Every finding on record at Royal Oaks Manor-Bradbury Oaks

Based on interview and record review the facility failed to inform and provide written information regarding advance directives (a legal document explaining a resident's health care wishes if he or she cannot speak for themselves) for two of five sampled residents (Residents 21 and 22). This failure resulted in Residents 21 and 22 being uninformed of their health care rights and had the potential to result in conflict regarding Residents' 21 and 22's health care decision choices.Findings: a. During a review of Resident 21's admission Record (AR), the AR indicated the facility originally admitted Resident 21 on 12/13/2025 with diagnoses including displaced trimalleolar fracture (a severe ankle break) of the left lower leg, subsequent encounter for open fracture type IIIA, IIIB, or IIIC (a condition where the bone breaks through the skin and there is major soft tissue damage) with routine healing and trigeminal neuralgia (a condition that causes facial pain). During a review of Resident 21's History and Physical (H&P), dated 12/15/2025, the H&P indicated Resident 21 had the capacity to make decisions. During a review of Resident 21's Minimum Data Set (MDS- a resident assessment tool), dated 12/17/2025, the MDS indicated Resident 21's cognitive (the ability to think and process information) skills for daily decision making were intact. During a review of Resident 21's Care Plan (CP) titled The resident's code status/advance directive is full code, initiated 12/31/2025, the CP's interventions indicated advance directive preferences were to be discussed with Resident 21 or Resident 21's responsible party (an individual chosen by the resident to act on behalf of the resident to support the resident in decision-making) on a quarterly basis and as needed. Additionally, the CP's interventions indicated advance directive education would be provided to Resident 21 upon admission and as needed. During a concurrent interview and record review on 12/31/2025 at 2:31 PM with the Social Service Director (SSD), Resident 21's Physician Orders for Life-Sustaining Treatment (POLST, a medical document for seriously ill or frail individuals that translates the person's treatment preferences into actionable medical orders, ensuring the person's wishes for life-sustaining care are followed across different healthcare settings, even when the person cannot communicate), dated 12/13/2025 was reviewed. The SSD stated the POLST did not indicate advance directives were discussed with Resident 21. The SSD stated it was the policy of the facility to give residents (in general) information regarding advance directives by the second or third day of admission. Additionally, the SSD stated the importance of discussing and offering advance directives with residents (in general) was to ensure the residents received life saving measures as requested. During an interview on 1/2/2026 at 8:43 AM with Resident 21, Resident 21 stated Resident 21 did not have an advance directive and had never received information regarding advance directives from the facility. b. During a review of Resident 22's AR, the AR indicated, Resident 22 was admitted to the facility on [DATE] with multiple diagnoses including unspecified dementia (a progressive state of decline in mental abilities), unspecified severity, without behavioral disturbance, psychotic (relating to or affected with a psychosis - a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) disturbance, mood disturbance, and anxiety (intense, excessive, and persistent worry and fear about everyday situations). During a review of Resident 22's POLST, dated 11/1/2025, the POLST indicated the POLST complemented an AD and was not intended to replace that document (AD). Resident 22's POLST did not indicate any information regarding an AD. During a review of Resident 22's H&P, dated 11/2/2025, the H&P indicated, Resident 22 did not have the capacity to understand and/or sign any form due to dementia. During a review of Resident 22's MDS, dated [DATE], the MDS indicated Resident 22's cognitive skills for daily decision making were moderately impaired (decisions poor, cues/supervision required). The MDS indicated Resident 22 did not have an AD. During a review of Resident 22's undated and unsigned Advance Health Care Directive Acknowledgement Form (AF), the AF indicated, Resident 22 was not given a copy of the Advance Health Care Directive Fact Sheet at the first face-to-face contact or clinic visit. During a review of the Advance Health Care Directive Fact Sheet, revised 2/15/2011, the sheet indicated an advance directive was a legal document that allowed individuals to state their wishes should they become unable to make healthcare decisions. The fact sheet indicated in California, the AD consisted of two parts: (1) appointment of an agent for healthcare and and (2) individual health care instructions. During a review of Resident 22's care plan (CP) titled, [Resident 22's] code status/advance directive is., date initiated 11/29/2025, the CP's interventions indicated to provide advance directive education upon admission and as needed. During a concurrent interview and record review on 12/31/2025 at 2:30 PM with the SSD, Resident 22's medical records (chart) and Social Service History & Initial Assessment (IA), dated 11/2/2025 were reviewed. The SSD stated, the SSD was responsible for obtaining or screening residents (in general) upon admission to obtain information regarding an AD, immediately, or when the SSD conducted my assessment (IA), on the second or third day after admission. The IA indicated, Resident 22 had an AD. The SSD stated, if a resident had an AD, the facility made a copy and filed the copy in the resident's chart. The SSD stated the SSD could not find a copy of Resident 22's AD in Resident 22's chart. The SSD stated, filing a copy of Resident 22's AD in the medical records was important for staff to know what Resident 22's medical wishes were, to avoid confusion among staff, because the POLST could change and the POLST did not replace an AD. During an interview on 1/2/2026 at 9:40 AM with Emergency Contact (EC) 2, EC 2 stated Resident 22 had an AD. EC 2 stated, the facility asked regarding an AD only during the meeting, two weeks [after Resident 22's admission]. During a review of the facility's policy and procedure (P&P), revised 9/2022, the P&P indicated the resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. The P&P indicated advance directives are honored in accordance with state law and facility policy. The P&P indicated prior to or upon admission of a resident, the SSD or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. The P&P indicated the resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so.

Based on observation, interview and record review, the facility failed to ensure, three of three sampled residents (Residents 29, 5 and 46), were provided with appropriate activities of daily living (ADLs, basic self-care tasks like bathing, dressing, eating, using the toilet, and moving around).These deficient practices had the potential to result in physical declines due to the lack of assistance with ADLs for Residents 29, 5 and 46.Cross Reference F550Findings: A. During a review of Resident 29's admission Record (AR), the AR indicated Resident 29 was admitted to the facility on [DATE] with diagnoses that included glaucoma (eye condition that damages the optic nerve which is crucial for good vision, associated with high pressure in the eye), irritable bowel syndrome (a common gastrointestinal disorder characterized by abdominal pain, cramping, bloating, diarrhea, and constipation), and spinal stenosis (pinching of the nerves within the spine causing back pain and weakness in the legs or arms). During a review of Resident 29's History and Physical (H&P), dated 1/7/2025, the H&P indicated Resident 29 was alert and was wheelchair bound. During a review of Resident 29's Bowel and Bladder Program Screener (BBPS), dated 7/21/2025, the BBPS indicated Resident 29 was alert and oriented, was always mentally aware of the need to toilet and needed one-person assistance to get to the bathroom/transfer to toilet/commode/urinal. The BBPS indicated adjusting clothing and wiping and Resident 29 was a candidate for retraining. During a review of the facility's care plan (CP) for ADLs self-care performance deficit related to limitations in functional and physical mobility, revised 8/2/2025, the CP's goal indicated for the resident to maintain current level of function in ability to participate in self-care tasks. The CP's intervention indicated Resident 29 was totally dependent on 1 staff for toilet use and to encourage Resident 29 to participate to the fullest extent possible with each interaction. During a review of a Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 10/21/2025, the MDS indicated Resident 29 had clear speech, had the ability to understand, and be understood by others. The MDS indicated Resident 29 was dependent (helper does all the effort) with toilette hygiene (ability to maintain hygiene, adjust clothes before and after voiding or having a bowel movement). During an observation and concurrent interview with Resident 29, on 12/31/2025 at 11:30 AM, Resident 29 was observed sitting on a wheelchair and was assisted by the Activities Director (AD) to the conference room. Resident 29 stated a few times last week (no specific date recall), Resident 29 asked Certified Nursing Assistant (CNA) 2 for assistance to the toilet. Resident 29 stated I have the urge to go to the bathroom sometimes, and I want to sit on the toilet and do what I feel I need to do. When I ask [CNA 2] to take me to the restroom, CNA 2 tells me, No you don't have to go, and does not take me and does not give me a reason why. Resident 29 stated Resident 29 preferred to sit on the toilet. During an interview with the AD, on 12/31/2025 at 12:38 PM, the AD stated Resident 29 was alert with periods of confusion. The AD stated on 12/30/2025, Resident 29 informed the AD CNA 2 did not take Resident 29 to the toilet when Resident 29 asked. During an interview on 12/31/2025 at 1:34 PM, with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated Resident 29 had urges for bowel movements. LVN 2 stated Resident 29 preferred to sit on the commode (portable toilet) when Resident 29 needed to use the restroom. LVN 2 stated ADLs were important because [encouraging] residents physically and psychologically to do things on their own was one of the most important things a nurse could do. During an interview, on 12/31/2025 at 1:42 pm, with CNA 7, CNA 7 stated Resident 29 preferred to be assisted to the commode when Resident 29 needed to use the restroom. CNA 7 stated if a resident requested assistance to the restroom, [staff] had to take the resident and if unable to take the resident, [staff] had to ask for help from other staff. During an interview with the Director of Nursing (DON), on 1/2/2026 at 10:35 AM, the DON stated examples of ADL's included bathing, personal grooming, toileting (assisting to the commode) and [ADLs] should be addressed as soon as possible. The DON stated staff should assist residents when residents asked [for assistance] because, if ignored, it could lead to incontinence (lack of bladder control) and loss of bowel control. B. During a review of Resident 5's AR, the AR indicated, Resident 5 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including major depressive disorder (a mental health condition characterized by persistent feelings of sadness, loss of interest, and other symptoms that significantly interfere with daily life), recurrent, unspecified, and unspecified macular degeneration (an eye disease that affects central vision where people can't see things directly in front of them). During a review of Resident 5's H&P, dated 7/2/2025, the H&P indicated Resident 5 was alert, oriented to person, place, and time. The H&P indicated Resident 5 had normal cognition (the mental action or process of acquiring knowledge and understanding). During a review of Resident 5's MDS, dated [DATE], the MDS indicated Resident 5 had impaired (sees large print, but not regular print in newspaper/books) vision and Resident 5's cognitive skills (ability to think and process information) for daily decision making were moderately impaired (decisions poor, cues/supervision required). The MDS indicated, Resident 5 was dependent (helper does all of the effort) and required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for ADLs and was on hospice (compassionate care for people who are near the end of life provided at the person's home or within a health care facility) care. During a review of Resident 5's CP, titled, The resident has an ADL self-care performance deficit., date initiated 7/17/2025, the CP's interventions indicated Resident 5 required (max) assist by (1) staff with personal hygiene and oral care. C. During a review of Resident 46's AR, the AR indicated, Resident 46 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including cerebral ischemia (a serious medical condition where the brain doesn't get enough blood flow) and end stage renal disease (ESRD – irreversible kidney failure). During a review of Resident 46's CP, titled, [Resident 46] has an ADL self-care performance deficit., date initiated 10/21/2024, the CP's interventions indicated to provide assistance with the following self-care and mobility usual performance such as oral hygiene-substantial/max assist and personal hygiene-dependent. During a review of Resident 46's H&P, dated 1/15/2025, the H&P indicated, Resident 46 was AOx3 (alert and oriented to person, place, and time). During a review of Resident 46's MDS, dated [DATE], the MDS indicated Resident 46's cognitive skills for daily decision making were moderately impaired. The MDS indicated Resident 46 was dependent and required substantial/maximal assistance (helper does more than half the effort) for ADLs. During a concurrent observation and interview on 12/30/2025 at 10:05 AM with CNA 3, Resident 5 was lying in bed, awake, and Resident 5's lips were dry, flaky, and were peeling. Resident 5 had drool with food debris on Resident 5's right side of the mouth. Resident 5's deformed fingers had brownish black colored substance (dirt like appearance) under Resident 5's fingernails. CNA 3 stated Resident 5's chapped lips could bleed, and stated Resident 5 was fed by facility staff. CNA 3 stated CNA 3 would give Resident 5 a bath. During an interview on 12/30/2025 at 10:58 AM, with CNA 3, CNA 3 stated Resident 5's family did not want hospice to take care of Resident 5 [and perform care like] bathing and wanted the facility to provide the care, the shower and everything. During a concurrent observation and interview on 12/31/2025 at 8:33 AM with Resident 46, Resident 46 was lying in bed, awake, and Resident 46's head was facing right. Resident 46 had food debris drool on the right side of Resident 46's mouth and whitish creamy colored discharge from Resident 46's inner corner of the left eye. Resident 46 stated, staff helped feed Resident 46, here and there. During an interview on 12/31/2025 at 11:59 AM with CNA 5, CNA 5 stated after staff collected resident's (in general) food trays, staff should check if residents were dirty after eating, no matter what, I always do check the resident after they eat, if they are dirty. During an interview on 1/2/2026 at 8:08 AM with LVN 5, LVN 5 stated, ADLs included providing cleanliness, oral care, and grooming. LVN 5 stated, staff should do oral care right after residents finished eating or when staff collected the meal trays. LVN 5 stated, Resident 5's chapped lips could crack, open, and cause the skin to open and bleed. LVN 5 stated, providing oral care and keeping fingernails clean were a part of grooming and were important for resident's well-being and for dignity. During a review of the facility's policy and procedure (P&P) titled, Dignity, revised date February 2021, the P&P indicated, each resident should be cared for in a manner that promoted and enhanced his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. During a review of the facility's P&P titled Activities of Daily Living (ADL), Supporting, revised 4/2025, the P&P's statement indicated residents are provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out ADLs. The P&P indicated residents who are unable to carry out ADLs independently receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. The P&P indicated appropriate care and services are provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: elimination (toileting) and hygiene (bathing, dressing, grooming, and oral care).

Based on observation, interview and record review, the facility failed to: 1.Destroy discontinued controlled medications (DCM - prescription drugs that have a potential for dependence and have been discontinued) deposited into the MedSafe (MS, refers to a specialized medication disposal receptacle used to manage unused, expired, or unwanted medications, designed to prevent misuse of medications) were still whole, identifiable, retrievable, and left with original packaging (blister packs [individually sealed compartments of medications, one dose per compartment]). 2. Verify and ensure accurate account of DCMs were deposited into the MS when the Consultant Pharmacist (CP) failed to verify accuracy of the Controlled Drug Record (CDR, a detailed log to track every movement of a tightly regulated drug, from the acquisition to final use or disposal, documenting the activity to ensure accountability and to prevent diversion) and the DCMs. 3. Ensure the box that contained DCMs, after removing the DCMs from the MS, was stored in a secured double locked area from [DATE] to [DATE] as indicated in the facility's policy titled Disposal of Medications. These deficient practices had the potential to delay inventory processes and compromise the accurate identification and disposition (safe and proper disposal of unused, unwanted, expired, or discontinued controlled drugs) of controlled medications, creating a possible risk for DCM diversion (illegal redirection of prescription medications like controlled drugs).Findings:1.During an observation and concurrent interview with Licensed Vocational Nurse 2 (LVN 2), inside the facility's medication room, on [DATE] at 10:24 AM, there was a blue receptacle (a container that holds something) that had three separate locks. LVN 2 stated this (pointed to the receptacle) was called a MS where all discontinued medications were deposited, including DCMs. LVN 2 stated DCMs were deposited by the Director of Nursing (DON) into the MS in its original medication packaging.During an interview, on [DATE] at 10:47 AM, with the DON, the DON stated the facility's protocol for DCMs was for a Licensed Nurse (LN) and DON to reconcile the number of DCMs [together] by verifying and signing the Controlled Drug Record (CDR, a detailed log to track every movement of a tightly regulated drug, from the acquisition to final use or disposal, documenting the activity to ensure accountability and to prevent diversion). The DON stated, after reconciling the DCMs, the DON unlocked and deposited the DCMs into the MS in the original packaging. The DON stated when the MS box was full, together, the CP and the DON opened the MS, removed the inner plastic liner bag from the MS containing all DCMs, secured the plastic liner bag with a zip tie, and placed the sealed liner inside a hard cardboard box. The DON stated the box was sealed and was ready for pick up [by a contracted waste company]. The DON stated the box holding the DCMs was If [the hard cardboard box was] tampered with, the medications could be identifiable because they were in [the original] packaging.During a telephone interview with the CP, on [DATE] at 11:25 AM, the CP stated the process of dissolution for DCMs was for the DON and a LN to deposit the DCMs into the MS whole and in their original packaging. The CP stated the CP only reviewed the CDRs and did not physically check/verify the contents in the MS. The CP stated when the MS was full, the DON and the CP removed and sealed the inner plastic liner holding all DCMs and placed the liner in a cardboard box, sealed the box, and was ready for shipment. The CP stated once the DCMs left the facility, the CP did not know or could not guarantee, it [the box with DCMs] was tampered with. The CP stated the CP did not have control over the disposition of DCMs or what [DCMs] were being disposed into the MS. The CP stated the CP did not physically inspect the contents of DCM inside the MS because it was against protocol. The CP stated, in the past, the CP removed the DCMs from the original packaging and wasted (destroy/dissolve/make unidentifiable) the DCMs at the facility and in the presence of the DON. The CP stated the CP liked having more control over the destruction process of DCMs.During a review of the facility's policy and procedure (P&P) titled Disposal of Medications, dated 11/2017, the P&P indicated controlled substances shall be destroyed by a registered nurse (RN) employed by the care center and a consultant pharmacist or a pharmacist from the contracted pharmacy and transferred to a container marked as for Incineration Only for release to a pharmaceutical waster contractor. The P&P indicated DO NOT USE A CONTINER USED FOR SHAPRS OR CONTAMINETED WASTE.During a review of the facility P&P titled Collection of Receptacle for Disposal of Medications, dated 1/2023, the P&P indicated once a substance has been deposited into a collection receptacle, the substance shall not be counted, sorted, inventoried, or otherwise individually handled. The P&P indicated if a substance needed to be removed from the receptacle prior to sealing the liner, it must be done by law enforcement.2.During an interview and concurrent record review of 27 CDRs, on [DATE] at 10:47 AM, with the DON, the DON stated the facility's protocol was for the DON and a LN to verify and sign the CDR to ensure the number of DCMs were the same as the number of DCMs deposited into the MS. The DON stated during the CPs monthly visits, the CP reviewed and signed the CDRs checking the controlled medication counts but the CP did not verify the deposited DCMs inside the MS. The DON stated 17 of the 27 reviewed CDRs did not have the CP's signature and were not reviewed by the CP. The DON stated the DON and the CP only checked the CDR but did not verify the accuracy of the CDR or the DCMs. The DON stated ensuring accuracy was important to prevent the risk of diversion.During a telephone interview with the CP, on [DATE] at 11:32 AM, the CP stated the CP monitored the CDR by signing the margin but did not physically check the contents of the MS to verify accuracy [of the CDR]. [Following this system,] the CP stated the CP could not ensure the DCMs inside the MS were the same DCMs listed on the CDR. The CP stated the CP took the word of the nurses when determining the accuracy of the DCM count. The CP stated the CP had no way of looking in the MS and confirm.During a review of the facility's P&P titled Disposal of Medications, dated 11/2017, the P&P indicated a controlled medication disposition log, or equivalent form, shall be sued for documentation. The consultant pharmacist or a pharmacist from the contracted pharmacy will verify accuracy and record shall be retained as per federal privacy and state regulations.3. During a record review of the Multipurpose Drug Disposition Record (MDDR), the MDDR indicated on [DATE], a United Parcel Service (UPS, a global shipping company) pick up was scheduled between the hours of 9 AM to 5 PM. The MDDR indicated Pharmacy visit new liner # . and Removal/sealed tracking # . was witnessed by the CP and the DON on [DATE]. The MDDR indicated a tracking number on [DATE].During a review of an email from the DON, dated [DATE], the email's subject indicated Waste [MS] pick-up the email indicated no one had picked up the cardboard box containing DCMs. During a review of a document from UPS titled Schedule a Pickup, the document's pickup date [DATE], the document indicated a pickup request was completed.During an observation on [DATE] at 10:24 AM, [DATE] at 8:17 AM, and on [DATE] at 9:32 AM, the door to the DON's empty office was wide open.During an interview with the DON, on [DATE] at 10:47 AM, the DON stated the facility's protocol for DCMs was for the DON and a LN to witness, and sign the CDR, and deposit all DCMs inside the MS in its original packaging. The DON stated that when the MS was full, the CP and the DON opened the MS together, removed, replaced, and sealed the inner plastic liner containing all DCMs and zip tie the liner. The DON stated, the DON would then place the inner liner inside a cardboard box, sealed the box, and the box was picked up by a medication waste company.During an interview with the DON, on [DATE] at 12:10 PM, the DON stated on [DATE], the CP and the DON collected the MS Waste (MSW - including DCMs) and sealed the cardboard box to make ready for disposal pick-up. The DON stated the MSW was not picked up until [DATE]. The DON stated the cardboard box containing MSW was stored in the DON's office, next to the DON's desk.During an interview with the DON on [DATE] at 10:35 AM, the DON stated on [DATE] to [DATE], multiple attempts were made for MSW pick up. The MSW box was stored in the DON office, next to the DON's desk from [DATE] to [DATE]. The DON stated the DON could not put the MSW back into the MS because a new box and liner were already in place and the DON did not have a key to open the MS. The DON stated the DON's office did not have a double lock. The DON stated it was important for DCMs to be securely stored in a double lock area for safe keeping and avoid tampering [diversion of DCMs].During a review of the facility's P&P titled Disposal of Medications, dated 11/2017, the P&P indicated controlled substances are subject to special handling, storage, disposal, and record keeping in the nursing care center. The P&P indicated controlled substances . remaining in the nursing care center after the order has been discontinued are retained in the nursing care center in a securely double locked area with restricted access until destroyed.During a review of the facility's P&P titled Collection of Receptacles for Disposal of Medications, dated 1/2023, the P&P indicated, under Receptacle Liners - Responsibility of Pharmacy and Facility/Community, the inner liner shall be tamper evident and tear resistant. The P&P indicated upon removal from the permanent outer container, sealed inner liners may be stored at the long-term care facility for up to three business days in a securely locked, substantially constructed cabinet or a securely locked room with controlled access until [picked up by the] UPS carrier .

Based on observation, interview, and record review, the facility failed to implement infection (the invasion and growth of germs in the body) prevention and control practices by failing to ensure: a. Masks were readily available upon entrance to the facility. b. Gloves were readily available outside of two of four sampled resident (Resident 3 and Resident 46) rooms, who were on Enhanced Barrier Precautions (EBP - infection control measures, primarily for nursing homes, using gowns and gloves during direct, high-contact care for residents with multidrug-resistant organisms [MDROs] or at high risk).These deficient practices had the potential to result in cross contamination (the process by which microorganisms are unintentionally transferred from one area/object to another with a harmful effect) and/or the development and transmission of disease (an illness or sickness) and infections for Resident 3 and Resident 46.Findings:a. During an observation on 12/30/2025 at 8:40 AM, a large three feet by three feet (3 ft x 3 ft, unit of length) freestanding sign indicating No Mask! No Entry! No Exemption! was outside in front of the facility's entrance door. There were no masks available upon entrance to the facility. Signage posted in the hallway indicated, To keep each other safe and healthy, this facility is asking everyone to please wear a mask. Masks can help prevent the spread of respiratory infections.b. During a review of Resident 3's admission Record (AR), the AR indicated, Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including personal history of urinary (tract) infections (UTI - an infection in the bladder/urinary tract), Extended Spectrum Beta Lactamase (ESBL - refers to specific bacteria, super-germs) resistance, and sepsis (a life-threatening blood infection), unspecified organism.During a review of Resident 3's History and Physical (H&P), dated 8/12/2025, the H&P indicated, Resident 3 did not have the capacity to understand and/or sign any forms.During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 10/14/2025, the MDS indicated Resident 3's cognitive skills (ability to think and process information) for daily decision making were severely impaired. The MDS indicated, Resident 3 was dependent (helper does all of the effort) for activities of daily living (ADL - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During a review of Resident 3's Order Summary Report (OSR), active orders as of 1/2/2026, the OSR indicated an order dated 8/13/2025 for EBP every shift for wound, gastrostomy tube (GT - a feeding tube inserted through the abdomen directly into the stomach), history of ESBL and Providencia Stuartii (a type of bacteria).During a review of Resident 46's AR, the AR indicated, Resident 46 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including cerebral ischemia (a serious medical condition where the brain doesn't get enough blood flow) and end stage renal disease (ESRD - irreversible kidney failure), and dependence on renal dialysis (a treatment that cleanses the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed). During a review of Resident 46's H&P, dated 1/15/2025, the H&P indicated, Resident 46 was AOx3 (alert and oriented to person, place, and time).During a review of Resident 46's MDS, dated [DATE], the MDS indicated Resident 46's cognitive skills for daily decision making were moderately impaired. The MDS indicated Resident 46 was dependent and required substantial/maximal assistance (helper does more than half the effort) for ADLs.During a review of Resident 46's OSR, active orders as of 1/2/2026, the OSR indicated an order, dated 6/19/2025 for EBP every shift d/t (due to) on hemodialysis.During a concurrent observation and interview on 12/30/2025 at 11:12 AM with Certified Nurse Assistant (CNA) 7, Resident 3's room had an EBP signage on the door and a black color trimmed 4-drawer PPE (personal protective equipment - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) cart was outside of Resident 3's room. The EBP signage indicated, providers and staff must wear gloves and a gown for high-contact resident care activities. There were no gloves in/on the PPE cart. CNA 7 stated, there was usually a box of gloves [in/on the PPE cart] because Resident 3 was on EBP.During a concurrent observation and interview on 12/30/2025 at 4:26 PM with CNA 4, Resident 46's room had an EBP signage on the door and a black color trimmed 4-drawer PPE cart outside of Resident 46's room. There were no gloves in/on the PPE cart. CNA 4 stated, staff followed whatever was indicated on the EBP signage such as wearing gowns and gloves. CNA 4 stated staff should ensure there were PPE supplies prior to entering Resident 46's room in order to follow EBP and as indicated on the signage.During an interview on 1/2/2026 at 1:42 PM with the Infection Preventionist (IP), the IP stated, masking was required since we're in the respiratory virus [a germ that attacks your nose, throat, and lungs] season. The IP stated, ensuring a supply of masks was readily available was important to enforce masking and to remind staff and visitors to wear masks, that's why we have that super big sign outside. The IP stated, ensuring a supply of PPE was readily available including gloves was important for staff to be compliant with EBP and for infection control.During a review of the undated Centers for Disease Control and Prevention's (CDC - the national public health agency who provides accurate data, health guidance, and preventive measures) EBP signage poster, the facility signage poster indicated, providers and staff must also wear gloves and gown for high-contact resident care activities: dressing, bathing, showering, transferring, changing linens, providing hygiene, changing [adult] briefs, assisting with toileting, and wound care.During a review of the CDC's Frequently Asked Questions (FAQ's) Absent Enhanced Barrier Precautions in Nursing Home, dated 6/28/2024, the FAQ's indicated, Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices).https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html During a review of CDC's guidelines titled Preventing Transmission of Viral Respiratory Pathogens in Healthcare Settings dated 5/21/2025, the guidelines indicated, healthcare facilities should ensure the availability of materials for adhering to respiratory hygiene/cough etiquette at facility entrances, triage areas, and waiting areas for patients and visitors. The guidelines indicated during periods of higher levels of community respiratory virus transmission, facilities should consider having everyone mask upon entry to the facility to ensure better adherence to respiratory hygiene and cough etiquette for those who might be infectious. Examples reflecting higher levels of community respiratory virus transmission could include months during the typical respiratory virus season (e.g., October-April).

Based on interview and record review, the facility failed to treat one of one sampled resident (Resident 29) with respect and dignity when Certified Nurse Assistant 2 (CNA 2) failed to assist Resident 29 to the restroom making Resident 29 feel bad, like a fireman dummy, and a child.This deficient practice had the potential to affect Resident 29's psychosocial well-being.Cross Reference F677Findings:During a review of an admission Record (AR), the AR indicated Resident 29 was admitted to the facility on [DATE] with diagnoses that included glaucoma (eye condition that damages the optic nerve which is crucial for good vision, associated with high pressure in the eye), irritable bowel syndrome (a common gastrointestinal disorder characterized by abdominal pain, cramping, bloating, diarrhea, and constipation), and spinal stenosis (pinching of the nerves within the spine causing back pain and weakness in the legs or arms).During a review of Resident 29's History and Physical (H&P), dated 1/7/2025, the H&P indicated Resident 29 was alert and was wheelchair bound.During a review of Resident 29's Bowel and Bladder Program Screener (BBPS), dated 7/21/2025, the BBPS indicated Resident 29 was alert and oriented, was always mentally aware of the need to toilet and needed one-person assistance to get to the bathroom/transfer to toilet/commode/urinal.During a review of the facility's care plan (CP) titled Risk for constipation [related to] low mobility, initiated 8/2/2025, the CP's goal indicated Resident 29 would pass soft, formed stools at the preferred frequency.During a review of the facility's CP for activities of daily living self-care performance deficit related to limitations, revised 8/2/2025, the CP's intervention indicated Resident 29 was totally dependent on 1 staff for toilet use and to encourage Resident 29 to participate to the fullest extent possible with each interaction. During a review of a Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 10/21/2025, the MDS indicated Resident 29 had clear speech, had the ability to understand, and be understood by others. The MDS indicated Resident 29 was dependent (helper does all the effort) with toilette hygiene (ability to maintain hygiene, adjust clothes before and after voiding or having a bowel movement).During an observation and concurrent interview with Resident 29, on 12/31/2025 at 11:30 AM, Resident 29 was observed sitting on a wheelchair and was assisted by the Activities Director (AD) to the conference room. Resident 29 stated a few times last week (no specific date recall), Resident 29 asked CNA 2 for assistance to the toilet. Resident 29 stated I have the urge to go to the bathroom sometimes, and I want to sit on the toilet and do what I feel I need to do. When I ask [CNA 2] to take me to the restroom, CNA 2 tells me 'no you don't have to go' and does not take me and does not give me a reason why. Resident 29 stated Resident 29 had control over his body and preferred to sit on the toilet. Resident 29 stated CNA 2 made Resident 29 feel bad like a fireman dummy, one that gets thrown around and gets attention when CNA 2 chooses or like a child asking for permission to go to the restroom, hoping they [CNA 2] will say yes.During an interview with the AD, on 12/31/2025 at 12:38 PM, the AD stated Resident 29 was alert with periods of confusion. The AD stated on 12/30/2025, Resident 29 informed the AD CNA 2 did not take Resident 29 to the toilet when Resident 29 asked.During an interview on 12/31/2025 at 1:34 PM, with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated Resident 29 had urges for bowel movements. LVN 2 stated Resident 29 preferred to sit on the commode when Resident 29 needed to use the restroom as a form of dignity. LVN 2 stated activities of daily living were important because [encouraging] residents physically and psychologically to do things on their own was one of the most important things a nurse could do.During an interview, on 12/31/2025 at 1:42 pm, with CNA 7, CNA 7 stated Resident 29 preferred to be assisted to the commode when Resident 29 needed to use the restroom. CNA 7 stated if a resident requested assistance to the restroom, [staff] had to take the resident and if unable to take the resident, [staff] had to ask for help from other staff.During an interview with the Director of Nursing (DON), on 1/2/2026 at 10:35 AM, the DON stated when a resident had the urge to have a bowel movement it was personal and this needed to be taken seriously because [not attending to this need] effected the resident's psychosocial [wellbeing] and dignity.During a review of the facility's policy and procedure (P&P) titled Dignity, revised 2/2021, the P&P's statement indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self - esteem. The P&P indicated residents are treated with dignity and respect at all times. The P&P indicated demining practices and standards of care that compromised dignity are prohibited. The P&P indicated staff are expected to promote dignity and assist residents: for example: promptly responding to a resident's request for toileting assistance.

Based on interview and record review, the facility failed to complete a Preadmission Screening and Resident Review Level 2 screening (PASARR II-a required federal assessment that ensures individuals with a mental disorder or intellectual disability are placed in appropriate facilities) for one of one sampled resident (Resident 2) when the facility did not reply to the recommendations by the California Department of Health Care Services (DHCS-a state agency that oversees the provision of health care and mental health services) for an attempted evaluation of PASARR level 2 as indicated by the facility's Policy and Procedure (P&P) titled, admission Criteria.This failure resulted in Resident 2 not receiving the PASARR level 2 screening for serious mental illness (SMI-a diagnosable mental, behavioral, or emotional disorder that significantly impairs a person's ability to function in major life activities) and had the potential for Resident 2 to not receive specialized services (the services specified by the State that exceed the services ordinarily provided by the nursing facility) for SMI.Findings:During a review of Resident 2's admission Record (AR), the AR indicated the facility originally admitted Resident 2 on 5/10/2024 with diagnoses including orthostatic hypotension (a sudden drop in blood pressure when standing) and unspecified dementia (the loss of the ability to think, remember, and reason that affect daily life and activities).During a review of Resident 2's History and Physical (H&P), dated 7/4/2025, the H&P indicated Resident 2 was alert and oriented to name only.During a review of Resident 2's PASARR Level 1 Screening (the PASARR prescreening process which determines if a resident has a mental disorder, intellectual disability or related condition), dated 12/19/2025, the PASRR Level 1 Screening indicated Resident 2 had an SMI.During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool), dated 12/22/2025, the MDS indicated Resident 2's cognitive (the ability to think and process information) skills for daily decision making were severely impaired (resident never or rarely makes decisions). During a concurrent interview and record review on 12/31/2025 at 1:24 PM with the Director of Nursing (DON), Resident 2's untitled DHCS notification letter, dated 12/24/2025, was reviewed. The DHCS notification letter's subject indicated Notice of attempted evaluation. The DHCS notification letter indicated, In the event of a positive SMI Level 1 Screening [PASSAR Level 1 Screening], a SMI Level 2 Mental health Evaluation [PASSAR Level 2 Screening] is required to determine if the individual can benefit from specialized services. However, a SMI Level 2 Mental Health Evaluation [PASSAR Level 2 Screening] was not scheduled for the following reason: Facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the Level 1 Screening. The DON stated the facility did not respond to Resident 2's DHCS notification letter. The DON stated the facility should have responded to Resident 2's DHCS notification letter to verify Resident 2 was receiving proper care and services.During a review of the facility's P&P titled, admission Criteria, revised March 2019, the P&P's policy statement indicated the facility admitted on ly residents who's medical and nursing care needs could be met. The P&P's policy interpretation and implementation indicated all new admissions and readmissions were screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD). Additionally, the P&P indicated if the level I screening indicated the individual may have met the criteria for a MD, ID, or RD, he or she was referred to the state PASARR representative for the Level II screening process. The P&P further indicated that upon completion of the Level II evaluation, the state PASARR representative would determine if the individual had a physical or mental condition, what specialized or rehabilitative services he or she needed, and whether placement in the facility was appropriate.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents' (Resident 5) eye wash irrigating solution, and a non-legend drug (medication that can be purchased over-the-counter [OTC] without a prescription) was not stored inside Resident 5's room. This deficient practice had the potential to result in non-licensed staff or family using the eye irrigating solution to treat Resident 5 and the potential to compromise Resident 5's physical well-being. Findings:During a review of Resident 5's admission Record (AR), the AR indicated, Resident 5 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including major depressive disorder (a mental health condition characterized by persistent feelings of sadness, loss of interest, and other symptoms that significantly interfere with daily life), recurrent, unspecified, and unspecified macular degeneration (an eye disease that affects central vision where people can't see things directly in front of them).During a review of Resident 5's History & Physical H&P, dated 7/2/2025, the H&P indicated Resident 5 was alert, oriented to person, place, and time. The H&P indicated Resident 5 had normal cognition (the mental action or process of acquiring knowledge and understanding). During a review of Resident 5's Minimum Data Set (MDS - a resident assessment tool), dated 10/29/2025, the MDS indicated Resident 5 had impaired (sees large print, but not regular print in newspaper/books) vision and Resident 5's cognitive skills (ability to think and process information) for daily decision making were moderately impaired (decisions poor, cues/supervision required). The MDS indicated, Resident 5 was dependent (helper does all of the effort) and required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for ADLs and was on hospice (compassionate care for people who are near the end of life provided at the person's home or within a health care facility) care.During a review of Resident 5's Order Summary Report (OSR), active orders as of 1/2/2026, the OSR did not indicate an order for Resident 5's eye wash irrigating solution to be used or stored inside Resident 5's room.During an observation on 12/30/2025 at 9:37 AM, there was a 4 Fl oz (fluid ounce - a unit of volume for liquids) bottle of Walgreens Soothing Eye Wash Eye Irrigating Solution on the sink counter of Resident 5's restroom. The solution's container box was marked with Resident 5's name.During an interview on 1/2/2026 at 8:08 AM with Licensed Vocational Nurse (LVN) 5, LVN 5 stated, Resident 5's eye wash irrigating solution was considered an OTC medication and was for [eye] treatment. LVN 5 stated, not leaving the eye wash irrigating solution inside Resident 5's room was important because the eye irrigating solution was considered a medication and only licensed staff [could administer this medication] to Resident 5 and staff needed to check Resident 5's room for safety to ensure it doesn't get into the wrong hands, should be properly handled by the proper staff. LVN stated, Resident 5's eye irrigating solution did not come from the facility's [pharmacy].During a review of the facility's undated policy and procedure (P&P) titled, House Supplied (Floor Stock) Medications, the P&P indicated the nursing care center may maintain a supply of commonly used OTC medications considered as floor stock or house medications as allowed by state regulations. The P&P indicated floor stock items were not to be administered without a current order from the resident's prescriber.During a review of the facility's P&P titled, Medications Brought to the Facility by the Resident/Family, revised 4/2007, the P&P indicated, the facility should ordinarily not permit residents and families to bring medication into the facility. The P&P indicated, if a medication was not otherwise and/or it was determined to be essential to the resident's life, health, safety, or well-being to be able to take a medication brought in from outside, the director of nursing services and nursing staff, with support of the attending physician an consultant pharmacist, should check to ensure that the medications have been ordered by the resident's attending physician, and documented on the physician's order sheet.During a review of the facility's P&P titled, Self-Administration of Medications, revised 2/2021, the P&P indicated, any medications found at the bedside that are not authorized for self-administration were turned over to the nurse in charge for return to the family or responsible party.

Based on interview and record review the facility failed to ensure a medication regimen review (MRR-a thorough evaluation of a resident's medications) was completed for one of five sampled residents (Resident 11) when Resident 11 did not have documented evidence of a completed MRR during the months of November and December 2025. This failure had the potential to result in Resident 11 experiencing adverse consequences (impairment or decline in an individual's mental, physical, functional, or psychosocial status [the emotional and social requirements that individuals must have to feel safe, supported, and capable of functioning well in their environment]) from medications. Based on interview and record review the facility failed to ensure a medication regimen review (MRR-a thorough evaluation of a resident's medications) was completed for one of five sampled residents (Resident 11) when Resident 11 did not have documented evidence of a completed MRR during the months of November and December 2025. This failure had the potential to result in Resident 11 experiencing adverse consequences (impairment or decline in an individual's mental, physical, functional, or psychosocial status [the emotional and social requirements that individuals must have to feel safe, supported, and capable of functioning well in their environment]) from medications. Findings:During a review of Resident 11's admission Record (AR), the AR indicated the facility originally admitted Resident 11 on 6/17/2024 with diagnoses including major depressive disorder (mental health condition where a person experiences a persistent low mood, loss of interest in activities and other symptoms that significantly impact daily life) and unspecified dementia (the loss of the ability to think, remember, and reason that affect daily life and activities).During a review of Resident 11's History and Physical (H&P), dated 7/20/2025, the H&P indicated Resident 11 had the capacity to understand and sign any form.During a review of Resident 11's Minimum Data Set (MDS- a resident assessment tool), dated 9/17/2025, the MDS indicated Resident 11's cognitive (the ability to think and process information) skills for daily decision making were moderately impaired (resident makes poor decisions requiring cues or supervision).During a review of Resident 11's Care Plan (CP) titled The resident [Resident 11] has Dx. [diagnosis] of depression-on antidepressant medication (Lexapro), initiated 10/7/2024, revised 10/24/2025, the CP's interventions indicated a pharmacy review would be done monthly or per protocol (a formal set of rules or procedures) for Resident 11.During a concurrent interview and record review on 1/2/2026 at 9:13 AM with the Director of Nursing (DON), the facility's 2025 MRR binder was reviewed. The DON stated Resident 11's MRR for November and December 2025 were not done. The DON stated the importance of completing and documenting monthly MRRs was to ensure Resident 11's safety and to ensure any recommendations regarding Resident 11's medications were addressed. During a review of the facility's Policy and Procedure (P&P) titled, Drug Regimen Review, effective 11/28/2016, revised 8/3/2023, the P&P's policy indicated the health center's drug regimen review program would include a monthly drug regimen review that included review of all medication orders and the documented medication administration process. The P&P's procedure indicated the DON was responsible for scheduling and maintaining monthly drug regimen reviews for quality improvement purposes. Additionally, the P&P's procedure indicated a record of the consultant pharmacist's observations and recommendations would be made available to the DON or designee within 48 hours of MRR completion.

Based on observation, interview, and record review, the facility failed to provide the following care and services as ordered by Hospice Agency 1's physician:1. An order for Boost (a nutritional supplement drink with essential nutrients to support the resident's nutritional needs) was missed and not included in Resident 1's nutritional supplement orders.2. An order for diclofenac sodium (a drug used in the treatment and management of acute and chronic pain associated with inflammatory conditions) was missed and not included in Resident 1's drug therapy orders. These deficient practices had the potential to result for further resident weight loss and uncontrolled pain.Findings:1. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 10/15/2025, with diagnoses that included displaced intertrochanteric fracture of the left femur (broken thigh bone) and dysphagia (difficulty swallowing). During a review of Resident 1's Minimum Data Set (MDS - a standardized resident assessment tool) dated 10/19/2025, the MDS indicated Resident 1 had moderate cognitive impairment. The MDS indicated Resident 1 required maximal assistance (helper lifts or holds trunk or limbs and provides more than half the effort) with toilet transfers and walking 10 feet) and required moderate assistance (helper lifts, holds or support trunk or limbs, but provides less than half the effort) with lying to sitting on the side of the bed, rolling left and right. During a review of Resident 1's weight on 11/25/2025 at 12:12 PM, Resident 1's weight on 11/20/2025 was 106 pounds (lb, a unit of weight) and on 11/24/2025, the weight was 96 lb. During a review of Resident 1's care plan for The resident has nutritional problem ., the care plan indicated Resident 1 was on hospice (a care focused on comfort and quality of life, not cure, for individuals with a serious or terminal illness) for expected weight loss and overall decline. During a concurrent record review and interview on 11/25/2025 at 4:16 PM, Resident 1's Hospice Agency 1's Current Treatment/Medication/DME List (CTMD) and Resident 1's Order Summary Report (OSR) as of 11/25/2025 was reviewed. The CTMD list included an order for Boost, one (1) can, 237 milliliters once a day for nutrition supplement. Registered Nurse Supervisor (RNS) 1 stated boost was not included in Resident 1's OSR as of 11/25/2025. RN 1 stated boost is a nutritional supplement that would help residents (in general) with weight loss. RN 1 stated RN 1 could not find any documentation that boost was discontinued or placed on hold. RN 1 further stated it needed to be included in Resident 1's active orders. During an interview on 11/26/2025 at 12:12 PM, Licensed Vocational Nurse (LVN) 1 stated there was a new order for boost last night and Resident 1 only had two (2) sips of the boost earlier in the morning. 2. During an observation on 11/26/2025 at 1:23 PM, Certified Nursing Assistant (CNA) 1 and CNA 2 repositioned Resident 1 toward the resident's left side. Resident 1 held the left upper leg with the left hand during repositioning. When asked if Resident 1 was in pain, Resident 1 stated, No. During a concurrent record review and interview on 12/26/2025 at 1:52 PM of Resident 1's Hospice Agency 1's Current Treatment/Medication/DME List (CTMD), there was an order for diclofenac 1% (percent, a portion of a whole) topical gel, one application four times daily for osteoarthritis (a degenerative joint disease resulting a chronic pain and stiffness) of the left hip and lumbar spine. The MDS Nurse stated that holding the left leg could be a sign the Resident 1 was experiencing pain by guarding the area that was in pain. The MDS Nurse stated residents (in general) with dementia may not always be able to verbally report pain. The MDS Nurse further stated the order for diclofenac was missed and that diclofenac could have helped with Resident 1's pain relief. During a review of Resident 1's Medication Administration Record (MAR) for 11/1/2025 to 11/30/2025, the MAR indicated Resident 1 received morphine sulfate (pain medication for the severe pain) on the following dates:11/22/2025 at 11:20 AM for a pain level of 9/10 (9/10 indicates very severe pain. A numeric pain scale is a tool to rate pain using numbers from 0 to 10, where 0 indicates no pain, 10 indicates worst pain imaginable).11/23/2025 at 8:35 AM and 5:48 PM for a pain level of 8/10 and 9/10.11/24/2025 at 8:40 AM, 11:19 AM, and 9:32 PM for a pain level of 9/10, 8/10, and 7/10.11/25/2025 at 7:46 AM for a pain level of 6/10. During a review of the facility's Policy and Procedure (P&P), titled Hospice Program, revised on July 2017, the P&P indicated it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs. These responsibilities include administering prescribed therapies.

During an interview and record review, the facility failed to ensure call lights were answered immediately for two of three sampled residents (Resident 2 and Resident 3).This deficient practice had the potential to result in residents' unmet needs.Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 11/1/2025, with diagnoses that included fracture of the right humerus (broken bone in the upper arm) and history of falling. During a review of Resident 2's Minimum Data Set (MDS - a standardized resident assessment tool) dated 11/7/2025, the MDS indicated Resident 2 had intact cognition and required maximal assistance (helper lifts or holds trunk or limbs and provides more than half the effort) with sit-to-stand and dependent with rolling left and right and lying-to-sitting. During a review of Resident 3's AR, the AR indicated the facility admitted Resident 3 on 11/14/2025, with diagnoses that included fusion of spine, lumbar region (surgery that connects two or more bones in the spine) and muscle weakness. During an interview on 11/25/2025 at 11:40 AM, Resident 2's Family member (FM 1) stated sometimes staff would take an hour to respond to the call light. FM 1 stated FM 1 would be the one who would assist Resident 2 to the bathroom when staff response was taking too long. During an interview on 11/25/25 at 11:47 AM, Resident 3 stated the resident had been at the facility for two weeks and there were two (2) times it took the facility staff an hour to respond to the call light, it happened once at night and once during the day. Resident 3 stated last night and this morning it was better because facility staff responded within 10-15 minutes. Resident 3 stated the resident would check the clock in front of Resident 3's bed. Resident 3 stated on those two times, no staff came to check what Resident 3 needed. Resident 3 stated the resident would usually call for assistance to the bathroom. During an interview on 11/25/2025 at 1:12 PM, Certified Nursing Assistant (CNA) 3 stated when call lights were pressed, staff needed to go immediately and if not possible, another staff needed to go and check because the call might be an emergency. During an interview on 11/25/2025 at 3:18 PM, Licensed Vocational Nurse (LVN) 2 stated call lights needed to be answered immediately because the call might be an emergency situation, an example would be difficulty breathing. During a review of the facility's Resident Council Meeting minutes indicated the following:On 7/29/2025, residents in attendance stated call lights were not answered timely during the 11:00 PM to 7:00 AM shift.On 9/30/2025, two residents stated call lights were answered, but the needs of the residents were not met. During a review of the facility's Policy and Procedure (P&P), titled Answering the Call Light, revised on September 2022, the P&P indicated, Answer the resident call system immediately. When answering an auditory request for assistance, identify yourself and politely respond to the resident by his/her name (e.g., This is Mrs. [NAME]. Mr. [NAME], how may I help you?). The P&P indicated:a. If the resident needs assistance, indicate the approximate time it will take for you to respond.b. If the resident's request requires another staff member, notify the individual.c. If the resident's request is something you can fulfill, complete the task within five minutes if possible.d. If you are uncertain as to whether or not a request can be fulfilled, or if you cannot fulfill the resident's request, ask the nurse supervisor for assistance.

B. During a review of Resident 23's AR, the AR indicated, Resident 23 was admitted to the facility on [DATE] with multiple diagnoses including shortness of breath, anxiety disorder (a mental health disorder of persistent and excessive feelings of worry or fear that interferes with daily activities), and fever, unspecified. During a review of Resident 23's H&P, dated 9/11/2024, the H&P indicated, Resident 23 had the capacity to understand and/or sign any form. During a review of Resident 23's MDS, dated [DATE], the MDS indicated, Resident 23's cognition (ability to think and process information) status was moderately impaired. The MDS indicated, Resident 23 did not receive the influenza vaccine in the facility. During a concurrent review of the activities CP with the Activities Staff (AS) on 11/14/2024 at 2:46 PM, the AS stated there was no activities CP developed for Resident 23. The AS stated the activities CP would guide the AS on what activities should be provided to Resident 23. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised March 2022, the P&P indicated, a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The P&P indicated assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The P&P indicated, the comprehensive, person-centered care plan was developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. 42307 Based on observation, interview, and record review, the facility failed to ensure comprehensive person-centered care plans (CP, provides direction on the type of nursing care an individual needs that includes goals of treatment, specific nursing interventions [actions, treatments, procedures, or activities designed to meet an objective], and an evaluation plan) was developed and implemented for two of two sampled resident (Resident 6 and Resident 23) in accordance with the facility's policy and procedure (P&P), titled, Care Plans, Comprehensive Person-Centered. This failure had the potential to result in Resident 6 and Resident 23 not to receive the necessary care and services in accordance with their specific needs and had the potential to cause Resident 6 pain and further complications. Cross Reference F684 Findings: A. During a review of Resident 6's Admission Record (AR), the AR indicated, Resident 6 was admitted to the facility on [DATE] with multiple diagnoses including displaced intertrochanteric fracture of left femur (a type of broken hip in the [femur] thigh bone), subsequent encounter for closed fracture with routine healing, essential primary hypertension (high blood pressure) and pain, unspecified. During a review of Resident 6's History and Physical (H&P), dated 9/25/2024, the H&P indicated, Resident 6 had trace edema (swelling caused by too much fluid trapped in the body's tissues) in the ankles. The H&P indicated, Resident 6 had the capacity to understand and/or sign any form. During a review of Resident 6's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 9/27/2024, the MDS indicated, Resident 6's cognition (ability to think and process information) status was severely impaired. The MDS indicated, Resident 6 had impairment on one side in the lower extremity (hip, knees, ankle, foot) and was dependent to requiring setup or clean-up assistance (helper sets up or cleans up) with Activities of Daily Living (ADL, term used in healthcare that refers to self-care activities). During a review of Resident 6's Order Summary Report (OSR), dated active as of 11/15/2024, the OSR indicated, a physician order dated 10/11/2024 to apply elastic stocking (TED Hose, a compressive stocking applied to the legs to help prevent swelling) to BLE (bilateral [both] lower extremities [legs]) one time a day for compression (thigh high) apply to BLE in the AM [morning] and remove at HS [before bedtime] and remove per schedule. During a concurrent observation and interview on 11/12/2024 at 10:20 AM with Resident 6 inside Resident 6's room, Resident 6 was awake and alert, had regular socks on, and was sitting up in the wheelchair. Resident 6's both legs were swollen and dependent (hanging down, below the mean level of the body). During a concurrent observation and interview on 11/13/2024 at 1:14 PM with Licensed Vocational Nurse (LVN) 3, inside Resident 6's room, Resident 6 was sitting up in the wheelchair with both legs swollen and dependent. LVN 3 stated, Resident 6 was at the facility for left lower extremity swelling and Resident 6 was at risk for developing edema because of the surgery. LVN 3 stated, Resident 6 was not care planned and there should be a care plan that addressed Resident 6's edema. LVN 3 stated, a CP basically tells us [nursing staff] for what we should be doing for Resident 6's care including Resident 6's problem (edema). LVN 3 stated, all licensed nurses were responsible for creating a CP as soon as residents (in general) were admitted to the facility. LVN 3 stated, a CP was important, so staff knew how to address Resident 6's edema. During an interview on 11/15/2024 at 1:36 PM with the Director of Nursing (DON), the DON stated, a CP was a plan of care that included the problem, goal, and interventions, and a CP should have been created to address Resident 6's edema.

Based on observation, interview, and record review, the facility failed to use appropriate alternatives prior to the use of bedrails for two of two sampled residents (Resident 12 and Resident 23.) This deficient practice had the potential to result in accidents for Resident 12 and Resident 23 due to the use of bedrails. Findings: A. During a review of Resident 12's Admission Record (AR), the AR indicated the facility admitted Resident 12 on 5/10/2024, with diagnoses that included dementia (a progressive state of decline in mental abilities,) muscle weakness, and difficulty with walking. During a review of Resident 12's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 8/15/2024, the MDS indicated Resident 3 was unable to express ideas and wants and was unable to understand verbal content. During an observation on 11/12/2024 at 10:35 AM, Resident 12 was asleep in bed, lying on her back. A quarter siderails was up on both sides of the bed. B. During a review of Resident 23's AR, the AR indicated Resident 23 was admitted to the facility on [DATE] with multiple diagnoses including shortness of breath, anxiety disorder (a mental health disorder of persistent and excessive feelings of worry or fear that interferes with daily activities), and psychosis not due to a substance or known physiological condition (a severe mental condition in which thought and emotions are so affected that contact with reality is lost). During a review of Resident 23's MDS, dated [DATE], the MDS indicated, Resident 23's cognition (ability to think and process information) status was moderately impaired. The MDS indicated, Resident 23 usually understood verbal content and usually was able to express ideas and wants. The MDS indicated Resident 23 required moderate assistance (helper does less than half the effort) with toileting hygiene, and bed mobility. The MDS indicated Resident 23 considered the following activity preferences as highly important: listening to music, go outside to get fresh air, participate in religious services or practices. During an observation on 11/12/2024 at 9:33 AM, Resident 23 was asleep in bed, the upper side rails were up on both sides of the bed. During a concurrent review of Resident 12 and Resident 23's Siderail Evaluations and interview on 11/14/2024 at 4:19 PM, the Siderail Evaluation forms indicated alternatives to attempt prior to the use of siderails was the use of a low bed. The Minimum Data Set Nurse (MDS Nurse) stated there was no clear documentation how the use of a low bed was not effective for Resident 12 and Resident 23, and there were no other alternatives attempted prior to the use of siderails. The MDS Nurse stated siderails were potential hazards especially for residents who had dementia because it could put residents (in general) at risk for entrapment. The MDS Nurse stated other alternatives included the use of pillows, foam bumpers or bolsters. During a review of the facility's undated Policy and Procedure (P&P) titled Bed Safety and Bedrails the P&P indicated the use of bed rails or side rails (including temporarily raising the side rails for episodic use during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. The P&P indicated prior to the installation or use of a side or bed rail, alternatives to the use of side or bed rails are attempted. Alternatives may include: roll guards; foam bumpers; lowering the bed; and/or use of concave mattresses to reduce rolling off the bed. The P&P indicated if attempted alternatives do not adequately meet the resident's needs the resident may be evaluated for the use of bed rails. This interdisciplinary evaluation includes: an evaluation of the alternatives to bed rails that were attempted and how these alternatives failed to meet the resident's needs; the resident's risk associated with the use of bed rails; input from the resident and/or representative; and consultation with the attending physician.

Based on interview and record review, the facility failed to ensure accuracy of medical records for one of one sampled resident (Resident 23) by failing to: A. Ensure Resident 23's Medication Administration Record (MAR, a log initialed and/or signed by the nurse with the date and time each time a medication is administered to a resident) was complete when on 9/21/2024, 9/25/2024, and 9/28/2024, the facility's Controlled Drug Record for Hydrocodone-Acetaminophen (pain medication used to relieve moderate to severe pain, works in the brain to change how your body feels and responds to pain) 5-325 mg (milligram, unit of measurement) indicated Hydrocodone-Acetaminophen 5-325 mg was removed and Resident 23's MAR did not reflect administration of Hydrocodone-Acetaminophen 5-325 mg. B. Ensure Resident 23's change of condition for the development of a skin rash was documented in Resident 23's medical record. These deficient practices resulted in an inaccurate MAR and had the potential to result in a medication error for Resident 23. Additionally, there was a potential for Resident 23 not to receive the necessary care and treatment for Resident 23's skin rash. Findings: A. During a review of Resident 23's Admission Record (AR), the AR indicated, Resident 23 was admitted to the facility on [DATE] with multiple diagnoses including shortness of breath, anxiety disorder (a mental health disorder of persistent and excessive feelings of worry or fear that interferes with daily activities), and psychosis not due to a substance or known physiological condition (a severe mental condition in which thought and emotions are so affected that contact with reality is lost). During a review of Resident 23's History and Physical (H&P), dated 9/11/2024, the H&P indicated, Resident 23 had the capacity to understand and/or sign any form. During a review of Resident 23's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/16/2024, the MDS indicated, Resident 23's cognition (ability to think and process information) status was moderately impaired. The MDS indicated, Resident 23 usually understood verbal content and usually was able to express ideas and wants. The MDS indicated Resident 23 required moderate assistance (helper does less than half the effort) with toileting hygiene, and bed mobility. During a review of Resident 23's Controlled Drug Record for Hydrocodone-Acetaminophen 5-325 mg., dated 9/9/2024, the Controlled Drug Record indicated the medication was removed on the following dates: 9/21/24 at 6 PM, 2 tablets were removed. 9/22/24 at 9 PM , 2 tablets removed. 9/23/24 at 2:15 AM, 2 tablets removed. 9/23/24 at 7 PM, 2 tablets removed. 9/24/24 at 11:42 AM, 2 tablets removed. 9/25/24 at 6:15 PM, 2 tablets removed. 9/28/24 at 11:20 AM, 2 tablets removed. 9/29/24 at 10:30 AM, 2 tablets removed. During a review of Resident 23's Medication Record (MAR) dated September 2024, the MAR indicated one tablet of Hydrocodone-Acetaminophen 10 mg-325 mg. was administered for moderate to severe pain on the following dates, 9/22/2024, 9/23/2024, 9/24/2024, and on 9/29/2024. Resident 23's September 2024 MAR indicated there was one more order for Hydrocodone-Acetaminophen 5-325 mg tablet, two tablets taken by mouth every 4 hours by mouth as needed for pain. The MAR was blank and did not indicate administration of Hydrocodone-Acetaminophen 5-325 mg from 9/1/24 to 9/30/24. During a concurrent interview 11/15/2024 at 4:46 PM and review of the MAR dated September 2024, with the Director of Nursing (DON), the DON stated on 9/2024, the facility used a different computer system to document in the MAR and if there was a computer issue, the licensed nurses would document on the paper MAR. Reviewed the paper MAR with the DON, there was written documentation on 9/24/24 at 11:50 am and on 9/29/24 at 10:30 am. During a concurrent review of Resident 23's Controlled Drug Record for Hydrocodone-Acetaminophen 5-325 mg and concurrent interview on 11/15/2024 at 5:05 PM, the DON stated there were days hydrocodone-acetaminophen was removed and not documented in Resident 23's MAR, the dates were 9/21/24, 9/25/24, and on 9/28/24. The DON stated licensed nurses needed to document on the MAR when hydrocodone-acetaminophen was removed from the supply and administered to Resident 23. During a review of the facility's Policy and Procedure (P&P) titled Administering Medications dated April 2019, the P&P indicated the director of nursing services supervises and directs all personnel who administer medications and/or have related functions and medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training. The P&P indicated the individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones and as required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. the date and time the medication was administered; b. the dosage; c. the route of administration; d. the injection site (if applicable); e. any complaints or symptoms for which the drug was administered; f. any results achieved and when those results were observed; and g. the signature and title of the person administering the drug. During a review of the facility's P&P, titled Charting and Documentation, dated July 2017, the P&P indicated information documented in the resident medical record included, medications administered. The P&P indicated documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. B. During a review of Resident 23's AR), the AR indicated, Resident 23 was admitted to the facility on [DATE] with multiple diagnoses including shortness of breath, anxiety disorder (a mental health disorder of persistent and excessive feelings of worry or fear that interferes with daily activities), and psychosis not due to a substance or known physiological condition (a severe mental condition in which thought and emotions are so affected that contact with reality is lost). During a review of Resident 23's H&P), dated 9/11/2024, the H&P indicated, Resident 23 had the capacity to understand and/or sign any form. During a review of Resident 23's MDS, dated [DATE], the MDS indicated, Resident 23's cognition (ability to think and process information) status was moderately impaired. The MDS indicated, Resident 23 usually understood verbal content and usually was able to express ideas and wants. The MDS indicated Resident 23 required moderate assistance (helper does less than half the effort) with toileting hygiene, and bed mobility. During a concurrent observation and interview on 11/12/2024 at 9:45 AM, Resident 23 had a red scabbed rash on the right arm and elbow. Resident 23 stated the rash was itchy Resident 23 tried not to scratch the area. During a follow-up interview on 11/13/2024 at 2:30 PM, Resident 23 stated Resident 23 did not know how long Resident 23 had the rash and stated maybe since last week. During a review of Resident 23's medical record, there was no change of condition evaluation (COC, a for indicating a sudden clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains) form. During a review of Resident 23's Long Term Evaluation Progress Notes dated 11/5/2024, 11/7/2024, 11/8/2024, the notes did not indicate Resident 23 had a skin rash or skin issues. During an interview on 11/14/2024 at 3:15 PM, the Treatment Nurse (TN) stated if a resident (in general) developed a new rash, the nurse needed to assess the rash and notify the physician. The nurse also needed to notify the Infection Prevention Nurse (IPN) since it was possible the rash could be infectious. The TN stated the rash was documented on the progress notes but the licensed nurse that discovered the rash needed to complete a COC form so staff would be able to monitor the rash, the area affected, and whether the rash had spread to other parts of the body. The TN stated the rash had spread from the elbow to the lower arm. During a review of the facility's Policy and Procedure (P&P) Charting and Documentation dated July 2017, the P&P indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. 42307

Based on observation, interview, and record review, the facility failed to maintain its infection prevention and control program for four of seven sampled residents (Resident 2, 26, 41, and 40) by failing to: A. Ensure enhanced barrier precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs, bacteria that have become resistant to certain antibiotics] in nursing homes) were followed and hand hygiene was performed when entering and exiting Room A. B. Ensure the toilet seat was clean in the shared restroom of Resident 2 and Resident 26. C. Ensure an open and unlabeled personal toiletry was not stored inside the shared restroom of Residents 41 and 40 D. Ensure the clean linen was handled properly in the laundry room. These deficient practices had the potential to result in transmission of infectious microorganisms (an organism that can be seen only through a microscope) and cross contamination (process by which bacteria can be transferred from one area to another) among Residents 2, 26, 41 and 40 and throughout the facility and result in infections. Findings: A. During an observation on 11/12/2024 at 10:43 AM, Room A had signage indicating EBP located on the wall next to Room A's door. Maintenance Technician (MT) 1 and MT 2 entered Room A without personal protective equipment (PPE, clothing or equipment that protects workers from injury or illness in the workplace) or without performing hand hygiene. While inside of Room A, MT 1 adjusted Resident 41's bed, per family member's request. MT 1 touched Resident 41's bed and MT 1's shirt came into direct contact with the bed linens. MT 1 and MT 2 exited Room A without performing hand hygiene. During a joint interview on 11/12/2024 at 10:50 AM, with MT 1 and MT 2, MT 1 stated MT 1 should have gowned up properly prior to entering Room A which was on EBP. MT 1 stated this helped prevent contamination of clothing, gowns, and protected both healthcare workers from potential infections and residents (in general) from acquiring infections. MT 1 stated MT 1 forgot to perform hand hygiene before and after entering Room A. MT 1 stated hand hygiene reduced the risk of spreading harmful germs between patients and healthcare workers, prevented the transmission of infections, and protected the patient's health. During a joint interview on 11/12/2024 at 10:50 AM, with MT 2 and MT 1, MT 2 stated MT 2 forgot to gown up (to wear a gown) before entering Room A and forgot to perform hand hygiene before and after entering the room. MT 2 stated any break in infection control was a problem because this could directly lead to the transmission of infectious diseases between patients and healthcare workers. During an interview on 11/14/2024 at 4:30 PM, with the Infection Preventionist (IP), the IP stated hand hygiene should be performed before and after entering residents' rooms. The IP stated hand hygiene significantly reduced the risk of spreading harmful germs between patients and healthcare workers, effectively preventing the transmission of infections and other potentially dangerous microorganisms that could be easily transferred through contaminated hands. The IP stated staff expectations with residents on EBP was to properly gown up when staff performed high-contact resident care activities (any medical procedure or task that involved a healthcare worker having close, direct physical contact with a patient's body). The IP stated staff should gown up [to follow] EBP if their clothing was likely to come into direct contact with [resident] bed linens. During a review of the facility's P&P titled, Handwashing/Hand Hygiene revised dated 8/2019, the P&P indicated: 1. The facility considers hand hygiene the primary means to prevent the spread of infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 3. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: 4. After contact with objects (e.g. medical equipment) in the immediate vicinity of the resident. During a review of the facility's P&P titled, Enhanced Barrier Precautions revised dated 3/2024, the P&P indicated enhanced barrier precautions are used as an infection prevention and control intervention to reduce the transmission of multi-drug resistant organisms (MDROs, [microorganisms that are resistant to one or more classes of antimicrobial agents like antibiotics and antifungals]) to residents. 42307 B. During a review of Resident 2's Admission Record (AR), the AR indicated, Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including other seizures (a sudden burst of electrical activity in the brain), chronic atrial fibrillation (long standing, rapid, irregular heart beat) and essential (primary) hypertension (high blood pressure). During a review of Resident 2's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 8/2/2024, the MDS indicated, Resident 2's cognition (ability to think and process information) status was severely impaired and used a wheelchair. The MDS indicated, Resident 2 was dependent (helper does all of the effort) with toileting. During a review of Resident 2's History and Physical (H&P), dated 9/20/2024, the H&P indicated, Resident 2 did not have the capacity to understand and/or sign any form. During a review of Resident 26's AR, the AR indicated, Resident 26 was admitted to the facility on [DATE] with multiple diagnoses including unspecified atrial fibrillation, essential (primary) hypertension and unspecified dementia (a general term to describe a group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function), unspecified severity, without behavioral disturbance, psychotic (a mental disorder characterized by disconnection from reality) disturbance, mood disturbance, and anxiety (intense, excessive, and persistent worry and fear about everyday situations). During a review of Resident 26's History and Physical, dated 6/9/2024, the H&P indicated, Resident 26 did not have the capacity to understand and/or sign any form. During a review of Resident 26's MDS, dated [DATE], the MDS indicated, Resident 26's cognitive status was severely impaired and Resident 26 used the walker or wheelchair. The MDS indicated, Resident 26 required substantial/maximal assistance (helper does more than half the effort) with toileting. During a concurrent observation and interview on 11/12/2024 at 9:04 AM with Certified Nursing Assistant (CNA) 2 inside the shared restroom of Resident 2 and Resident 26, the toilet seat had a large brownish colored fecal (poop) smear. CNA 2 stated, the smear should not be there, not even at home because it was a health risk and cross contamination concern. CNA 2 stated, the toilet seat should have been cleaned. During an interview on 11/12/2024 at 9:12 AM with CNA 4, CNA 4 stated, staff needed to check, and the facility liked to clean up as much as possible and would call maintenance to sanitize Resident 2 and Resident 26's shared toilet seat for sanitary purposes. C.During a review of Resident 41's AR, the AR indicated, Resident 41 was admitted to the facility on [DATE] with multiple diagnoses including traumatic subdural hemorrhage (significant bleeding inside the skull) with loss of consciousness of unspecified duration, subsequent encounter, type 2 diabetes mellitus (adult-onset high blood sugar level) without complications, essential (primary) hypertension (low blood pressure). During a review of Resident 41's H&P, dated 8/28/2024, the H&P indicated, Resident 41 was minimally verbal and not able to follow commands. During a review of Resident 41's MDS, dated [DATE], the MDS indicated, Resident 41's cognitive (ability to think and process information) skills for daily decision making were severely impaired (never/rarely made decisions). The MDS indicated, Resident 41 was dependent for activities of daily living (ADL, term used in healthcare that refers to self-care activities). During a review of Resident 40's AR, the AR indicated, Resident 40 was admitted to the facility on [DATE] with multiple diagnoses including hypotension (low blood pressure), unspecified, down syndrome (a genetic chromosome 21 disorder causing developmental and intellectual delays) and cachexia (a general state of ill health involving great weight loss and muscle loss). During a review of Resident 40's H&P, dated 10/4/2024, the H&P indicated, Resident 40 did not have the capacity to understand and/or sign any form. During a review of Resident 40's MDS, dated [DATE], the MDS indicated, Resident 40's cognitive status was moderately impaired. The MDS indicated, Resident 40 was dependent to requiring substantial/maximal assistance with ADLs. During a concurrent observation and interview on 11/12/2024 at 10:48 AM with Licensed Vocational Nurse (LVN) 2, inside the shared restroom of Resident 41 and Resident 40, on top of the sink there was an unlabeled 33.8 fl. oz (fluid ounce, a unit of measurement) bottle of Tena (name brand) cleansing cream. LVN 2 stated, the cleansing cream was used to clean the private areas of the body. LVN 2 stated, the cleansing cream should have been labeled with a resident's name to avoid cross contamination. D. During a concurrent observation and interview on 11/15/2024 at 11:45 AM with the Housekeeping/Laundry Supervisor (HLS) and the Building and Grounds Director (BGD) inside the laundry room, Laundry Aide (LA) 1 and LA 2 were removing dried laundry from the dryers and putting the dried laundry into a hamper. LA 2 was grabbing dried linens from the hamper to be sorted out/folded and in the process while LA 2 was handling the linen, the bottom of the linen was touching and dragging on the floor. LA 1 stated, the linen should not be touching the floor since the floor was dirty, affects the patients and for infection control purposes. During an interview on 11/15/2024 at 1:22 PM with the Infection Preventionist (IP), the IP stated, the toilet seat should not be left with fecal smear absolutely not for infection control [purposes]. The IP stated, personal toiletry should be labeled with resident's name to prevent cross contamination. During a review of the facility's P&P titled, Departmental (Environmental Services) - Laundry and Linen, revised January 2014, the P&P indicated, clean linen will remain hygienically clean (free of pathogens in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination. During a review of the facility's P&P titled, Handling Clean Linen, revision date 11/14/23, the P&P indicated, after washing, cleaned/dried textiles, fabrics and clothing shall be pressed, folded and packaged for transport, distribution and storage by methods that ensure their cleanliness until used.

B. During a review of Resident 39's AR, the AR indicated, Resident 39 was originally admitted to the facility on [DATE] with multiple diagnoses including anxiety disorder (a mental health disorder of persistent and excessive feelings of worry or fear that interferes with daily activities), encounter for attention to gastrostomy (a surgical procedure used to insert a tube often referred to as a G-tube through the abdomen and into the stomach for feeding and medications) and need for assistance with personal care. During a review of Resident 39's History and Physical, dated 10/16/2024, the H&P indicated, Resident 39 was in NAD (no acute distress) and was awake, alert, and oriented x 3 (to person, place, and time). During a review of Resident 39's MDS, dated [DATE], the MDS indicated, Resident 39's cognition (ability to think and process information) status was moderately impaired. The MDS indicated, Resident 39 was dependent (helper does all the effort, 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) to requiring substantial/maximal assistance (helper does more than half of the effort) for all activities of daily living. The MDS indicated, Resident 39 had a feeding tube (e.g. nasogastric [a thin, soft tube that is inserted through the nose and into the stomach to deliver food, liquids, or medicine] or abdominal [PEG]). During a concurrent observation and interview on 11/12/2024 at 9:46 a.m. with the Director of Staff Development (DSD) inside Resident 39's room, Resident 39 was asleep in bed and the call light was not within sight. The DSD looked for Resident 39's call light and found the call light looped around Resident 39's G-tube feeding pump, located in the back and on the left side of Resident 39's head of bed. The DSD stated Resident 39's call light should be within Resident 39's reach so Resident 39 could call for help when needed. During an interview on 11/14/2024 at 9:31 a.m. with the Director of Nursing (DON), the DON stated it was important of course for the call light to always be within the reach of residents (in general) for residents to use and to call in case residents needed help and assistance. The DON stated the call light was part of communicating their [residents] needs. During a review of Resident 39's Care Plan (CP, provides direction on the type of nursing care an individual needs that include goals of treatment, specific nursing interventions [actions, treatments, procedures, or activities designed to meet an objective] and an evaluation plan]), titled, Resident 39 uses quarter side rails to enhance functional independence & promote skin integrity, date initiated 10/28/2024, the CP indicated, one of the interventions was to place the call light cord within easy reach. 50016 Based on observation, interview, and record review, the facility failed to ensure call lights were within reach for two of two sampled residents (Resident 300 and 39) as indicated in the facility's policy and procedure (P&P) titled Answering Call Light. This deficient practice had the potential to result in a delay or the inability for Residents 300 and 39 to obtain necessary care and services. Findings: A. During a review of Resident 300's Admission Record (AR), the AR indicated the facility admitted Resident 300 on 11/6/2024, with diagnosis including, encephalopathy (a serious health problem that affects brain function or structure), muscle weakness, and cellulitis (a bacterial [living organism that can cause an infection] infection that affects the skin and tissues below). During a review of Resident 300's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 11/12/2024, the MDS indicated Resident 300 had severe cognitive (the ability to understand and process information) impairment. The MDS indicated Resident 300 required substantial/maximal assistance (helper does more than half the effort and helper lifts or holds trunk or limbs and provides more than half the effort) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and required substantial/maximal assistance (helper does all the effort) with mobility. During an observation on 11/12/2024 at 10:21 AM, Resident 300 was lying in bed and Resident 300's call light was observed hanging from the upper bed rail tucked between the wall and Resident 300's bed mattress. During an interview on 11/12/2024 at 10:21 AM, with Resident 300, Resident 300 stated that Resident 300 did not know where Resident 300's call light was located. Resident 300 stated Resident 300 was admitted to the facility about a week ago and Resident 300 was unaware of the facility's call light system and waited for staff to enter the room [to ask] for assistance. During an interview on 11/12/2024 at 10:49 AM, with Certified Nursing Assistant (CNA) 2, CNA 2 stated Resident 300's call light was not within Resident 300's reach and the call light should have been placed where it was easily accessible to Resident 300 in case Resident 300 required assistance. CNA 2 stated resident (in general) call lights must always be within reach [because] this allowed the residents to quickly request assistance and improved communication between patients and staff. CNA 2 stated this ensured patients connected with staff and [call lights within reach were] important for patient safety and satisfaction. CNA 2 stated residents should be educated and on the call light system upon admission and frequently reminded on the importance of using the call light system. During an interview on 11/14/2024 at 1:31 PM, with the DON, the DON stated call lights were important as they provided residents with a direct means to communicate their needs to staff. The DON stated call lights ensured patient safety and satisfaction. The DON stated residents should be educated on call lights because they served as a critical communication tool between patients and staff. During a review of the facility's P&P titled Answering Call Light, dated revised 9/2022, indicated that the facility will: 1. Upon admission and periodically as needed, explain, and demonstrate use of the call light to the resident. 2. Ask the resident to return the demonstration. 3. Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor.

Based on observation, interview, and record review, the facility failed to ensure grooming was provided to one of two sampled resident (Resident 18) who had dark brown substance under three fingernails of the left hand. This deficient practice had the potential to affect Resident 18's wellbeing and the potential to contaminate Resident 18's environment. Findings: During a review of Resident 18's Admission Record, the Admission Record indicated the facility admitted the resident on 6/19/2021, with diagnoses that included anxiety (emotion characterized by an unpleasant state of inner turmoil,) osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage.) During a review of Resident 18's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 8/15/2024, the MDS indicated Resident 18's cognitive (ability to understand and process information) skills for daily decision making were severely impaired. The MDS indicated Resident 18 sometimes understood verbal content and rarely was able to express ideas and wants. The MDS indicated Resident 18 was dependent with all activities of daily living. During an observation on 11/12/2024 at 10:01 AM, Resident 18 had dark brown substance under 3 fingernails of the left hand. During a concurrent observation and interview on 11/14/2024 at 09:30 AM, Resident 18 had dark brown substance under Resident 18's left three fingernails. Certified Nursing Assistant 1 (CNA 1) stated the dark brown substance under the fingernails could be because Resident 18 scratched staff. During an interview on 11/15/2024 at 03:30 PM, the Director of Staff Development (DSD) stated daily activities of daily living (ADL, term used in healthcare that refers to self-care activities) care included providing showers or bed baths, incontinent care, nail care, shaving and oral care. During a review of the facility's Policy and Procedure (P&P) titled Activities of Daily Living, Supporting dated March 2018, the P&P indicated residents who were unable to carry out activities of daily living independently would receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, interview and record review, the facility failed to ensure activities were provided to one of three residents (Resident 23). This deficient practice had the potential to affect Resident 23's emotional and psychosocial wellbeing. Findings: During a review of Resident 23's Admission Record (AR), the AR indicated, Resident 23 was admitted to the facility on [DATE] with multiple diagnoses including shortness of breath, anxiety disorder (a mental health disorder of persistent and excessive feelings of worry or fear that interferes with daily activities), and psychosis not due to a substance or known physiological condition (a severe mental condition in which thought and emotions are so affected that contact with reality is lost). During a review of Resident 23's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/16/2024, the MDS indicated, Resident 23's cognition (ability to think and process information) status was moderately impaired. The MDS indicated, Resident 23 usually understood verbal content and usually was able to express ideas and wants. The MDS indicated Resident 23 required moderate assistance (helper does less than half the effort) with toileting hygiene, and bed mobility. The MDS indicated Resident 23 considered the following activity preferences as highly important: listening to music, go outside to get fresh air, participate in religious services or practices. During multiple observations from 11/12/2024 to 11/14/2024, Resident 13 was observed lying in bed. During an observation on 11/12/2024 at 9:33 AM, Resident 23 was asleep, lying in bed with the head of the bed up 45 degrees, daily chronicle was on top of the table, TV was on. During an observation on 11/13/2024 at 11:29 AM, Resident 23 was lying in bed. During an observation on 11/13/2024 at 1:35 PM, Resident 23 awake, was lying in bed, and watching TV. During an observation on 11/14/24 at 9:19 AM to 9:21 AM Resident Assistant 1 (RA 1) was passing out daily chronicles to 4 residents (unidentified). RA 1 left the chronicles on top of resident table and in 3 minutes completed room visits for 4 residents. RA 1 stated RA 1 was doing room visits by handing out chronicles and turned-on TVs if the residents wanted to watch TV. During a review of Resident 23's Activity Assessment with the Activities Staff (AS) AS stated the assessment indicated Resident 23 considered the following activity preference as highly important: listen to music, to go outside to get fresh air, and participating in religious services or practices. During a review of Resident 23's Activity Program Attendance (APA) 11/1/2024 to 11/12/2024 and a concurrent interview with the Activity Staff (AS). The APA indicated there were no activities provided to Resident 23 from 11/1/2024 to 11/9/2024. The AS stated Activities needed to be provided at least three times a week. The AS stated when the Activities Director was working, the AS was responsible for visiting residents who did not attend group activities. The AS stated the AS was responsible for group activities while the Activities Director was off work. The AS stated, RA 1 was assisting with room visits such as passing out chronicles and providing social interaction. The AS stated when activities were not provided for an extended period [of time], Resident 23 could feel bored and unengaged. During a review of the Policies and Procedures (P&P) titled New Activity Program Introduction dated 8/6/2003, the P&P indicated it was the policy of the facility to ask residents what they enjoyed participating in and for the new activity program to reflect resident interest.

Based on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 6) received treatment and care in accordance with the physician's order by failing to ensure Resident 6's edema (swelling caused by too much fluid trapped in the body's tissues) was cared for adequately. This deficient practice had the potential to result in Resident 6's edema not improving and had the potential to cause pain and further complications to Resident 6. Cross Reference F656 Findings: During a review of Resident 6's Admission Record (AR), the AR indicated, Resident 6 was admitted to the facility on [DATE] with multiple diagnoses including displaced intertrochanteric fracture of left femur (a type of broken hip in the [femur] thigh bone), subsequent encounter for closed fracture with routine healing, essential primary hypertension (high blood pressure) and pain, unspecified. During a review of Resident 6's History and Physical (H&P), dated 9/25/2024, the H&P indicated, Resident 6 had trace edema (swelling caused by too much fluid trapped in the body's tissues) in the ankles. The H&P indicated, Resident 6 had the capacity to understand and/or sign any form. During a review of Resident 6's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 9/27/2024, the MDS indicated, Resident 6's cognition (ability to think and process information) status was severely impaired. The MDS indicated, Resident 6 had impairment on one side in the lower extremity (hip, knees, ankle, foot) and was dependent to requiring setup or clean-up assistance (helper sets up or cleans up) with Activities of Daily Living (ADL, term used in healthcare that refers to self-care activities). During a review of Resident 6's Order Summary Report (OSR), dated active as of 11/15/2024, the OSR indicated, a physician order dated 10/11/2024 to apply elastic stocking (TED Hose, a compressive stocking applied to the legs to help prevent swelling) to BLE (bilateral [both] lower extremities [legs]) one time a day for compression (thigh high) apply to BLE in the AM [morning] and remove at HS [before bedtime] and remove per schedule. During a concurrent observation and interview on 11/12/2024 at 10:20 AM with Resident 6 inside Resident 6's room, Resident 6 was awake and alert, had regular socks on, and was sitting up in the wheelchair. Resident 6's both legs were swollen and dependent (hanging down, below the mean level of the body). Resident 6 stated, Resident 6 broke her left femur. Resident 6 stated, the facility had not talked to Resident 6 about Resident 6's swollen legs and Resident 6 had to ask staff to place Resident 6's legs up on pillows when Resident 6 was in bed. During an observation on 11/13/2024 at 8:59 AM inside Resident 6's room, Physical Therapist (unnamed) was working with Resident 6. Resident 6 had regular socks on. During a concurrent observation and interview on 11/13/2024 at 1:14 PM with Licensed Vocational Nurse (LVN) 3, inside Resident 6's room, Resident 6 was sitting up in the wheelchair with both legs swollen and dependent. LVN 3 stated, Resident 6 was at the facility for left lower extremity swelling and Resident 6 was at risk for developing edema because of the surgery. LVN 3 measured Resident 6's edema and Resident 6 had pitting edema of 2+ (determined by applying pressure on the affected area and then measuring the depth of the pit, or depression, and how long it lasts, also known as a rebound time). LVN 3 stated, Resident 6 should have Resident 6's legs elevated and the physician's order for Resident 6 to have elastic stockings on was not followed. During an interview on 11/15/2024 at 1:36 PM with the Director of Nursing (DON), the DON stated, one of the interventions for edema was to elevate the [Resident 6's] extremities and follow the physician's orders. During a review of the facility's policy and procedure (P&P) titled, Applying Anti-Emboli Stockings (TED Hose), revision date October 2020, the P&P indicated, the purpose of the P&P procedure was to improve venous return to the heart, to improve arterial circulation to the feet, to minimize edema to the legs and feet.

Based on observation, interview, and record review, the facility failed to ensure floor mats were in place for one of one sampled resident (Resident 8), who was identified as high risk for falls and as indicated in Resident 8's physician's order, Plan of Care (CP) for at risk for falls, and the facility's policy and procedure (P&P) titled Falls and Fall Risk, Managing. This deficient practice had the potential to result in falls and serious injuries leading to fractures (break in the bone) and bleeding to Resident 8. Findings: During a review of Resident 8's Admission Record (AR), the AR indicated the facility admitted Resident 8 on 3/14/2024, and readmitted on [DATE], with diagnoses including malignant neoplasm of ascending colon (a cancerous growth in the colon [large intestine or large bowel]), difficulty walking, and muscle weakness. During a review of Resident 8's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 10/15/2024, the MDS indicated Resident 8's cognition (ability to understand and process information) was intact. The MDS indicated Resident 8 required setup or clean-up assistance (helper sets up or cleans up and resident completes activity; helper assists only prior to or following the activity) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity; assistance may be provided throughout the activity or intermittently) with mobility. During an observation on 11/12/2024 at 09:15 AM, Resident 8 was in Resident 8's room and was sitting on Resident 8's wheelchair. There were no floor mats in Resident 8's room. During an interview on 11/13/2024 at 1:35 PM, with Certified Nursing Assistant (CNA) 3, CNA 3 stated Resident 8 was at high risk for falls. CNA 3 stated interventions in Resident 8's plan of care (CP) for falls included floor mats to ensuring Resident 8's safety. CNA 3 stated Resident 8 should have had floor mats in place. During an interview on 11/14/2024 at 1:31 PM, with the DON, the DON stated staff should be following physician orders regarding medical equipment such as safety [floor] mats. The DON stated this ensured Resident 8's safety and the potential to reduce fall?related trauma if Resident 8 got up from bed, lost balance, and fell to the floor. During a review of Resident 8's admission Fall Risk Assessment, dated 7/9/2024, the assessment indicated Resident 8 was a high risk for falls. During a review of Resident 8's Order Summary Report (OSR), dated active as of 11/13/2024, the report included a physician's order, dated 10/11/2024, that indicated to keep Resident 8's bed low with floor mats every shift. During a review of Resident 8's CP, revision dated 10/26/2024, the CP indicated Resident 8 was at risk for falls due to impaired mobility and history of falling. The CP's interventions indicated to utilize devices as appropriate to ensure safety (i.e. bed mats, sensor alarms, etc). During a review of the facility's P&P titled Falls and Fall Risk, Managing, revision dated 3/2018, indicated based on the facility's previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The P&P indicated the staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with history of falls.

Based on observation, interview and record review, the facility failed to follow Pharmacist's recommendation to perform a gradual dose reduction (GDR, the stepwise tapering [to reduce dose over time] of a dose to determine if symptoms, conditions, or risks can be managed by use of a lower dose or determination of whether the dose or medication can be discontinued) for Seroquel, an antipsychotic medication (main class of drugs used to treat people that have mental disorders like schizophrenia [mental disorder characterized by loss of contact with the environment]), for one of one sampled resident (Resident 12). This deficient practice had the potential to result in unnecessary use of Seroquel and could potentially lead lethargy and adverse side effects (unwanted, undesired effect of a medication) to Resident 12. Findings: During a review of Resident 12's Admission Record, the Admission Record indicated the facility admitted the resident on 5/10/2024, with diagnoses that included dementia (a progressive state of decline in mental abilities,) muscle weakness, and difficulty in walking. During a review of Resident 12's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 8/15/2024, the MDS indicated Resident 3's cognitive (ability to understand and process information) for daily decision making were severely impaired. The MDS indicated Resident 3 was unable to express ideas and wants and unable to understand verbal content. During multiple observations on the following dates and times, Resident 12 was asleep in bed. On 11/12/2024 at 10:35 AM, Resident 12 was asleep in bed. Resident 12's roommate stated I don't think you will get any response from Resident 12. On 11/13/2024 at 11:22 AM, Resident 12 was asleep in bed. On 11/13/2024 at 1:15 PM, Resident 12 was asleep in bed. On 11/13/2024 at 3:05 PM, Resident 12 was asleep in bed. During an observation on 11/15/2024 at 8:39 AM, the Treatment Nurse (TN) checked and repositioned Resident 12, Resident 12 was calm and cooperative. The TN stated Resident 12 was always compliant with turning and repositioning, Resident 12 was nice, and cooperative and was never combative. During an interview on 11/15/2024 at 11:17 AM, with Restorative Nurse Assistant 1 (RNA 1) stated when RNA 1 got Resident 12 up on the chair, Resident 12 slept. RNA 1 stated Resident 12 slept all the time. During a review of Resident 12's Order Summary Report (OSR), active as of 11/15/2024, the report indicated a physician's order for Seroquel 25 MG (milligram, unit of measurement), to take one tablet by mouth at bedtime for Psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality) manifested by pulling staff member's hair. During a review of Resident 12's Medication Regimen Review (MRR), recommendations created between 9/1/2024 to 9/17/2024 and a concurrent interview with the Infection Prevention Nurse (IPN). The MRR indicated a recommendation to evaluate Resident 12's current dose and consider a dose reduction, the MRR indicated Resident 12 had been taking Seroquel 25 mg since 6/17/2024 and had dementia. The MRR's physician/prescriber response was blank and had no documentation from the physician. The IPN stated the Director of Nursing was responsible for following up on the recommendations indicated on the MRR but the IPN stated the IPN could not see any documentation that the physician was notified of the recommendation or the physician's response to the recommendation. During a review of Resident 12's care plan for behavior related to psychosis, date initiated 10/8/2024, the care plan indicated the last GDR was on 6/17/2024, Seroquel was decreased from 37.5 mg to 25 mg. The care plan indicated to observe closely for side effects of antipsychotic medication including lethargy. During a review of the facility's Policy and Procedure (P&P) titled Psychotropic Medication Use dated July 2022, the P&P indicated residents on psychotropic medications receive gradual dose reductions (coupled with non pharmacological interventions), unless clinically contraindicated, in an effort to discontinue these medications.

Based on observation, interview, and record review, the facility failed to provide care and services to prevent a fall for one of three sampled residents (Resident 1) by failing to: 1. Ensure Certified Nursing Assistant 1 (CNA 1) provided two-person physical assistance (help from two persons) to transfer (moving a resident from one place to another) Resident 1 from the toilet to the wheelchair when CNA 1 used the Sara lift (mechanical lift, a device used by staff to transfer residents from one location to another e.g., a bed to a chair). 2. Ensure CNA 1 followed the facility's Policy and Procedures (P&P) titled, Lifting Machine, Using a Mechanical, and Fall & Fall Risk, Managing. As a result, on 4/23/2024, at 3 p.m., Resident 1 fell forward from the Sara lift. Resident 1 experienced 7 out of 10 pain (on a pain scale from 0 to 10, 0 means no pain and 10 means the worst possible pain felt, severe/intense pain) on Resident 1's left shoulder. The X-ray (imaging study that takes pictures of bones and soft tissues) results indicated Resident 1 had a fracture in the neck of the humerus (long bone that runs from the shoulder and shoulder blade to the elbow), and Resident 1 was transferred to the General Acute Care Hospital 1's (GACH 1's) Emergency Department (ED). Findings: During a review of Resident 1's Admission Record (AR), the AR indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including seizures (sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness), and chronic (long-standing) atrial fibrillation (irregular rapid heart rate). A review of Resident 1's care plan (CP) titled, Falls, dated 8/15/2022, the CP indicated Resident 1 had risk factors that required monitoring and intervention to reduce the potential for self-injury associated with possible occurrence of falls. The CP indicated to consider Resident 1's medical conditions including, sensory alterations (sensory impairment, sensory overload, and sensory deprivation), balance, gait (walk), assistive devices, cognition (ability to understand and process information), mood/behavior, safety awareness, compliance, medications, and restrictions. The CP indicated Resident 1's risk factors included decreased functional mobility, wheelchair-bound, impaired ability to balance self with transfers, and needed assistance to maintain posture and safety. The CP indicated Resident 1 required extensive assistance [from staff] with bed mobility and transfers. The CP interventions indicated to observe Resident 1 for unsteady/unsafe transfers or positioning ability and to provide balance support and physical assistance to Resident 1 as needed. During a review of Resident 1's Fall Risk Assessment (FRA) dated, 10/3/2023, timed at 7:01 p.m., the FRA indicated Resident 1 was chair bound and required assistance with toileting. The FRA indicated Resident 1 required assistance (person, furniture/walls, or device) when Resident 1 stood on both feet. During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 2/1/2024, indicated Resident 1's cognition was severely impaired. The MDS indicated Resident 1 was dependent (helper [staff] does all the effort and the resident does none of the effort to complete the activity, or the assistance of two or more helpers was required for the resident to complete the activity) on staff for transfers from chair/chair-to-bed and toilet transfers. During a review of Resident 1's Interdisciplinary (related to more than one branch of knowledge) Notes-Change in Condition Evaluation (COC, a sudden clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains), dated 4/23/2024, timed at 5:47 p.m., the COC indicated on 4/23/2024, at 3 p.m., while Resident 1 was being transferred from the toilet to the chair using the Sara lift Resident 1's knees buckled (lost the ability to support the weight and gave out), and Resident 1 was supporting herself [by grabbing the] Sara lift's handlebars.The COC indicated Resident 1 was in stable condition and was conversing with staff. The COC indicated Resident 1 was brought back to the nurse's station by staff (unidentified), and Resident 1 verbalized Resident 1 had 7 out of 10 pain on Resident 1's left shoulder. During a review of Resident 1's stat (immediately, without delay) Radiology 1 (a branch of medicine that uses imaging technology to diagnose and treat disease) X-ray Report, dated 4/23/2024, at 7:02 p.m., the X-ray report indicated Resident 1 had an acute (sudden) fracture involving the left humerus. During a review of the Interdisciplinary Notes dated 4/24/2024, at 7:50 a.m., the notes indicated Resident 1 woke up at around 3:10 a.m., complained of 8 out of 10 pain on Resident 1's left shoulder, and requested for pain medication. The notes indicated Resident 1 stated Resident 1 could not fall asleep due to the pain on the left shoulder. The notes indicated Resident 1 had bruising on the left wrist, and Resident 1 did not want anyone [staff] to move or change her. The notes indicated Resident 1 needed assistance from two CNAs (any two CNAs) for bed repositioning. A review of the Interdisciplinary Notes, dated 4/24/2024, timed at 11:48 a.m., the notes indicated Medical Doctor (MD) 1 was notified Resident 1 continued to have extreme pain and an inquiry to send Resident 1 to GACH's ED for further evaluation. The notes indicated MD 1 requested a call to MD 2 (orthopedic physician, a branch of medicine that focuses on the correction of deformities of bones and muscles) to see (check) Resident 1 on 4/24/24 and to change pain medication (Norco 325 milligram (mg), pain medication for moderate to severe pain) administration to every 4 hours as needed. The notes indicated MD 2 was unable to see Resident 1, and at 11 a.m., the ambulance arrived at the facility to transfer Resident 1 to GACH 1 due to Resident 1's fracture on the left upper extremity (arm). During a review of Resident 1's Orthopedic Group Report (OGR), encounter date 4/26/2024, the report indicated Resident 1 presented with a complaint of left shoulder pain and indicated Resident 1 stated Resident 1 was in the bathroom and fell forward onto Resident 1's left shoulder. The report indicated Resident 1 was diagnosed with a fracture in the neck of the left humerus. The report indicated Resident 1's left humerus fracture was a surgical neck fracture and typically would require surgery, however, due to Resident 1's relative lack of function, her age, her mentation (the process of using your mind to consider something carefully), Resident 1's family members and Resident 1 refused surgery. During a concurrent observation and interview on 5/9/2024, at 2 p.m., Resident 1 was wearing a black sling (a device used to support and keep still [immobilize] an injured part of the body) on Resident 1's left arm and Resident 1 had facial grimacing when being moved by staff. Resident 1 stated the girl (unidentified staff) did something that caused me to slip and fall. Resident 1 stated due to the fall, Resident 1 developed a fear of the machine (Sara lift). Resident 1 stated after the fall, Resident 1 experienced bad pain (unrated) on the left shoulder. Resident 1 stated after Resident 1 fell , Resident 1 went to the dining-activity room to play a game of volleyball but Resident 1 could not play due to the pain. Resident 1 stated Resident 1's current pain level was a 6 out of 10 pain and Resident 1 asked LVN 2 for pain medication. During an interview on 5/9/2024, at 3 p.m., CNA 2 stated CNA 2 had worked at the facility for [AGE] years. CNA 2 stated CNA 2 had, in the past, used the [NAME] mechanical lift to take Resident 1 to the bathroom. CNA 2 stated CNA 2 and all new CNAs received training on how to use the Sara lift. CNA 2 stated the Sara lift was always used with two staff and the staff would push the lift to the bathroom while Resident 1 stood on the lift's foot support. CNA 2 stated, [usual facility practice included] one CNA was positioned in the front of the lift and another CNA was positioned behind the resident. During an interview with CNA 1, on 5/10/2024, at 12:41 p.m., CNA 1 stated CNA 1 used the Sara lift more than ten times in the past (prior to the incident with Resident 1's fall on 4/23/24) including using the lift to assist Resident 1. CNA 1 stated, on 4/23/24, (did not remember exact time) CNA 1 came into Resident 1's room to assist Resident 1 to the bathroom located inside Resident 1's room. CNA 1 stated CNA 1 was assisting Resident 1 from the wheelchair to the bathroom and used the Sara lift by herself. CNA 1 stated when transferring Resident 1 from the wheelchair to the Sara lift, CNA 1 made sure Resident 1's wheelchair wheels were locked, Resident 1 was strapped to the Sara lift's belt, and clipped the Sara lift sling onto Resident 1. CNA 1 stated CNA 1 made sure Resident 1 was holding the handles on the Sara lift while Resident 1 stood (after being lifted) on the Sara lift's foot support (affixed to the Sara lift). CNA 1 stated CNA 1 pushed the button on the Sara lift and Resident 1 was lifted off the wheelchair to the Sara lift's foot support and CNA 1 [pushed the Sara lift] and took Resident 1 to the bathroom. CNA 1 stated CNA 1 lowered the Sara lift and Resident 1 sat comfortably on the toilet [Resident 1 remained strapped on the Sara lift]. CNA 1 stated CNA 1 stepped outside of the bathroom to provide privacy to Resident 1 and left the bathroom door open. CNA 1 stated Resident 1 made CNA 1 aware Resident 1 was ready. CNA 1 stated CNA 1 entered the bathroom, pushed the button on the Sara lift and lifted Resident 1 up while Resident 1 held onto the Sara lift bars. CNA 1 stated CNA 1 transferred Resident 1 from the toilet to the Sara lift by herself. CNA 1 stated CNA 1 noticed Resident 1's knees buckled (knee instability, when the knees bend and give out), and Resident 1 fell forward. CNA 1 stated CNA 1 and Resident 1 started yelling help. CNA 1 stated CNA 1 was the only staff present while CNA 1 assisted Resident 1 to the bathroom using the Sara lift. CNA 1 stated CNA 1 normally transferred residents (in general) and Resident 1 alone using the Sara lift. CNA 1 stated Sara lift transfers were always done by one staff, and this was how CNA 1 was taught. CNA 1 stated 'this was normal practice. During an interview, on 5/10/2024, at 2:57 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated LVN 1 worked at facility for a total of 5 years and stated the Sara lift was used when a resident (in general) had some movement and was able to stand up but did not have the balance or the strength to transfer out of the bed to the toilet. LVN 1 stated LVN 1 was taught to use the Sara lift with two staff for resident transfers and this was the facility's policy. LVN 1 stated it was not safe to use the Sara lift with one person because the resident's knees can fail (buckle) LVN 1 stated two staff positioned one on each side when using the Sara lift and one staff stood in front [of the lift] and the other staff stood behind the resident. LVN 1 stated using the Sara lift with two staff helped [staff] intervene if something happened to the resident. LVN 1 stated this was important [to follow] for the safety of the resident and for staff safety. LVN stated this prevented injuries for CNAs, and the residents. LVN 1 stated Resident 1 was able to follow directions but needed to have assistance from two staff because Resident 1 was very scared of the Sara lift. LVN 1 stated when Resident 1 was on the Sara lift, she would start shaking and stated hurry up. LVN 1 stated Resident 1 was on the heavy side (large frame), so it was hard to maneuver the Sara lift in a safe way and it was hard to maneuver the resident and the Sara lift with only one person (staff). During a phone interview, on 5/10/2024, at 4:51 p.m., with CNA 3, CNA 3 stated CNA 3 worked at the facility for 3.5 years. CNA 3 stated the Sara lift should be used with two staff. During an interview, on 5/10/2024, at 5:18 p.m., with the Director of Nursing (DON), the DON stated for safety [purposes] it was the policy of the facility to use the Sara lift with two staff. The DON stated using the Sara lift with two staff was important in case there was a malfunction or in the event the resident got spooked (frighten/scare) by the lift. A review of the facility's P&P titled, Lifting Machine, Using a Mechanical, revised in July 2017, the P&P indicated the purpose of this procedure is to establish principles of safe lifting using a mechanical lifting device and it is not a substitute for [the device's] manufacturer's training or instructions. The P&P indicated At least two nursing assistants are needed to safely move a resident with a mechanical lift. A review of the facility's P&P titled, Fall & Fall Risk, Managing, revised in March 2018, the P&P indicated Based on previous evaluations and current data [of the resident] the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.

Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who had a diagnosis of dementia (loss of memory and other mental abilities severe enough to interfere with daily life), was assessed at high risk for falls, and elopement (a resident who's incapable of protecting himself/herself adequately and who departed the health care facility unsupervised and undetected) received care and services to prevent a fall by failing to: 1. Implement Resident 1's Care Plan (CP, a form where one can summarize a person's health conditions, specific care need, and current treatments) interventions related to repetitive wandering (moving from place to place without a fixed plan) behavior and attempts to leave the facility unattended. 2. Update Resident 1's CP interventions titled, Cognitive Loss/Dementia, and Activities, when Certified Nurse Assistant (CNA 2) recognized that Resident 1 needed a one-to-one supervision (one staff supervising one resident), and when the Social Services Director (SSD) recognized that Resident 1 made frequent elopement attempts and stated the facility was fearful that Resident 1 might leave the facility without staff noticing. As a result, on 3/29/2024, Resident 1 fell while running toward the front lobby and attempting to leave the facility. Resident 1 sustained a left distal radius (one of two large bones of the forearm) fracture (broken left wrist) and right humerus (long bone that runs from the shoulder and shoulder blade to the elbow) fracture. The facility transferred Resident 1 to the General Acute Care Hospital (GACH) where Resident 1 was put on a cast (a protective shell of fiberglass [a textile fabric made from woven glass filaments], plastic, or plaster [substance that becomes hard as it dries], and bandage that was molded to protect broken or fractured limb(s) as the broken bone(s) healed) on Resident 1's left arm and a sling (a device used to support and keep still (immobilize) an injured part of the body) on Resident 1's right arm. Findings: During a review of Resident 1's Admission Record, (AR) the AR indicated the facility admitted Resident 1 on 2/6/2024 with diagnoses that included dementia, muscle weakness (a lack of muscle strength), and encephalopathy (a group of conditions that cause brain dysfunction). During a review of Resident 1's Falls Risk Assessment, (FA) dated 2/6/2024, the FA indicated Resident 1 had a total score of 11 (a score of 10 or more indicated high risk for falls). The FA indicated Resident 1 was a high risk for falls due to Resident 1 had gait (manner of walking) and balance problems, needed assistant from staff with toileting and received multiple medications. During a review of Resident 1's Minimum Data Set, (MDS, a resident assessment and care screening tool) dated 2/12/2024, the MDS indicated Resident 1 was moderately impaired with cognitive skills (thinking, reasoning, remembering). The MDS indicated Resident 1 required substantial/ maximal assistance (helper provided more than half the effort) for eating and personal hygiene. During a review of Resident 1's CP, titled Cognitive Loss/Dementia, related to Resident 1 had impaired cognition related to Dementia which resulted in repetitive wandering, dated 3/8/2024, the CP indicated, Resident 1 walked aimlessly along hallways towards the front lobby, unassisted and without sense of direction. The CP's goal indicated Resident 1's safety would be maintained daily, and Resident 1 would fulfill the need to walk about in safety without distracting others. The CP's intervention indicated for staff to provide Resident 1 regular opportunities to go outdoors with supervision and assist the resident as needed. During a review of Resident 1's Elopement Risk Assessment, (EA) dated 3/11/2024, the EA indicated Resident 1's total score was a 29 (a score of 10 or more indicated at risk for elopement). The EA indicated Resident 1 was at high risk for elopement due to Resident 1 made attempts to get out of the facility (elope) and Resident 1 stated Resident 1 wanted to get out of the facility but Resident 1 did not know where Resident 1 would go. During a review of Resident 1's CP titled, Activities, related to Resident 1 attempted to leave the facility unattended, dated 3/25/2024, the CP's goal indicated Resident 1 would not try to leave the facility unattended. The CP's intervention indicated Resident 1 would walk two to three times a week. During a review of Resident 1's Interdisciplinary (IDT, a group of dedicated healthcare professionals who work together to provide personalized health care for the resident/patient) Notes, dated 3/29/2024, the IDT notes indicated Resident 1 was sent to the GACH after sustaining a fall and the hospital Registered Nurse (RN) reported to the facility that Resident 1 had a left distal radius fracture and right humerus fracture. The IDT notes indicated Resident 1 returned to the facility on the same day (3/29/24) with a sling on Resident 1's right arm and cast on Resident 1's left arm. During a review of Resident 1's Fall Situation, Background, Assessment and Recommendation (SBAR, structured communication framework that helps teams share information about the condition of a resident), dated 3/30/2024, timed at 8:08 a.m., late entry for 3/29/2024, the SBAR indicated Resident 1 had a witnessed fall to the floor. The SBAR indicated Resident 1 was found flat on the resident's back and was transferred to the emergency room (GACH) for further evaluation. The SBAR indicated Resident 1 was taken to the nurse's station for close monitoring, and Resident 1 kept getting up and going to other resident's rooms. The SBAR indicated re-direction did not work and Resident 1 was seen by staff running down the main hall around 9:30 a.m. and at 9:35 a.m., Resident 1 had an unwitnessed fall. The SBAR indicated Resident 1 had a knot on top of Resident 1's right temple (the side of the head behind the eyes) and Resident 1 mentioned she had pain (unrated) on the right shoulder shooting down to Resident 1's arm. The SBAR indicated Resident 1 had swelling on the right arm and right wrist. During a concurrent observation and interview on 4/15/2024 at 9:30 a.m., Resident 1 had a sling on the right arm and a cast on the left wrist/arm. Resident 1 stated [the day of the fall (3/29/24)] Resident 1 was running with Resident 1's daughter at the park and Resident 1 fell . During an interview on 4/15/2024 at 10:18 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the interventions implemented for Resident 1 included frequent visual checks every one to two hours due to Resident 1's high risk for elopement and falls. During an interview on 4/15/2024 at 10:27 a.m. with the Activities Coordinator (AC), the AC stated prior to Resident 1's fall (3/29/2024), Resident 1 was always saying, I have to go, I have to go, and tried to leave the facility. The AC stated, before the fall, Resident 1 used to walk up and down the hallways all the time. During an interview on 4/15/2024 at 11:48 a.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated prior to Resident 1's fall (3/29/24), Resident 1 was known to be very confused and known to wander. CNA 2 stated despite attempts at keeping Resident 1 near the nursing station, it was difficult to monitor (watch) Resident 1 when the staff were busy with other tasks. CNA 2 stated the morning when Resident 1 fell , Resident 1 had verbalized wanting to leave the facility and tried wandering toward the front lobby. CNA 2 stated no staff was specifically designated to watch Resident 1when the residents were at the nursing station. CNA 2 stated a staff should be at the nursing station watching the residents. CNA 2 stated Resident 1 wandered frequently, and it ultimately led to Resident 1 falling and sustaining a fracture on Resident 1's arm. CNA 2 stated CNA 2 reported to a charged nurse (unable to identify)) that Resident 1 required one to one staff monitoring (one staff monitor one resident) because Resident 1 had unpredictable behavior when some days, Resident 1 sat and did nothing and other days, Resident 1 walked around the facility and tried to leave. During an interview on 4/15/2024 at 2:36 p.m. with the Director of Nursing (DON), the DON stated on day Resident 1 fell (3/29/2024, unable to recall the time). Resident 1 was sitting down in the hallway with other residents. The DON stated a resident (unidentified) yelled out, she's running, and CNA 3 came around the nurse's station and saw Resident 1 running down the hall toward the front lobby and CNA 3 started running after Resident 1. The DON stated she saw the Administrator (ADM) got up, ran to the front lobby and she followed the ADM. The DON stated, she saw Resident 1 was on the floor of the front lobby, rolled on Resident 1's back. The DON stated interventions that were implemented for Resident 1 who was high fall risk included frequent rounds (visual checks). The DON stated frequent rounds meant monitoring Resident 1 more frequently than every two hours. The DON stated prior to Resident 1's fall on 3/29/2024, Resident 1 was taken outside for walks only when someone had time because this [activity] was not a regular part of Resident 1's care. During an interview on 4/15/2024 at 4:33 p.m. with the Social Services Director (SSD), the SSD stated the SSD had contacted Resident 1's family prior to Resident 1's fall (2/26/24) due to the SSD recognized Resident 1 made frequent elopement attempts and stated the facility was fearful Resident 1 might leave without staff noticing. During a concurrent interview and record review on 4/15/2024 at 4:50 p.m. with the DON, Resident 1's CP titled Cognitive Loss/Dementia, dated 3/8/2024 and CP titled Activities dated 3/25/24 were reviewed, the DON stated there were no documentations indicated Resident 1's CP interventions were implemented by facility's staff for these CPs. During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, dated 7/2017 the P&P indicated implementing interventions to reduce accident risks and hazards shall include ensuring that the interventions are implemented and documented. During a review of the facility's P&P titled, Dementia - Clinical Protocol, dated 11/2018, the P&P indicated the IDT will identify a resident-centered care plan to maximize remaining function and quality of life, direct care staff will support the resident in initiating and completing activities and tasks of daily living. The P&P indicated the staff will monitor the individual with dementia for changes in condition and decline in function and will report these findings to the physician, the IDT will adjust interventions and the overall plan depending on the individual's responses to those interventions, progression of dementia. The P&P indicated the IDT will identify and document the resident's condition and level of support needed during care planning and review changing needs as they arise.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to one of three sampled residents (Resident 28), who developed a pressure ulcer/sore (localized injury to the skin and / or underlying tissue as a result of pressure or pressure in combination with shear (skin layers are laterally shifted in relation to each other) and/or friction (rubbing)) at the facility by: 1. Failure to implement Resident 28's plan of care to reposition every two hours or as needed and offload (remove) pressure from the coccyx (tailbone). 2. Failure to include in the plan of care Resident 28's preference to sit most of the day in the wheelchair and interventions to ensure offloading, repositioning and toileting. 3. Failure to refer Resident 28 to physical therapy for recommendations about posture and devices to address proper body alignment while in a wheelchair. As a result, Resident 28, who was readmitted without pressure sores on 9/25/18, developed on 10/21/18 a Stage II (partial thickness skin loss involving epidermis, dermis, or both (top layers of the skin)) pressure sore to the coccyx. By 11/3/18, the pressure sore deteriorated to a Stage III (full-thickness skin and tissue loss with fatty tissue visible, slough and/or eschar (dead tissue) may be visible) and caused Resident 28 pain. Findings: On 11/1/18, Resident 28 was observed at 6:25 p.m., sitting in a wheelchair with pressure relieving cushion. On 11/2/18, at 5:01 p.m., 5:55 p.m., and at 7:10 p.m., Resident 28 was observed sitting in her wheelchair. A review of the Admission Record indicated Resident 28 was initially admitted to the facility on [DATE] and re-admitted on [DATE], with [DIAGNOSES REDACTED]. The History and Physical (H & P), dated 9/25/18, indicated Resident 28 had intact skin. A review of the Minimum Data Set (MDS - standardized assessment and care-planning tool) dated 10/9/18, indicated Resident 28 had moderately impaired cognition (the mental action or process of acquiring knowledge and understanding), required extensive assistance (staff provided weight bearing support) with two-person assist for transferring and one-person assist for bed mobility, toilet use, personal hygiene, and dressing. The MDS indicated Resident 28 did not have pressure sore and was incontinent (unable to control) of bowel and bladder functions. A review of the plan of care developed on 10/12/18 for Resident 28's risk for developing a pressure sore due to decreased functional mobility related to [MEDICAL CONDITION], muscle weakness, and scoliosis had a goal for Resident 28 not to have open skin areas caused by pressure or friction for the next 90 days. The interventions included repositioning Resident 28 every two hours or as needed and to offload the pressure areas of concern, if applicable. The plan of care was updated/revised indicating on 10/21/18; Resident 28 developed a coccyx Stage II pressure sore. The revised goal was for the pressure sore to resolve within 30 days. The revised interventions included repositioning Resident 28 every two hours and as needed. The plan of care, updated on 11/1/18, indicated Resident 28 had MASD (Moisture Associated Skin Damage), on both buttocks and the peri-area (the area below the pelvis and between the thighs). The interventions included to check and change Resident 28's briefs every two to three hours or as needed, keep area clean and dry, and assist with toileting as needed. On 11/3/18, at 9:39 a.m., during a treatment observation of Resident 28's coccyx pressure sore and a concurrent interview, Registered Nurse 1 (RN 1) stated Resident 28's pressure sore was a Stage II but was now a Stage III. RN 1 stated Resident 28 did not like to be in bed and sat in her wheelchair for long hours. RN 1 stated Resident 28 was incontinent and often needed to be changed. On 11/3/18, at 9:55 p.m., 11:58 a.m., 4:45 p.m., and at 5:48 p.m., Resident 28 was observed sitting in her wheelchair. On 11/3/18, at 3:28 p.m. during a review the Skin Evaluation forms and an interview, RN 1 stated he called Resident 28's physician and received a new treatment order for the Stage III pressure sore. RN 1 stated RN 2 performed the wound care on 11/2/18, but RN 2 did not document a change of the pressure sore status. A review of the Skin Evaluation forms indicated Resident 28 had a coccyx pressure sore assessed as follows: - On 10/21/18, Stage II, measuring 0.3 centimeters (cm) in length by 0.3 cm in width by 0.1 cm in depth, described as a shallow open ulcer (sore) with red/pink color with no drainage. - On 10/22/18, Stage II, measuring 0.5 cm in length by 1 cm in width with no depth and 100 % dermis. - On 10/29/18, Stage II, measuring 0.5 cm in length by 0.8 cm in width with no depth and 100 % dermis. - On 11/3/18, Stage III, measuring 1 cm by 0.8 cm by 0.2 cm with 100 % slough, moderate yellow drainage, redness on surrounding area measuring 5 cm by 4 cm, slightly tender to touch. On 11/4/18, at 10:01 a.m. and at 11:48 a.m., Resident 28 was observed sitting in her wheelchair. During an interview on 11/4/18, at 10:15 a.m., RN 2 stated when she performed the wound care on 11/2/18, the pressure sore was slightly pink. RN 2 stated Resident 28 was sitting long periods in the wheelchair. RN 2 stated that Certified Nursing Assistants (CNAs) should reposition Resident 28 while on the wheelchair and make her stand a little to relieve the pressure. RN 2 stated she did not instruct the CNAs to reposition Resident 28 while in the wheelchair. During a concurrent record review, RN 2 confirmed the plan of care for pressure sore did not include Resident 28's preference to sit most of the day in the wheelchair and interventions to reposition Resident 28 while in the wheelchair. On 11/4/18, at 11:26 a.m., during an interview, the Director of Nursing (DON) stated Resident 28 had scoliosis which could have contributed to Resident 28's development of the coccyx pressure sore. The DON stated there was no referral for physical therapy ((PT) a healthcare specialty that evaluate, assess, and provide treatment to individuals with limitations in functional mobility) for evaluation and recommendations about Resident 28's proper body alignment while sitting in a wheelchair to prevent pressure on the coccyx area. The DON stated Resident 28 was often observed crying. During an observation on 11/4/18, at 1:54 p.m., Resident 28 was observed sitting at the edge of the bed, moaning and crying. During a concurrent interview, in the presence of Licensed Vocational Nurse 1 (LVN 1), Resident 28 stated she was in a lot of pain pointing towards the coccyx area. LVN 1 asked the intensity of pain using the scale of 0-10 (0, being no pain and 10, being the worst pain), Resident 28 replied, It's between 7 or 8. A review of the Medication Administration Record [REDACTED]. During an interview on 11/4/18, at 2:12 p.m., CNA 1 stated she routinely took care of Resident 28 during the day shift (7 a.m. to 3 p.m.). CNA 1 stated every morning, at around 9:30 a.m., she assisted Resident 28 to sit in the wheelchair to attend activities. CNA 1 stated after lunch, at approximately 1:15 p.m., she would take Resident 28 back to bed. CNA 1 stated she was aware Resident 28 had pressure sore to the coccyx area and was incontinent of bladder and bowel. CNA 1 stated she did not attend to Resident 28 while in the dining room between 9:30 a.m. to 1:15 p.m. because of other assignments she needed to do. During a telephone interview on 11/4/18, at 2:15 p.m., the Director of Rehabilitation Services (DRS) stated the facility did not refer Resident 28 to the Rehabilitation Department for evaluation. The DRS stated that a specific type of cushion (pommel cushion) could be used on the wheelchair to prevent Resident 28 from sliding (cause friction/shear) and relieve pressure on the coccyx by maintaining proper body alignment and make the resident more comfortable while on the wheelchair. A review of the facility's undated policy and procedure, titled, Prevention of Pressure Ulcer Injury, for residents with pressure ulcer injury, the facility will identify and treat the underlying cause of the pressure injury and consider possible risk and complications. The interventions included, identifying responsible discipline for each approach and the monitoring and observation of the underlying condition. According to Medical-Surgical Nursing, Ninth Edition, 2013, pages 186-187, Prevention remains the best treatment for [REDACTED]. Never position the patient directly on the pressure sore. According to National Pressure Ulcer Advisory Panel (NPUAP) handbook on Prevention and treatment of [REDACTED]. Moisture Associated Skin Damage (MASD) is the general term for inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or mucus. It is proposed that for MASD to occur, another complicating factor is required in addition to mere moisture exposure. Possibilities include mechanical factors (friction), chemical factors (irritants contained in the moisture source), or microbial factors (microorganisms). https://www.woundsource.com/print/patientcondition/moisture-associated-skin-damage-masd

Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from excessive medication doses for one of three sampled residents (Resident 1). Resident 1 was given two doses of [MEDICATION NAME] 0.75 mg (an opioid / narcotic medication used as a pain reliever) and two doses of [MEDICATION NAME] 1 mg (a sedative medication used to treat anxiety disorders) by two separate nurses within one hour. This deficient practice caused Resident 1 to be over-sedated, exhibiting side effects of difficult to arouse, garbled speech, drooling from mouth, and too drowsy to eat. In addition, Resident 1 missed the next scheduled, routine dose of [MEDICATION NAME], for anxiety. Findings: On 9/4/15, at 1 p.m., an unannounced visit was conducted to investigate a complaint alleging Resident 1 received an over-dose of [MEDICATION NAME] 0.75 mg and [MEDICATION NAME] 1 mg, by two separate nurses during the same shift, on 8/1/15. Resident 1 was over-sedated the next day and unable to participate in activities. A review of Resident 1's medical record indicated the resident was a [AGE] year-old female, who was readmitted to the facility, on 6/7/13, with [DIAGNOSES REDACTED]. (an illness which involves sad mood and thoughts). A review of the resident's Minimum Data Set (MDS - an assessment and care planning tool), dated 5/23/15, indicated Resident 1 had impaired cognition and communication, had behavioral symptoms of agitation, and required supervision with transfers and toilet use. A review of the care plan, evaluated on 7/2/15, indicated Resident 1 had a problem with periodic behavioral symptoms, related to anxiety and pain (severe pain to her back). The care plan goal indicated Resident 1 would respond cooperatively resulting in the lowest maintanance dose of [MEDICAL CONDITION] medication use daily. The care plan intervention / action indicated for facility staff to administer the anti-anxiety medication as ordered ([MEDICATION NAME] for anxiety symptoms). In addition, the care plan indicated dose reduction was not indicated due to failed dose reduction on 6/24/14 (over one year prior). A review of the Pharmacist's Medication Regimen Review, dated 7/22/15, indicated Resident 1 received [MEDICATION NAME] 1 mg twice per day since 10/2014. The Regimen Review form indicated to please evaluate the current dose of [MEDICATION NAME] and consider a gradual taper, to ensure Resident 1 received the lowest possible effective / optimal dose. A review of the medical record indicated the pharmacist's recommendations were not addressed. A review of Medication Record, dated 8/2015, indicated Resident 1 was to receive [MEDICATION NAME] .75 milligrams (mg) by mouth, every eight hours for pain and unspecified backache. The Medication Record indicated Resident 1 was to receive [MEDICATION NAME] 1 mg by mouth, twice a day for anxiety (2 p.m. and 10 p.m.) and [MEDICATION NAME] 0.5 mg every 12 hours, as needed for anxiety. On 9/4/15, at 2:01 p.m., during an interview with the director of nursing (DON), she stated she was called the night of 8/1/15, by the licensed vocational nurse (LVN 1), who informed her she administered [MEDICATION NAME] .75 mg and [MEDICATION NAME] 1 mg to Resident 1 for agitation at 10 p.m. (not for pain), and did not document the administration of both medications in the eMAR (electronic medication administration record). The DON stated due to the ongoing agitation of Resident 1, LVN 2 also administered [MEDICATION NAME] .75 mg and the [MEDICATION NAME] 1 mg to Resident 1 at 10 p.m. (the same time as LVN 1), and signed out the administrations in the eMAR, but not the Narcotic Book. During the interview with the DON, on 9/4/15, at 2:15 p.m., she stated, The medication nurses are supposed to administer the medication and document administration in the eMAR and the Narcotic book right after the administration. During a telephone interview with LVN 1, on 9/4/15, at 3:48 p.m., LVN 1 stated, I gave Resident 1 both the [MEDICATION NAME] and [MEDICATION NAME], signed them out in the narcotic book, gave LVN 2 the medication keys, and went on my break. LVN 1 stated, When I got back to sign the medications out on the eMAR, I saw LVN 2 had signed out on the eMAR, and that was when we discovered Resident 1 had been given two doses of the two medications. LVN 1 stated, The on call physician ordered us to take her vital signs and monitor her. Resident 1 slept all night. A review of the Controlled Drug Record Individual Patients Narcotic Record, dated 8/1/15, was reviewed with the DON which stipulated [MEDICATION NAME] 1 mg tablet and [MEDICATION NAME] 0.75 mg was documented and initialed by LVN 1 at 10 p.m. for administration. The Narcotic Record stipulated LVN 2 initialed and documented time of administration of [MEDICATION NAME] 1 mg at 10 p.m. and 10:45 p.m., for the [MEDICATION NAME] .75 mg, dated 8/1/15. On 9/4/15, at 4 p.m., during an interview with the registered nurse (RN 1), he stated, I came on shift the morning of 8/2/15 (the next day), and was informed by LVN 1 of the double medication administrations by LVN 1 and LVN 2 the night before. RN 1 stated, Resident 1 was very drowsy, I told the patient care giver (PCG) to monitor her breathing due to the double dose of her medications. RN 1 stated, I called the physician in the mid-morning to get an order to hold Resident 1's 2 p.m. dose of [MEDICATION NAME] 1 mg, due to the resident being drowsy, but arousable. RN 1 stated, The medication administration procedure for our staff is pour, pass, then sign. A review of Resident 1's physician's orders [REDACTED]. This indicated Resident 1 did not receive the two doses of [MEDICATION NAME] which were routinely scheduled for anxiety. A review of the interdisciplinary notes, dated 8/2/15, at 7 a.m., indicated Resident 1 was in the wheelchair at the nursing station noted drowsy, difficult to arouse. The notes indicated Resident 1 was leaning her head and torso forward, speech was garbled, and Resident 1 was drooling from the mouth. The note indicated Resident 1 was too drowsy to eat, and was assisted back into bed. A review of the interdisciplinary notes, dated 8/2/15, late entry by LVN 1 indicated the DON instructed LVN 1 to complete a medication error form and contact the physician. A review of the Disciplinary Notice, dated 8/6/15, indicated the incident date of 8/1/15, LVN 1 administered the medications [MEDICATION NAME] and [MEDICATION NAME] to Resident 1 and did not sign the eMAR, and LVN 2 administered the same medications, during the same shift. The Disciplinary Notice indicated this incident resulted in Resident 1 receiving double the ordered dose. A review of the facility's policy and procedure titled, Psychoactive Drug Medication Administration General Guidelines, dated 9/2010, indicated the individual who administered the medication, records the administration on the resident's MAR, following the medication being given. The policy indicated in no case should the individual who administered the medication report off-duty, without first recording the administration of any medication.