notice a Resident missing, we are supposed to report the incident to our charge nurse and begin looking for the Resident. During a concurrent observation and interview on 3/19/20 at 3:47 p.m., LVN2 stated that Resident 1 had Dementia, was confused and forgetful, and needed reorientation many times. LVN2 stated Residents who have Dementia and are confused should be monitored for elopement. LVN2 stated Resident 1 was not monitored for elopement. LVN2 stated that the receptionist desk located at the front door is not staffed from 5:00 p.m. through 9:00 a.m LVN2 stated we monitor the front door from the nursing stations. LVN2 was escorted to nursing station 1 and nursing station 2 to demonstrate front door observation. LVN2 acknowledged she could not see the front door from nursing station 1 or nursing station 2. During an interview on 3/19/20 at 4:20 p.m., SSD stated she was in a meeting with FAM1, the DON, and the Case Manager (CM). SSD stated FAM1 may have mentioned Resident 1 leaving FAM1's house and FAM1 is concerned with Resident 1 being at home. SSD stated Resident 1 has Dementia and has episodes of confusion and forgetfulness. During an interview on 3/19/20 at 5:40 p.m., DON stated she did not report Resident 1's elopement on 3/18/20 to The Department of Public Health (DPH) because Resident 1 had already been located. DON stated she completed the State of California Report of Suspected Dependent Adult/Elder Abuse (SOC 341) today. During a telephone interview on 3/23/20 at 1:36 p.m.,. LVN1 stated he was notified by F1 on 3/18/20 at 8:25 a.m. that Resident 1 was found in the street and was taken to GACH. LVN1 stated he immediately notified the Administrator, DON, Physician, and Resident 1's family member. LVN 1 stated he did not notify DPH because It is not in my instructions to notify DPH. A review of the SOC 341 dated 3/19/20, indicated DON reported Resident 1's elopement to FAM1 and the local Ombudsman on 3/19/20. A review of Resident 1's Progress Note, dated 3/18/20, and timed at 12:32 p.m., indicated Licensed Vocational Nurse (LVN)1 documented at 8:25 a.m., F1 rang the facility doorbell and notified LVN1 that Resident 1 was found walking in the street with a wound to his head. F1 informed LVN1 he transported Resident 1 to GACH emergency room and notified Resident 1's daughter. A review of FD1 Prehospital Case Report indicated on 3/18/20 at 8:01 a.m., Resident one was found sitting on the sidewalk with a laceration to his head. The Prehospital Case Report indicated Resident one was transported to GACH. A review of Resident 1's GACH Emergency Department (ED) notes dated 3/18/20 at 8:49 a.m. indicated Resident 1 was admitted to ED with [MEDICATION NAME] head trauma (head injury) and left [MEDICAL CONDITION] (wound produced by tearing of soft tissue). A review of Resident 1's Computed Tomography Scan (CT) performed by GACH, indicated a left frontal cortical hemorrhagic contusion (area of bleeding on surface of the brain). A review of the facility's Policy and Procedure (P & P) titled, Elopement indicated the facility's policy does not include instructions to notify DPH within a specific time frame if the facility determines a Resident has eloped.

Based on observation, interview, and record review, the facility's staff failed to provide oversight and monitoring for one of five sampled residents (Resident 1) resulting in an elopement (an act or instance of leaving a safe area or safe premises) from the facility. As a result of this deficient practice, Resident 1 eloped into the surrounding neighborhood unsupervised, and sustained a laceration to the forehead and a subarachnoid hemorrhage((SAH)bleeding in the space between the brain and the surrounding tissues that cover the brain) after a fall. As a result of the facility's system failure to provide oversight and monitoring Residents 2, 3, 4 and 5, were at risk for harm related to the resident's unsupervised wandering (traveling aimlessly from place to place) and/or elopement behavior(s) and at risk of not having safety needs met. Findings: A review of Resident 1's Admission Record indicated the resident was initially admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 1/13/20, indicated the resident had moderate cognitive (ability to process thoughts) impairment. A review of Resident 1's History and Physical, dated 1/7/20, indicated Resident 1 did not have the capacity to understand and make decisions and is diagnosed with [REDACTED]. During a telephone interview on 3/19/20 at 11:52 a.m., Resident 1's family member (FAM1) stated she received a telephone call from Licensed Vocational Nurse (LVN1) on 3/18/20 at 8:25 a.m FAM1 stated LVN1 informed her that Resident 1 had eloped from the facility, was found a couple of blocks away, and was taken to General Acute Care Hospital (GACH). FAM1 stated that during the initial meeting with the facility on 1/8/2020, she informed the Director of Nursing (DON) and the Social Service Director (SSD) of Resident 1's history of eloping from their residence on several occasions. During a telephone interview on 3/19/20 at 12:15 a.m., FAM1 stated she visits Resident 1 everyday and his sensor pad bed alarm only works intermittently. FAM1 stated there was no sensor pad alarm on Resident 1's wheelchair. During a concurrent observation and interview on 3/19/20 at 11:27 a.m., Maintenance Supervisor (MS1) stated the facility's front door alarm does not activate when exiting the facility. MS1 exited the facility and the door alarm did not activate. During an interview on 3/19/20 at 11:42 a.m., the DON stated Resident 1 does not have orders for a Wanderguard. DON stated the facility's front door alarm is only activated by Residents wearing a Wanderguard and the front door alarm will not activate for regular traffic. During a review of a video surveillance tape dated 3/18/20 and timed at 7:47 a.m. with Social Service Director (SSD), Resident 1 was observed exiting the facility through the facility's front door unsupervised. No receptionist was observed at the front desk located next to the facility's front door. SSD stated Someone is supposed to be at the receptionist desk at all times. I'm not sure why no one was there. During an interview on 3/19/20 at 12:55 p.m., the Receptionist (REC1) stated I start at 9:30 a.m. and there is no one at this desk from 7:00 a.m. to 9:00 a.m The front door is locked from the outside and the nurses monitor the front door from the nurse's station during this period. During an interview on 3/19/20 at 1:10 p.m., Certified Nursing Assistant (CNA1) stated Resident 1 is confused at times and must be redirected. CNA1 stated Resident 1 has orders for a sensor pad bed alarm and a sensor pad wheelchair alarm. CNA1 stated the charge nurse and herself are responsible for ensuring the bed alarms are turned on and functioning. CNA1 stated Resident1's bed alarm was not turned on at the beginning of her shift. CNA1 stated she forgot to check Resident 1's bed alarm because she was in a rush and there was so much going on. CNA1 stated she noticed Resident 1 not in his room at 7:45. CNA1 stated she notified LVN1 at this time. During a concurrent observation and interview on 3/19/20 at 3:47 p.m., LVN2 stated that Resident 1 had Dementia, was confused and forgetful, and needed reorientation many times. LVN2 stated Residents who have Dementia and are confused should be monitored for elopement. LVN2 stated Resident 1 was not monitored for elopement. LVN2 stated that the receptionist desk located at the front door is not staffed from 5:00 p.m. through 9:00 a.m LVN2 stated we monitor the front door from the nursing stations. LVN2 was escorted to nursing station 1 and nursing station 2 to demonstrate front door observation. LVN2 acknowledged she could not see the front door from nursing station 1 or nursing station 2. During an interview on 3/19/20 at 4:20 p.m., SSD stated she was in a meeting with FAM1, the DON, and the Case Manager (CM). SSD stated FAM1 may have mentioned Resident 1 leaving FAM1's house and FAM1 is concerned with Resident 1 being at home. SSD stated Resident 1 has Dementia and has episodes of confusion and forgetfulness. During a telephone interview on 3/23/20 at 1:36 p.m., LVN1 states Resident 1 had orders for sensor pad bed and wheelchair alarms. LVN1 states that he assumed Resident 1's bed alarm was turned on and he did not check the alarms when he started his shift at 7:00a.m. on 3/18/20. LVN1 acknowledged that Resident 1's bed alarm was not turned on at 7:42 a.m. on 3/18/20. LVN1 stated he was notified by F1 on 3/18/20 at 8:25 a.m. that Resident 1 was found in the street and was taken to GACH. A review of Resident 1's Elopement/Wandering Evaluation dated 1/6/20, timed at 6:56 p.m., indicated Resident 1's predisposing disease as Dementia (a condition characterized by decline in memory, problem solving skills, and other thinking skills that affect a person's ability to perform everyday activities) and indicated Resident1 has episodes of intermittent confusion. A review of Resident 1's Physician Orders, dated 2/29/20 and timed at 3:13 p.m., indicated an order for [REDACTED].>A review of Resident 1's Progress Note, dated 3/18/20, and timed at 12:32 p.m., indicated Licensed Vocational Nurse (LVN)1 documented at 8:25 a.m., F1 rang the facility doorbell and notified LVN1 that Resident 1 was found walking in the street with a wound to his head. F1 informed LVN1 he transported Resident 1 to GACH emergency room and notified Resident 1's daughter. A review of FD1 Prehospital Case Report indicated on 3/18/20 at 8:01 a.m., Resident one was found sitting on the sidewalk with a laceration to his head. The Prehospital Case Report indicated Resident one was transported to GACH. A review of Resident 1's GACH Emergency Department (ED) notes dated 3/18/20 at 8:49 a.m. indicated Resident 1 was admitted to ED with [MEDICATION NAME] head trauma (head injury) and left [MEDICAL CONDITION] (wound produced by tearing of soft tissue). A review of Resident 1's Computed Tomography Scan (CT) performed by GACH, indicated a left frontal cortical hemorrhagic contusion (area of bleeding on surface of the brain). A review of the facility's Policy and Procedure (P & P) titled, Resident Rights. Abuse: Prevention of and Prohibition Against, revised 11/28/2017, indicated It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The Facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents to be from abuse, neglect, misappropriation of resident property, and exploitation. The policy also indicated The Facility will engage in training and orienting its new and existing nursing staff on topics which relate to the delivery of care in the post-acute setting. Topics of such training will include, but not be limited to: wandering or elopement type behaviors. The policy defines neglect as the failure of the Facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

Based on interview and record review, the facility failed to ensure one of three sampled residents, Resident 1, with a history of multiple falls, was closely monitored and supervised to prevent repeated falls and serious injury. This deficient practice resulted in Resident 1 having an unwitnessed fall while taking a shower unassisted, sustaining a right ankle fracture (broken bone) and requiring admission to General Acute Care Hospital 1 (GACH 1) for a right ankle surgery. Findings: A review of the Admission Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 1's care plan dated 2/28/18, revised 6/1/18 indicated Resident 1 was at risk for falls related to hospitalization , aging process and with episode of taking showers without informing staff on his own. The care plan for Resident 1 indicated interventions to include reinforce teaching regarding safety, calling for assistance, as needed. A review of the Minimum Data Set (MDS - standardized assessment and care-screening tool) dated 8/7/18, indicated Resident 1 was able to remember and make decisions. Resident 1 required physical help in part of the bathing activity and required supervision with setting up support for bed mobility, transfer, walk in the room and corridors, eating and toilet use. Resident 1 required limited assistance with one-person physical assist with dressing and personal hygiene. Resident 1 used walker and wheelchair for mobility. A review of a Fall Risk assessment dated [DATE] indicated Resident 1 was at high risk for falls with a history of falls in the past three months, had balance problems while standing/walking, decreased muscular coordination/jerking movements, changes in gait pattern when walking and required the use of assistive devices. A care plan developed on 8/27/18, for Resident 1's ADL self-performance deficit related to decreased balance, decreased right upper extremity range of motion (ROM), increased pain on right shoulder, back and hip, indicated in the approaches to provide Resident 1 with assistance as needed. A review of the nursing Progress Notes indicated Resident 1 had unwitnessed falls on 5/23/18 and on 8/12/18. On 8/12/18, the documentation indicated Resident 1 used the toilet by himself and when tried to reach the toilet paper, he lost his balance and fell on the floor. A review of nursing Progress Note dated 9/25/18, timed at 10:30 a.m. indicated Registered Nurse 1 (RN 1) was called by a nursing staff after hearing Resident 1 yelling for help. RN 1 found Resident 1 sitting on the shower floor with the shower chair in front of him. Resident 1 stated he stood up from the shower chair and slipped off the floor. Resident 1 tried to prevent the fall by holding on to the wall but failed and on his right side hitting his right ankle. Resident 1 complained of pain rated 8/10 (pain rating scale from zero indicating no pain and 10 the worst possible pain) to his right leg. Resident 1 was transferred the same day of the fall, 9/25/18, to GACH 1. Further review of the clinical record disclosed there were no additional interventions the interdisciplinary team had identified to address that the resident continued to go to the shower room by himself. There was no system in place to prevent the resident to go to the shower room unattended. A review of GACH 1's x-ray (taking images pictures of the inside of the body) results for two views of the right ankle, dated 9/26/18 indicated the Resident 1 had an acute tri-malleolar fracture (is a three-part break) of the ankle. A review of a GACH 1's Physician's Discharge Summary, dated 9/27/18 indicated Resident 1 was admitted on [DATE] and discharged on [DATE] back to the facility after undergoing surgery to repair the right ankle fracture. On 9/28/18, at 10:30 a.m., during an interview, the facility's Director of Nursing (DON) confirmed Resident 1 fell in the shower room on 9/25/18. DON was unable to provide documented evidence of a system in place that the facility used to safely monitor the resident from going to the bathroom unassisted to prevent repeated falls and serious injury. On 10/30/18, at 3:15 p.m., during an interview, Resident 1 stated on the morning of the fall (9/25/18), the resident asked a Certified Nursing Assistant, if he could take a shower. Resident 1 stated he could not remember the CNA's name but was told to go ahead and take a shower and they would be in to assist. According to Resident 1, staff never showed up. Resident 1 stated he usually takes a shower by himself and unassisted. On 11/14/18, at 3:50 p.m., during an interview, MDS 1 stated on 9/25/18, she was in her office, which was across from the shower room and she heard yelling. MDS 1 stated she went to the shower room and found Resident 1 on the floor in the shower by himself and she notified RN 1 of the incident.

Based on observation, interview, and record review, the facility's staff failed to follow its smoking policy and procedure for three of three sampled residents (Residents 1, 4, and 5). The facility's staff failed to provide smoking safety education, especially regarding oxygen use upon admission and ongoing to the residents and family members as stipulated in its policy, to ensure smoking material was not keep in the resident's possession and at the residents' bedside. Resident 1, who was receiving oxygen (O2) via nasal cannula (plastic prong tubing placed in nose attached to an oxygen canister),was playing with a lighter on 12/11/14, at 1:40 a.m., in his room while in bed. When the resident flicked the lighter, the oxygen exploded resulting in facial burns on Resident 1. As a result of these deficient practices Resident 1 sustained first and second degree burns (first-degree burns affect only the outer layer of the skin and second-degree burns affect both the outer and underlying layer of the skin, both degree of burns results in pain, redness, swelling, but blistering (partial thickness burns)) is included in second degree burns) to the resident's face and nasal passages, which had a potential to compromise Resident 1's airway and put the resident's roommate and other residents, visitors and staff in danger. Resident 1 required a transfer to two hospitals. Resident 1 was treated with narcotic pain medications, breathing treatments, wound dressings, while the resident ' s airway patency was closely monitored. These deficient practices also put Residents 4 and 5 at risk for harm, due to the lack of education and adhering to the facility ' s policy and procedure. Findings: The Department received an entity reported incident, alleging that a resident (Resident 1), who was receiving oxygen (O2) via a nasal cannula, was using his cigarette lighter to see if it worked, so he could smoke later. The action resulted in facial burns that required a transfer to a general acute care hospital (GACH). Resident 1 was not observed in his room during the unannounced ERI investigation on 12/12/14, at 1:50 p.m. At 1:55 p.m., on 12/12/14, during an interview, the director of nurses (DON) stated Resident 1 was transferred to GACH 1 and then to GACH 2, due to the need for a higher level of care of the facial burns. The DON was asked for a list of residents who smoked and six residents were identified. Residents 4 and 5 were interviewed. a. A review of Resident 1's Admission Record (face sheet) indicated the resident was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of a Minimum Data Set (MDS), a standardized assessment and screening tool, dated 9/15/14, indicated Resident 1 was cognitively impaired (mental processes of perception, memory, judgment, and reasoning). According to the MDS, Resident 1 required extensive assistance (staff provide weight-bearing support) from staff with a two- person physical assist for bed mobility, transferring, and toilet use. Resident 1 had impairment of both upper extremities (arms). The resident used both a walker and wheelchair as mobility aids. A review of a physician's orders [REDACTED]. A review of a nurse's progress note, dated 12/11/14, and timed at 1:40 a.m., indicated a licensed vocational nurse (LVN 1) heard an unusual noise, followed by a burning smell near Room 10. The nurse's progress note indicated LVN1 entered Resident 1's room (Room 8) and noted the resident was in bed with a burnt nasal cannula and black powder on his face. LVN1 immediately turned the O2 concentration off and assessed the resident's condition; LVN1 assessed Resident 1 to have burned marks on his nose, cheeks, and forehead. The progress note indicated LVN1 rendered first aid, and then removed the cigarettes and the lighter from Resident 1. On 12/12/14, at 4:15 p.m., during a telephone interview, LVN1 stated he worked during the night shift on 11 p.m.-7 a.m., from 12/10/14 to 12/11/14. LVN 1 stated at approximately 1:40 a.m., he heard an unusual swishing sound. LVN 1 stated when he followed the sound to the Resident 1's room, he smelled burnt hair, and saw the resident's face was covered in black powder with a disfigured nasal cannula still in Resident 1's nose. LVN1 stated he found unlit cigarettes in the resident's pockets and Resident 1 stated that he made a mistake of mixing oxygen and the cigarettes. A review of a nurse's progress notes, dated 12/11/14, and timed at 3 p.m., indicated Resident 1 was transferred to the GACH via paramedics. On 12/12/14 at 5 p.m., while at the facility, Resident 1 was observed returning to the facility from the GACH, lying on a gurney. At 5:05 p.m., on 12/12/14, Resident 1 was observed sitting in his bed with a Vaseline gauze (a fine mesh, absorbent gauze with white petrolatum; keeps wound moist, usually used for burns) covering the resident's bilateral (both) checks and nose. On 12/12/14, at 5:08 p.m., during an interview, Resident 1 stated that he was trying to test his lighter to make sure it worked and he burnt himself because he forgot that he had the oxygen on. Resident 1 stated he brought the lighter with him upon admission three months prior and that the facility's staff did not educate him regarding the facility's safety smoking policy. Resident 1 stated the staff never told him he could not have his lighter and/or cigarettes at the bedside. A review of GACH 1's record, indicated Resident 1 was seen at the hospital after the flash burn ((flash flame explosion) any burn injury caused by intense flashes of light, high voltage electric current, or strong thermal radiation) to the face while Resident 1 was trying to light a cigarette with oxygen via nasal cannula in place. According to GACH 1's records, Resident 1 was transferred from GACH 1 to GACH 2 (a higher level of care hospital) on 12/11/14. According to GACH 2's records, Resident 1 was admitted for monitoring of the resident's airway, due an abnormal finding on the chest x-ray. According to the chest x-ray, the resident's broncho-vascular area (lungs/bronchioles (part of the respiratory system anatomy)) had increased markings (indicative of an increase in fluid or edema). Resident 1 had coarse breath sounds with bilaterally (both lungs) wheezing (a high-pitched whistling sound made while breathing) in both upper lobes of the resident's lungs. Resident 1 required respiratory breathing treatments of Duoneb/mucomyst (use to relax muscles in the airways and increase air flow to the lungs/ for abnormal mucous secretions). Resident 1 was pre-medicated with Oxycodone (narcotic/pain medication) by mouth prior to resident's face being washed with soap and water; bacitracin (an antibiotic ointment) was applied to the resident's facial open areas, and covered with Vaseline gauze and burn netting. GACH 2's plan of care for Resident 1 included the above daily wound treatment at the SNF for 14 days, followed-up with an appointment at an outpatient burn clinic. On 12/19/15, at 3 p.m., during an interview, the facility's social worker (SW) stated the morning Resident 1 was burned she found two lighters and cigarettes at Resident 1's bedside. The SW stated she educated residents and their family members regarding the facility's smoking safety. The SW stated the residents could not keep cigarettes and lighters with them and she stated she had educated Resident 1's family member to not to give cigarettes and lighters to the resident. On 12/19/14, at 3:15 p.m., Resident 1 stated he was now famous at the facility and because of him; the facility's smoking policy had changed. Resident 1 stated no one at the facility told him that he was not supposed to keep his lighter and cigarettes. Resident 1 stated there were no rules about smoking before he burnt himself. Resident 1 stated he would go to the facility's patio and smoke whenever he wanted. Resident 1 stated now he has to adhere to a smoking schedule and have to be supervised by the staff when he smoked. When Resident 1 was asked how he obtained the cigarettes, Resident 1 stated his family member (FM 2) brought him two packs of cigarettes every weekend. On 12/19/14, at 3:40 p.m., during a telephone interview, FM 2 stated she would give Resident 1 cigarettes every time she visited. When FM2 was asked if someone at the facility had provided education regarding smoking safety and to not to provide Resident 1 with cigarettes and lighters, FM 2 stated the facility's staff only informed her not to give Resident 1 cigarettes and lighters after the burned incident. At 4:15 p.m., on 12/19/15, during an interview, LVN 2 stated the residents were not supposed to keep cigarettes and lighters. LVN 2 stated it was the facility's staff responsibility to remove the cigarettes and lighters from the residents. A review of Resident 1's nursing care plan, dated 9/17/14, and titled, Potential for injury r/t (related) to smoking, indicated the resident had potential for injury related to smoking. The goal was for Resident 1 to be compliant with the smoking protocols and an individual smoking plan. The nursing interventions included the facility's staff to explain the smoking policy, educate the resident's family member to ensure they gave all smoking materials to staff for safe keeping, monitor to assess the resident's compliance with the facility's smoking policy and individual plan, and to report non-compliance or unsafe smoking habits to the resident's physician and responsible party. A review of a smoking assessment for Resident 1, dated 9/17/14, indicated the resident had no cognitive, vision, or balance deficit. The assessment indicated Resident 1 smoked morning, afternoon, and evening every day. Under the section for additional comments was left blank. b. On 12/12/14, at 2:40 p.m., during an interview, Resident 4 stated that there was an incident with Resident 1, who was smoking while the oxygen was on. Resident 4 stated Resident 1 burned his face and after that, the staff took his cigarettes and lighter. Resident 4 stated prior to Resident 1's burn incident he kept his own cigarettes and lighter and used to smoke whenever he wanted but now, he had to follow the facility's smoke break schedule. Resident 4 stated he smoked one pack of cigarettes a day by smoking several cigarettes at a time. A review Resident 4's Admission Record (Face sheet), indicated the resident was admitted to the facility initially on 7/5/12 and last readmitted on [DATE]. Resident 4's [DIAGNOSES REDACTED]. A review of Resident 4's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 9/23/14, indicated the resident was alert and had the ability to recall. A review of Resident 4's smoking care plan, initially dated 6/23/13, was canceled and updated on 12/2014. The facility's smoking policy was also included in the resident ' s smoking assessment dated [DATE]. c. At 3 p.m., on 12/12/14, Resident 5 was interviewed regarding the facility's smoking policy and procedure. Resident 5 stated the facility's staff explained the smoking safety to him that day (12/12/14) due to Resident 1's burn accident. Resident 5 stated in the past, he had his lighter and cigarettes and whenever he wanted to smoke and would just pull a chair to the corner of the patio and smoke unsupervised. A review of Resident 5's Admission Record indicated the resident was admitted to the facility on [DATE]. Resident 5's [DIAGNOSES REDACTED]. A review of Resident 5's MDS, dated [DATE], indicated the resident was alert and had the ability to recall. A review of Resident 5's care plan for smoking and smoking assessment indicated it was not updated and revised to include the facility's policy until after the smoking incident with Resident 1. On 12/12/14, at 3:30 p.m., during an interview, the DON stated upon a resident's admission, the admitting nurse should conduct a smoking assessment with all new residents. The DON stated the admitting nurse should then initiate a smoking care plan, and explain the facility's smoking policy, which included no smoking material at the residents ' bedside and supervision required for the residents who smoked. On 12/12/14, at 4:20 p.m., during an interview, the activity director (AD), stated under no circumstances, will the residents be allowed to keep cigarettes or lighters with them. The AD stated that the DON keeps the residents' cigarettes and lighters. The AD stated prior to the smoking accident, the charge nurses kept the cigarettes and lighters in the medication cart, which was contrary to what Residents 4 and 5 stated. An article by the National Fire Protection Association (NFPA) titled, Fires and Burns Involving Home Medical Oxygen, dated August 2008, indicated oxygen was one of three parts of the fire triangle. A heat source and fuel (something that can burn) are also required. Oxygen itself is not flammable, but the heat triggers a chemical reaction between the oxygen and fuel molecules. An increased oxygen makes more oxygen available for the chemical reaction, meaning that any fire that occurs will burn faster and hotter. Increased oxygen also lowers the temperature at which things will ignite, including hair, clothing, plastic, skin oils, furniture, etc. Because oxygen is colorless and odorless, elevated levels are not detectable by human senses, which is why patient education is imperative. In 2011, U.S. fire departments responded to an estimated 90,000 smoking-material fires in the U.S., with an estimated 540 civilian deaths. A review of the facility's policy and procedure, with a revised date of 3/2008, and titled, Smoking Policy, indicated no lighting materials (matches and lighters), tobacco products, or smoking devices would not be allowed in the possession of the residents. The policy further stipulated, upon a resident's admission (7-10 days), residents who desire to smoke will be assessed as well as their ability to do so safely. All new admissions will be on supervised smoking until the assessment was reviewed by the interdisciplinary (IDT) team. Then it would be determine if the resident would be allowed to smoke either under supervision or independently with or without any protective devices. In either case, the policy stipulated that no lighting materials, tobacco products, or smoking devices would allowed in the possession of the resident. The policy further indicated smoking materials will be retained by nursing staff and the resident may come and request for one or two cigarettes at a time they desire to go out to smoke.

A pattern of the facility's staff failure to establish and maintain an infection control program under which it investigates, controls, and prevents recurrent urinary tract infections (UTI) for Resident 8. The systems failed and resulted in an immediate threat to the health and safety for Resident 8. Resident 8, who had [DIAGNOSES REDACTED]. The resident required daily intermittent catheterization (I/C) every four hours to relieve the bladder of urine. The resident was observed during an I/C procedure and he did not wash his hands or his penis prior to the procedure. The facility failed to stock or have readily available the necessary supplies for the resident to use sterile technique to perform the intermittent catheterization as per the physician's orders [REDACTED]. The facility failed to teach, reinforce, and reevaluate the resident's continued ability to perform I/C to prevent recurrent urinary tract infections after many urinary tract infections. The resident developed five UTIs within the last 12 months, of various organisms, which the resident received many antibiotics. On October 14, 2011, at 8:30 a.m., the facility only had six urinary straight catheters and two single use sterile Foley insertion trays (used for sterile catheterization procedure) after receiving their supply order three days prior. On October 14, 2011, at 10:43 a.m., an immediate Jeopardy (IJ) was declared and the facility's administrator and director of nurses were notified. The facility submitted an acceptable plan of action. The IJ was abated on October 14, 2011, at 3:40 p.m., and the administrator and director of nurses were informed, after the survey team confirmed the facility's plan of action was implemented as follows: 1. The facility's Interdisciplinary Team met with Resident 8 to discuss the current treatment plan. 2. The resident's plan of care was updated. 3. The director of nurses or designee will ensure that necessary catheterization supplies are readily available for the resident's use by reviewing the inventory log weekly. 4. A licensed nurse will review on a quarterly basis the resident's technique for self-catheterization. Necessary correction will be made. 5. A licensed nurse will monitor any signs of complications resulting from self-catheterization. Necessary correction will be made. 6. The director of nurses or designee will conduct a quarterly in-service (X3) to license nursing personnel on the procedure for intermittent catheterization. 7. Licensed nursing personnel will undergo a competency skills check on intermittent catheterization. 8. Quality Assessment and Assurance and Continuous Quality Improvement Committees will monitor compliance by review of the infection control sub-committee report. Necessary corrections will be made. Based on observation, interview, and record review, the facility failed to follow and implement its infection control program under which it investigates, controls, and prevents infection and follow the plan of care for incontinence and recurrent urinary tract infection as stipulated per the physician's orders [REDACTED]. Resident 8 who had a [DIAGNOSES REDACTED]. There was no documented evidence the resident was taught and reevaluated about proper sterile technique in performing intermittent catheterizations prior to the survey. Resident 8 was observed catheterizing himself without washing his hands or penis. The resident stated the facility did not have supplies (catheters and kits) to perform the procedure all the time. Resident 8 contracted five urinary tract infections (UTIs) within the past 12 months, consisting of the organisms, Escherichia coli ((E. coli) a Gram-negative, rod-shaped bacterium), Methicillin-resistant Staphylococcus aureus (MRSA/ infection is caused by a strain of staph bacteria that becomes resistant to the antibiotics commonly used to treat ordinary staph infections), and Proteus Mirabilis (part of the [MEDICATION NAME] family of gram-negative bacilli) over a 12 month period. The resident received five different types of antibiotics for the UTIs and developed resistance to one of them ([MEDICATION NAME]) after receiving that particular antibiotic many times. According to the Centers for Disease Control and Prevention (CDC), antibiotic resistance is the ability of bacteria or other microbes to resist the effects of an antibiotic that reduces or eliminates the effectiveness of drugs, chemicals, or other agents designed to cure or prevent infections. Bacteria survive and continue to multiply causing more harm. These recurrent UTIs, with multiple use of antibiotics, put the resident at risk for pyelonephritis (a specific type of urinary tract infection (UTI) that generally begins in your urethra or bladder and travels up into your kidneys, which requires prompt medical attention) which can lead to chronic kidney disease (CKD/ is a progressive loss in renal function over a period of months or years) and failure, urosepsis (a sepsis that complicates a urinary tract or prostate infection and require treatment with antibiotics), and the multiple use of antibiotics put the resident at risk for other antibiotic resistant infections. Findings: On October 12, 2011, at 1:30 p.m., during a Quality of Life group meeting, Resident 8, who self-catheterizes every four hours, stated he was upset and frustrated, because approximately a couple of weeks ago, he had been without urinary catheters for two days. As a result, the resident stated he was in pain and did not drink water for two days so that he would not have to urinate. When asked if he had spoken to anyone regarding the lack of catheters the resident stated that he had spoken to the administrator and the director of nursing (DON). The ombudsman who was present during the group meeting stated she was aware the resident had been without urinary catheters last year, because the resident had filed a complaint with the ombudsman's office. She stated she had spoken to the facility about the issue and thought it had been resolved and was unaware that it was a continuing problem. On October 13, 2011, at 12 p.m., during an observation, in the presence of Licensed Nurse 4 (LVN), the resident was observed self-catheterizing. The resident put on gloves without washing his hands then proceeded to lubricate the catheter. The resident did not at any time clean the penis prior to catheterizing himself. When the resident was asked if it was a normal procedure for him to not wash his hands and to not clean the penis the resident stated he did not have the proper cleaning supplies at his bedside. He stated every time he needed to void he would have to call or look for the nurses to give him supplies. The resident further stated he was frustrated at having to request supplies every time he had to urinate and felt he should have supplies at his bedside for emergencies. The resident stated sometimes he would feel pain from the need to urinate and that he could not always wait until he received the supplies. When the resident was asked what he used to clean the penis prior to catheterizing he stated alcohol wipes. According to the Center for Disease Control (CDC) guidelines for prevention of catheter-associated urinary tract infections strongly recommended to educate personnel in correct catheter care and insertion techniques. The CDC strongly recommended inserting catheters using sterile equipment and aseptic technique (a procedure that is performed under sterile conditions) catheter care. On October 12, 2011, a review of Resident 8's Admission Record indicated the resident was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), a standardized assessment and care screening tool, dated July 13, 2011, indicated the resident was Spanish speaking and required an interpreter to communicate with a doctor or health care staff. The MDS indicated the resident was able to make himself understood and able to understand others. According to the MDS, the resident had no signs or symptoms of delirium nor did he exhibit any behavior symptoms or rejection of care. The MDS did indicate the resident had impairment to both sides of the lower extremity and required intermittent catheterization. A review of the Care Assessment Area (CAA) Worksheet (triggers used to identify plan of care issues), dated July 7, 2011, indicated Resident 8 required one-person extensive assist with activities of daily living (ADL) such as bed mobility, transferring, dressing, toilet use, personal hygiene, and bathing. The CAA also indicated the resident had orders to catheterize self every four hours as needed for urinary retention, "observing clean technique (sic)" which contradicts the facility's policy. According to the CAA, the staff was to provide proper supplies for intermittent catheterization and ensure observance of good catheterization, good handwashing technique, before and after the procedure, and to monitor for bleeding as well as urine output, which the facility's staff failed to implement. A physician's orders [REDACTED]. A review of a care plan titled, "Incontinence" dated May 9, 2011 and revised July 13, 2011, indicated the staff should monitor the resident's urine output and bleeding. However, on October 13, 2011, at 2:20 p.m., Licensed Vocational Nurse 1 was asked if the facility had ever observed a return demonstration of the resident self catheterization. The LVN stated that if it had been done the documentation could be found on the resident's intake and output form. When asked if she had ever observed the resident self catheterizing LVN 1 stated, "No, he was independent. We do not watch him catheterize. " A review of another care plan titled, "Urinary Tract Infection-Recurrent " dated May 9, 2007, and revised July 13, 2011, indicated the nursing staff should assess the resident for incontinence, presence of cloudy, and/or foul smelling urine. A physician's orders [REDACTED]. A review of a Medication Administration Record (MAR), for the month of September 2010, indicated the resident was being treated with [MEDICATION NAME] (an anti-infective) 100 milligram (mg) one tab to be administered to the resident by mouth two times a day for 10 days. A review of the MAR for the month of October 2010 indicated the resident received [MEDICATION NAME] 100 mg one capsule by mouth two times per day for 10 days. A review of a "Physician's Progress Note" dated September 11, 2010 and timed at 3:20 p.m., indicated the resident had a UTI when seen by urologist at a general acute hospital (GACH), and the resident had been treated with [MEDICATION NAME] (an anti-infective use to treat urinary tract infections). The internal medicine assessment note indicated, the resident had chronic kidney disease (CKD) secondary to recurrent UTI and dehydration with an elevated creatinine of 2.0 (over 1.4 is high). According to WebMD, the blood creatinine level shows how well the kidneys are working and a high creatinine level may mean the kidneys are not working well. A review of the Licensed Nurses Progress Notes, dated September 7, 2010 through September 20, 2010, indicated the resident was receiving antibiotic medications by mouth for a urinary tract infection. A review of another " Physician's Progress Note " dated November 12, 2010, and timed at 9 a.m., indicated the internal medicine physician wrote under assessment (A) the resident had recurrent UTIs. A physician's orders [REDACTED]. A review of a Licensed Nurses Progress Note, dated May 18, 2011, at 6:35 p.m., indicated the resident was complaining of stomach pain and had a discharge of pus (a whitish-yellow, yellow, or yellow-brown exudate produced by vertebrates during inflammatory pyogenic bacterial infections) from the penis. The nurse called the physician and a culture of the pus was ordered by the physician on May 19, 2011. A review of a laboratory report, dated May 23, 2011, indicated Resident 8's penis culture was positive for methicillin/[MEDICATION NAME] resistant. Organism 1: light growth Escherichia coli. Organism 2: light growth Staphylococcus Aureus. Written on the report was "Doxycyclin 100 mg. Bid X 10 days." However, a further review of the culture and sensitivity (C/S/ a culture is done to identify what kind of organism (usually bacteria) and the sensitivity checks to see what kind of medicine would best treat the infection) indicated [MEDICATION NAME] was not listed as one of the drugs the organism was sensitive to. A review of another physician's orders [REDACTED]. The physician order [REDACTED]. A review of a MAR for the month of May 2011, indicated "Doxycyclin" (misspelled) 100 mg to be given by mouth two times per day for 10 days for penile Methicillin Resistant Staphylococcus Aureus infection ((MRSA), which is a resistant strain of staph bacteria that is resistant to the antibiotics commonly used to treat ordinary staph infections). A review of Licensed Nurses Progress Notes, dated May 23, 2011 through June 27, 2011 indicated the resident was on contact isolation for "penile discharge." A review of MARs revealed a physician's orders [REDACTED]. Another physician's orders [REDACTED]. A laboratory report, dated June 10, 2011, indicated the penis discharge culture had moderate growth of Proteus mirabilis (family of gram-negative bacilli). A review of a physician's orders [REDACTED]. A review of a Licensed Nurses Progress Note, dated June 13, 2011, timed at 5:30 p.m., indicated the resident continued to have a penile discharge and was ordered Keflex 500 mg to be administered three times a day for 10 days. Another note, on June 13, 2011, at 6:45 p.m., indicated the resident was complaining of nausea and vomiting as a result of receiving the Keflex antibiotic. According to the note, Keflex was discontinued and a new antibiotic, Bactrim DS (an anti-infective used in treating urinary tract infections) was started. A physician's orders [REDACTED]. A review of the same physician's orders [REDACTED]. Another physician's orders [REDACTED]. A Licensed Nurse's Notes, dated June 15, 2011, indicated the resident had another episode of vomiting. According to the note, the resident stated the antibiotic made him vomit. The physician was notified and the antibiotic was discontinued again. A review of a MAR for the month of July 2011, indicated Bactrim DS ([MEDICATION NAME]-[MEDICATION NAME]) one tab to be administered to the resident by mouth twice a day for 10 days. The order was discontinued on July 8, 2011. The record also indicated [MEDICATION NAME] ((Cipro) an anti-infective used to treat urinary tract infections) 500 mg to be administered to the resident one tab by mouth twice a day for 7 days for UTI. The order was discontinued on July 11, 2011, without any written documentation why. A review of a Physician's Progress Note, dated July 3, 2011 and timed at 9:05 a.m., indicated the resident was having gastro-intestinal upset (GI) upset as a result of the antibiotic therapy for the penile discharge. The facility had further system failures as indicated in a Licensed Nurses Progress Note, dated July 11, 2011 at 10 a.m. The note indicated the facility received the resident's old laboratory results on July 7, 2011 from a culture and sensitivity dated June 22, 2011. According to the note, the physician ordered Bactrim DS for UTI based on the old laboratory report. However, this was the second time the resident had an ordered to receive Bactrim DS, as indicated in the clinical records, although the resident was allergic to Bactrim. The order was changed [MEDICATION NAME] on July 11, 2011, the physician discontinued Cipro, after receiving the antibiotic for four days. A Licensed Nurses Progress Note, dated July 16, 2011, timed at 2 p.m., indicated the resident stated he scratched the inside of his penis while inserting the catheter, which caused bleeding. A review of the MAR, dated August 2011, indicated [MEDICATION NAME] 250 mg to be given to the resident by mouth two times a day for 10 days to treat phlegm and UTI. The physician's orders [REDACTED]. A review of a laboratory report, dated August 25, 2011, indicated the resident's urine culture had more than 100,000 colonies/ml of Escherichia coli. The report also indicated the organism was resistant to [MEDICATION NAME], and [MEDICATION NAME]. Another MAR, dated August 2011, indicated [MEDICATION NAME] (an anti-infective used to treat UTI) 100 mg to be administered to the resident by mouth two times per day for 10 days for the [DIAGNOSES REDACTED]. Then Keflex 250 mg was ordered to be administered to the resident by mouth three times a day for 10 days for UTI, although in June 2011, the resident had nausea and vomiting after receiving this antibiotic. A review of Licensed Nurses Progress Note, dated August 29, 2011, timed at 8:30 p.m., indicated the physician was notified the resident was vomiting. According to the note, the resident stated the vomiting was a result of the antibiotic Keflex. The physician discontinued Keflex and ordered [MEDICATION NAME] (anti-infective third generation cephalosporin) intravenous (IV) to be started the next morning. A review of a physician's orders [REDACTED]. [MEDICATION NAME] IV antibiotic therapy was started on August 30, 2011 and completed on September 5, 2011. A Licensed Nurses Progress Note, dated September 7, 2011 and timed at 12 p.m., indicated a urinalysis was obtained after the resident was transferred to a GACH due to an elevated temperature and right flank abdominal pain. The resident was started on antibiotic therapy for UTI and continued on antibiotic therapy through September 18, 2011. In an interview, on October 13, 2011, at 2:25 p.m., LVN 2 was asked if Resident 8 had ever been assessed for self-catheterization. The LVN stated the issue had been discussed in the Interdisciplinary meeting, however, she was not aware of any teaching that had been done. On October 13, 2011, at 2:30 p.m., in an interview, the director of nursing (DON) stated the resident has had re-current UTIs and he had not been re-assessed in regards to self-catheterization. The DON stated the facility needed to re-educate the resident. When asked if she could find any documentation indicating the resident had been educated in the facility on how to self-catheterize the DON stated she could not. On October 14, 2011, at 7:10 a.m., one Foley Insertion Tray was observed at the resident's bedside. The tray included [MEDICATION NAME] iodine ((PVP) used for the prevention and treatment of [REDACTED]. An interview with the resident, while at the bedside, the resident stated the kit had been given to him the night before (on October 13, 2011) by the DON. The resident stated it was to be used for his next catheterization, but that the kit was only good for one use. The resident stated this was the first time he had received a kit, because the staff would just give him individual alcohol wipes. He stated the only time he had been taught how to self-catheterize prior to the survey, had been at the GACH prior to his admission to the skilled nursing facility (SNF) in 2003. When asked about the time he was without catheters for two days the resident stated the facility had offered him a different type of catheter, but neither he nor a licensed nurse had been able to use the catheter because it would bend making it difficult for insertion. The resident stated after two days, when he was finally able to catheterize, his urine smelled very bad. When asked if he had experienced pain after waiting two days to catherize the resident stated, "Yes." When asked if he could rate the pain on a scale of one to ten, ten being very intense pain, the resident stated his pain level was at five. On October 14, 2011, at 7:15 a.m., in an interview, the DON was asked if she was aware the resident had been without catheters before for two days. The DON stated the facility had changed vendors and the resident did not like the catheters from the new vendor. When asked when the facility had changed vendors the DON stated, "It was around August 2011." The DON was asked what the process was to ensure the resident had enough supplies. The DON stated during the evening shift (3 p.m. to 11 p.m.) the resident would ask for supplies. At that time, the resident would be provided with six catheters, however he was not always given a kit (Foley Insertion Tray). The DON stated the resident was required to ask the nurses for the supplies he needed to catheterize. When asked what supplies are given to the resident the DON replied, "Alcohol wipes and lubricant." The DON also stated the facility does not carry the single PVP swabs that are found in the kit. On October 14, 2011, at 8 a.m., an observation of the facility's supply room was made in the presence of Certified Nurse Assistant 1 (CNA) who stated she was also responsible for ordering supplies. Among the supplies observed were six size 14 French (F) catheters, the size Resident 8 used, and one Foley Insertion Tray. During the observation, CNA 1 stated she orders five Foley Insertion Trays per week. She also stated she was not aware Resident 8, used the kits, only that she was told by the LVN to order five per week. In an interview, on October 14, 2011, at 8:05 a.m., LVN 3 stated the facility's two treatment carts (which are stocked with supplies used for various treatments) did not contain any Foley Insertion Trays or catheters. On October 14, 2011, at 8:07 a.m., in an interview Resident 8 stated he had one catheterization kit for the day, which he was getting ready to use. The resident was asked how it felt to use alcohol wipes on his penis, he stated, "It stings." The resident also asked if it was possible for the survey team to speak to the staff about giving him supplies. He stated it was hard for him to always have to look for staff every time he needed to urinate. In addition, the resident expressed fear and concern that as a result of speaking to the survey team about his problems he had been experiencing in the facility. Resident 8 stated, "The facility would have him examined by a psychiatrist to make it look like he was crazy." On October 14, 2011, at 10:45 a.m., the clinical resource specialist was asked if it was appropriate to use alcohol wipes to clean the penis prior to catheterization. She stated using alcohol wipes on the penis was not the standard of practice. On October 14, 2011, at 11:12 a.m., in an interview, the supervisor ombudsman stated the resident had filed a complaint last year indicating the facility had not provided him with catheters. However, she too, stated she thought the issue had been resolved because her worker had spoken to the facility and was told the catheters had been acquired from a sister facility. During a telephone interview, on October 14, 2011, at 12:40 p.m., Resident 8's attending physician stated the facility had called her the night before (Thursday, October 13, 2011) after the survey team expressed concerns about the resident's lack of training and supplies for catheterization. She stated the facility informed her the resident was non-compliant. The physician stated she asked them if they had documented and care planned the resident's non-compliance. The physician stated, " The head nurse should get the nurses to do what they are supposed to do." She also stated a few years back she had discussed the proper technique for self-catheterization with the resident and that he had not followed sterile technique. When asked if she had or seen any documentation of the resident not being compliant, she stated, " No, not recently." The physician stated, " I've told the nurses he needs to be watched and monitored. They are supposed to watch him." The physician stated she had verbally re-iterated to the nurses last year, the importance of monitoring the resident. She further stated she should not have to write an order for [REDACTED]." She also stated the resident needed to be monitored on a regular basis and that was why she wrote and told the nurses to monitor him. When asked if she was aware the facility was giving the resident alcohol preps to clean his penis prior to the procedure, she stated " No. " In an interview, on October 14, 2011, at 1:20 p.m., the facility's medical director stated self-catheterization was a sterile procedure and the urinary meatus (the point at which, in males, the urine and semen exits the urethra) should be cleaned with [MEDICATION NAME] if not there is a high chance of contracting UTI. The director also stated intermittent catheterization was less likely to cause a UTI as opposed to an indwelling catheter. According to Medline Plus Medical Encyclopedia, infections occur less often in males and using intermittent catheterization compared to the use of an indwelling catheter. When the medical director was asked if it was acceptable to use alcohol around the urinary meatus the director stated, " No, it will burn." The director was asked what he would do for a resident who was self-catheterizing and having re-current UTIs. The director stated it was important to re-educate individuals who are self-catheterizing in order to make sure they are doing the procedure correctly. On October 14, 2011, at 3 p.m., the resident was asked how he would feel if the facility assisted him with self-catheterization. The resident stated, "I would appreciate the help, because it is difficult to position myself due to being paralyzed and gathering the necessary supplies for the procedure." On October 17, 2011, at 7:50 a.m., in an interview, the director of social services stated recently the facility had changed vendors. As a result, Resident 8 had complained the new catheters were too "Flimsy." She stated she had to go to other sister facilities to obtain catheters for the resident. In an interview on October 17, 2011, at 8 a.m., CNA 2 stated Resident 8 was very pleasant and easy to work with. She also stated she had never witnessed him being combative. When asked if she had ever witnessed the resident catheterizing himself, she stated, "No." On October 18, 2011, at 8 a.m., CNA 1, who was responsible for patient care, as well as ordering the facility's supplies, stated the supplies were ordered once a week, no later than 1 p.m. She stated the charge nurse or DON were responsible for letting her know what to order. However, she stated sometimes things are missed and when that happens, it can take days to receive the supplies. According to the physician's orders [REDACTED]. A review of the facility's form titled, Purchase Orders, dated July, 2011 through September 2011, indicated the number of 14Fr catheters ordered for the facility were as follows: July 12, 2011= 12 July 19, 2011=36 July 26, 2011=36 August 2, 2011=24 August 11, 2011=36 August 16, 2011=24 August 23, 2011=36 September 6, 2011=36 All the above orders were less than the 42 catheters per week Resident 8 required to catheterize himself at least every four hours, per the physician's orders [REDACTED]. A review of the facility's undated policy titled, "General Catheter Care" indicated catheters will be inserted using strict aseptic technique and sterile supplies. Hand washing will be completed immediately prior to and after any manipulation of the catheter site and or equipment. According to Encyclopedia of Nursing and Allied Health, an article titled,"Catheterization Male " indicated the nurse usually teaches the patient and or caregiver to use aseptic technique for catheter care. Nursing interventions and patient education can make a difference in the incidence of urinary tract infections in the hospital, nursing homes, and home care units.

Based on observation, interview, and record review, the facility failed to follow the physician's orders for two of 12 sampled residents (Residents 8 and 9) and one randomly selected resident (Resident 15). Resident 8 had a physician's order indicating the staff should monitored the resident while intermittent self-catheterizing was done, which they failed to follow. Resident 8 contracted many urinary tract infections (UTIs), consisting of the organisms, Escherichia coli ((E. coli) a Gram-negative, rod-shaped bacterium), [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA/ infection is caused by a strain of staph bacteria that becomes resistant to the antibiotics commonly used to treat ordinary staph infections), and Proteus Mirabius (part of the [MEDICATION NAME] family of gram-negative bacilli) over a 12 month period. The resident also had an episode internal penile bleeding. Resident 9 had an order for [REDACTED]. The registered nurse (RN 1) was observed checking the radial pulse (pulse taken on the lateral of the wrist). Resident 15 had an order for [REDACTED]. These failures to repeatedly not follow the physician's orders resulted in Resident 8 not performing self-catheterization properly with a sterile technique, developing many urinary tract infections, and having to receive five different antibiotics; The staff not following the physician's orders to check the apical pulse put Resident 9 at risk of receiving medication that lowers the heart rate too low; Resident 15 was at risk of not receiving the adequate amount of medication due to the nurse not administering on an empty stomach, as ordered by the physician. Findings: a. On October 13, 2011, at 12 p.m., in the presence of a licensed nurse (LVN 4), Resident 8 was observed self-catheterizing. The resident put on gloves without washing his hands then proceeded to lubricate the catheter. The resident did not at any time clean the penis prior to catheterizing. When the resident was asked if it was a normal procedure for him to not wash his hands and not clean the penis the resident stated "Yes" because he did not have the proper cleaning supplies at his bedside. On October 13, 2011, a review of Resident 8's "Admission Record " indicated the resident was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), a standardized assessment and care screening tool, dated July 13, 2011, indicated the resident was Spanish speaking and required an interpreter to communicate with a doctor or health care staff. The MDS also indicated the resident was able to make himself understood and able to understand others. According to the MDS, the resident had no signs or symptoms of [MEDICAL CONDITION] nor did he exhibit any behavior symptoms or rejection of care. The MDS did indicate the resident had impairment to both sides of the lower extremities and required intermittent catheterization. A review of the Care Assessment Area (CAA) Worksheet (triggers used to identify plan of care issues), dated July 7, 2011, indicated Resident 8 required a one-person extensive assist with activities of daily living (ADL), such as bed mobility, transferring, dressing, toilet use, personal hygiene, and bathing. The CAA also indicated the resident had orders to self-catheterize every four hours as needed for [MEDICAL CONDITION], observing clean technique (sic) which contradicts the facility's policy. According to the CAA, the staff was to provide proper supplies for intermittent catheterization and ensure observance of good catheterization, good hand-washing technique, before and after the procedure, and to monitor for bleeding as well as urine output, which the staff failed to implement. A physician's order dated May 14, 2007, indicated the resident was to catheterize self every four hours or as needed for [MEDICAL CONDITION] and the staff was to monitor the urination and output for bleeding at each episode of catheterization. A review of a care plan titled, "Incontinence" dated May 9, 2011 and revised July 13, 2011, indicated the staff should monitor urinary output and monitor for bleeding. A review of a Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"Monitor Urination Call Medical Doctor (MD) if problem occurs." On October 13, 2011, at 12 p.m., in an interview, the resident was asked if any of the nurses ever observe him while he catheterizes himself. The resident stated, "No, I catheterize and after I'm done I call the nurses so they can throw away the urine." In an interview, on October 13, 2011, at 2:20 p.m., Licensed Vocational Nurse 1 (LVN) was asked if the facility had ever observed Resident 8 perform a return demonstration of self-catheterization. The LVN stated that if it had been done the documentation could be found on the resident's intake and output form. When asked if she had ever observed the resident self catheterize the LVN stated, "No, he is independent. We do not watch him catheterize." During a telephone interview, on October 14, 2011, at 12:40 p.m., Resident 8's attending physician stated the facility had called her the night before (Thursday, October 13, 2011) after the survey team expressed concerns about the resident's lack of training and supplies for catheterization. She stated the facility informed her the resident was non-compliant. The physician stated she asked them if they had documented and care planned the resident's non-compliance. The physician stated, " The head nurse should get the nurses to do what they are supposed to do." She also stated a few years back she had discussed the proper technique for self-catheterization with the resident and that he had not followed sterile technique. When asked if she had or seen any documentation of the resident not being compliant, she stated, " No, not recently." The physician stated, "I've told the nurses he needs to be watched and monitored. They are supposed to watch him." The physician stated she had verbally re-iterated to the nurses last year, the importance of monitoring the resident. She further stated she should not have to write an order for [REDACTED]." She also stated the resident needed to be monitored on a regular basis and that was why she wrote and told the nurses to monitor him. When asked if she was aware the facility was giving the resident alcohol preps to clean his penis prior to the procedure, she stated "No." In an interview, on October 17, 2011, at 8 a.m., Certified Nursing Assistant 2 (CNA 2) stated Resident 8 was very pleasant and easy to work with. She also stated she had never witnessed him being combative. When asked if she had ever witnessed the resident catheterizing himself, she stated, " No." See F441 for further information for Resident 8. b. On October 12, 2011 at 8:05 a.m., during a medication pass observation, Registered Nurse 1 (RN) was observed checking Resident 9's radial pulse prior to administering [MEDICATION NAME] (an anti-arrhythmic used for the treatment of [REDACTED]. A review of the "Admission Record" indicated Resident 9 was admitted to the facility on [DATE] and readmitted on [DATE]. The resident's [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), a standardized assessment and care screening tool, dated August 19, 2011, indicated the resident was able to understand and sometimes be understood. The MDS also indicated the resident required extensive assistance with activities of daily living (ADLs), such as transferring, dressing, eating, toilet use, and personal hygiene. A review of a physician's order dated June 24, 2011, indicated [MEDICATION NAME] (([MEDICATION NAME])) via enteral tube (a feeding tube) every day at 9 a.m. for [MEDICAL CONDITION], but hold if the apical pulse was less than 50 (normal pulse reference range is 60-100 beats per minute). In an interview, on October 12, 2011, at 9:15 a.m., the director of nursing (DON) was asked how the pulse should be taken for a resident with an order for [REDACTED]. The DON re-iterated an apical pulse should be taken before administering [MEDICATION NAME]. On October 12, 2011, at 11 a.m., RN 1 was asked how the pulse should be taken prior to administrating [MEDICATION NAME].The RN stated it depended on the physician's order. When RN 1 was asked to read Resident 9's physician's order for [MEDICATION NAME], the RN stated the order indicated an apical pulse should be taken prior to administering [MEDICATION NAME]. On October 14, 2011, at 1:20 p.m., in an interview, the medical director was asked how the pulse should be taken for a resident who was receiving [MEDICATION NAME]. The medical director stated an apical pulse should be taken. In an interview, on October 18, 2011, at 8:30 a.m., Resident 9 was asked how her pulse was being taken prior to receiving her medications ([MEDICATION NAME]). The resident stated the nurses had always checked her pulse on her wrist, but that morning they had taken her pulse using a stethoscope. A review of the facility's revised May 2007 policy titled, "Medication Administration " indicated medications must be administered in accordance with the written orders of the attending physician. c. On October 12, 2011, a review of an "Admission Record" indicated Resident 15 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED].), [DIAGNOSES REDACTED] vasculature, or brain). A Minimum Data Set (MDS), a standardized assessment and care screening tool, dated August 11, 2011, indicated the resident was able to make herself understood and understand others. The MDS also indicated the resident required extensive assistance in transfers, dressing, and personal hygiene. According to the MDS, the resident had an impairment on one side of her upper extremity and on both sides of her lower extremities. A physician's order dated April 15, 2008, indicated [MEDICATION NAME] ([MEDICATION NAME]) 100 milligrams (mg) by mouth twice a day to treat peripheral arterial disorder. The physician's order indicated to give the medication two hours after breakfast and two hours after dinner. On October 12, 2011, at 8:30 a.m., during a medication pass observation, a registered nurse (RN1) was observed giving Resident 15 the medication [MEDICATION NAME], which was less than two hours after breakfast. In an interview, on October 12, 2011, at 9:15 a.m., the DON stated the staff begins serving the breakfast trays at approximately 7 a.m. On October 12, 2011, at 11 a.m., RN1 was questioned about not waiting two hours to give the [MEDICATION NAME] medication according to the physician's order. After RN 1 looked at Resident 15's physician's order, she agreed the medication was supposed to be given two hours after breakfast and she gave it to the resident too soon. The Federal Drug Administration (FDA) recommended the dosage of [MEDICATION NAME] to be 100 mg two times a day taken at least half an hour before or two hours after breakfast and dinner. A review of the facility's revised May 2007 policy titled, "Medication Administration" indicated medications must be administered in accordance with the written orders of the attending physician.

Based on observation, interview, and record review, the facility's staff failed to ensure one of 12 sampled residents was free of neglect and mistreatment (Resident 8). Resident 8, who was a paraplegic (paralysis of the lower part of the body, commonly affecting both legs and often internal organs below the waist), had [DIAGNOSES REDACTED]. The facility failed to provide the necessary supplies, training, assessment, and re-evaluation for the resident to performed intermittent catheterization. The facility failed to stock or have readily available the necessary supplies for Resident 8 to perform sterile technique intermittent self-catheterization as per the facility's policy and procedure, which resulted in the neglect of Resident 8. These failures resulted in Resident 8 feeling upset, frustrated, and also fearful after speaking to the survey team about it. Resident 8 contracted many urinary tract infections (UTIs), consisting of the organisms, Escherichia coli ((E. coli) a Gram-negative, rod-shaped bacterium), [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA/ infection is caused by a strain of staph bacteria that becomes resistant to the antibiotics commonly used to treat ordinary staph infections), and Proteus Mirabilis (part of the [MEDICATION NAME] family of gram-negative bacilli) over a 12 month period. The resident received five different types of antibiotics for the UTIs and developed resistant to one of them after receiving that particular antibiotic many times. Findings: On October 12, 2011 at 1:30 p.m., during a Quality of Life group meeting, Resident 8, who self-catheterizes every four hours, stated he was upset and frustrated, because approximately one week prior he had been without urinary catheters for two days. As a result, the resident stated he was in pain and did not drink water for two days so that he would not have to urinate. When asked if he had spoken to anyone regarding the lack of catheters the resident stated that he had spoken to the administrator and the director of nursing (DON). The ombudsman, who was present during the group meeting, stated she was aware the resident had been without urinary catheters last year, because the resident had filed a complaint with the ombudsman's office. She stated she had spoken to the facility about the catheter issue and thought it had been resolved and was unaware that it was a continuing problem. On October 13, 2011, at 12 p.m., during an observation, in the presence of Licensed Nurse 4 (LVN), the resident was observed self-catheterizing. The resident put on gloves without washing his hands then proceeded to lubricate the catheter. The resident did not clean the penis prior to catheterizing. When the resident was asked if it was a normal procedure for him to not wash his hands and to not clean the penis the resident stated he did not have the proper cleaning supplies at his bedside. He stated every time he needed to void he would have to call or look for the nurses to give him supplies. The resident further stated he was frustrated with having to request for supplies every time he had to urinate, he felt he should have supplies at his bedside for emergencies. The resident stated sometimes he would feel pain from the need to urinate and could not always wait until he received the supplies. When the resident was asked what he used to clean the penis prior to catheterizing he stated, "Alcohol wipes." According to the Center for Disease Control (CDC) guidelines for prevention of catheter-associated urinary tract infections strongly recommended to educate personnel in correct catheter care and insertion techniques. The CDC strongly recommended inserting catheters using sterile equipment and aseptic technique (a procedure that is performed under sterile conditions) catheter care. On October 13, 2011, a review of the Minimum Data Set (MDS), a standardized assessment and care screening tool, dated July 13, 2011, indicated the resident was Spanish speaking and required an interpreter to communicate with the doctor or health care staff. The MDS indicated the resident was able to make himself understood and able to understand others. According to the MDS, the resident had no signs or symptoms of [MEDICAL CONDITION] nor did he exhibit any behavior symptoms or rejection of care. The MDS indicated the resident had impairment to both sides of the lower extremities and required intermittent catheterization. A physician's orders [REDACTED]. On October 13, 2011, at 2:20 p.m., Licensed Vocational Nurse 1 was asked if the facility had ever observed a return demonstration of the resident self-catheterizing. The LVN stated that she had never observed the resident self-catheterizing and stated, "The resident was independent. We do not watch him catheterize." In an interview, on October 13, 2011, at 2:25 p.m., LVN 2 was asked if Resident 8 had ever been assessed for self-catheterization. The LVN stated the issue had been discussed in the Interdisciplinary meeting; however, she was not aware of any teaching that had been done. On October 13, 2011, at 2:30 p.m., in an interview, the director of nursing (DON) stated the resident had recurrent UTIs and he had not been re-assessed about self-catheterization. The DON stated the facility needed to re-educate the resident. When asked if she could find any documentation indicating the resident had been educated in the facility on how to self-catheterize the DON replied, she could not. A review of the facility's undated policy titled, "General Catheter Care" indicated catheters will be inserted using strict aseptic technique and sterile supplies. Hand washing will be completed immediately prior to and after any manipulation of the catheter site and or equipment. On October 14, 2011, at 7:10 a.m., one Foley insertion tray was observed at the resident's bedside. The tray included [MEDICATION NAME] iodine ((PVP) used for the prevention and treatment of [REDACTED]. An interview with the resident, while at the bedside, the resident stated the kit had been given to him the night before (on October 13, 2011, after the survey team had made inquiries) by the DON. The resident stated it was to be used for his next catheterization, but that the kit was only good for one use. The resident stated this was the first time he had received a kit, because the staff usually gave him individual alcohol wipes. He stated the only time he had been taught how to self-catheterize prior to the survey, had been at the GACH prior to his admission to the skilled nursing facility (SNF) in 2003. When asked about the time he was without catheters for two days the resident stated the facility had offered him a different type of catheter, but neither he nor a licensed nurse had been able to use the catheter because it would bend making it difficult for insertion. The resident stated after two days, when he was finally able to catheterize, his urine smelled very bad. When asked if he had experienced pain after waiting two days to catheterize the resident stated, "Yes." When asked if he could rate the pain on a scale of one to ten, ten being very intense pain, the resident stated his pain level was at five. On October 14, 2011, at 7:15 a.m., in an interview, the DON was asked if she was aware the resident had been without catheters before for two days. The DON stated the facility had changed vendors and the resident did not like the catheters from the new vendor. When asked when the facility had changed vendors the DON stated, "It was around August 2011." The DON was asked what the process was to ensure the resident had enough supplies. The DON stated during the evening shift (3 p.m. to 11 p.m.) the resident would ask for supplies. At that time, the resident would be provided with six catheters; however he was not always given a kit (Foley Insertion Tray). The DON stated the resident was required to ask the nurses for the supplies he needed to catheterize. When asked what supplies are given to the resident the DON replied, "Alcohol wipes and lubricant." The DON also stated the facility does not carry the single PVP swabs that are found in the kit. On October 14, 2011, at 8 a.m., an observation of the facility's supply room was made in the presence of Certified Nurse Assistant 1 (CNA) who stated she was also responsible for ordering the facility ' s supplies. Among the supplies observed were six size 14 French (F) catheters, the size Resident 8 used, and one Foley Insertion Tray. During the observation, CNA 1 stated she orders five Foley Insertion Trays per week. She also stated she was not aware Resident 8, used the kits, only that she was told by the LVN to order five per week. In an interview, on October 14, 2011, at 8:05 a.m., LVN 3 stated the facility has two treatment carts, which are stocked with supplies used for various treatments. However, upon observation the carts did not contain any Foley Insertion Trays or catheters. On October 14, 2011, at 8:07 a.m., in an interview Resident 8 stated he had the one catheterization kit for the day, which he was preparing to use. The resident was asked how it felt to use alcohol wipes on his penis, he stated "It stings." The resident also asked if it was possible for the survey team to speak to the staff about giving him supplies. He stated it was hard for him to always have to look for staff every time he needed to urinate. In addition, the resident expressed fear and concern, as a result of speaking to the survey team, that the facility would in turn have him examined by a psychiatrist to make it look like he was crazy. On October 14, 2011, at 11:12 a.m., in an interview, the supervisor ombudsman stated the resident had filed a complaint last year (February 2010) indicating the facility had not provided him with catheters. However, she stated she thought the issue had been resolved because her worker had spoken to the facility and was told the catheters had been acquired from a sister facility. During a telephone interview, on October 14, 2011, at 12:40 p.m., Resident 8's attending physician stated the facility had called her the night before (Thursday, October 13, 2011) after the survey team expressed concerns about the resident's lack of training and supplies for catheterization. The physician stated, "The head nurse should get the nurses to do what they are supposed to do." The physician stated, "I've told the nurses he needs to be watched and monitored during the catheterization procedure. They are supposed to watch him." The physician stated she had verbally re-iterated to the nurses last year of the importance of monitoring Resident 8. In an interview on October 17, 2011, at 8 a.m., CNA 2 stated Resident 8 was very pleasant and easy to work with. She also stated she had never witnessed him being combative. According to the physician's orders [REDACTED]. A review of the facility's form titled, Purchase Orders, dated July 2011 through September 2011, indicated the number of 14Fr catheters ordered for the facility were as following: July 12, 2011= 12 July 19, 2011=36 July 26, 2011=36 August 2, 2011=24 August 11, 2011=36 August 16, 2011=24 August 23, 2011=36 September 6, 2011=36 All the above orders were less than the 42 catheters per week Resident 8 required to catheterize himself at least every four hours, per the physician's orders [REDACTED]. A review of the facility's undated policy titled, " In the Nursing Home" indicated all residents have the right to be free from "abuse and neglect." The policy indicated neglect was when the resident's needs were not met and indicated the resident should report it to the family, Ombudsman, and or State Agency.