Every finding on record at Sequoia Transitional Care

Based on interview and record review, the facility failed to notify the physician of a change of condition for one of three sampled residents (Resident 1) when there was significant weight loss. This failure resulted in the physician being unaware of significant weight loss and the potential for Resident 1 to have unmet nutritional needs.Findings:During a review of Resident 1's IDT (Interdisciplinary Team-group of medical professionals from diverse specialties who work together to address a patient's complex needs) - Weight Variance Assessment (WVA) dated 2/16/26, the WVA indicated, Problem weight (lb-pound) -18 lbs.weight loss/gain (%) -9.6 %.in (x) number of weeks.2.During a review of Resident 1's WVA dated 2/23/26, the WVA indicated, Root cause analysis.26 lb/13% wt. (weight) loss x 3 weeks since admit.During a review of Resident 1's WVA dated 3/2/26, the WVA indicated, Root cause analysis.29 lb/15 % wt loss x4 weeks since admit.During a review of Resident 1's WVA dated 3/9/26, the WVA indicated, Root cause analysis.36 lb/19% wt loss x 5 weeks since admit.During a review of Resident 1's WVA dated 3/16/26, the WVA indicated, Root cause analysis.37 lb/20% wt loss x 6 weeks since admit.During a review of Resident 1's WVA dated 3/30/26, the WVA indicated, Root cause analysis.38 lb/20% wt loss x 2 monoths [sic] since admit.During a concurrent interview and record review on 6/3/26 at 2:40 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 reviewed the weight committee binder notes. LVN 1 stated she was responsible for notifying the physician with a change of condition when there was a significant weight change. LVN 1 stated a significant weight loss was a loss or gain of 5% in 30 days, 7.5 % in 90 days and 10 % in 6 months. LVN 1 stated Resident 1 had experienced a significant weight loss from admit (1/31/26) up to 4/8/26 when her weight stabilized. LVN 1 stated at the time she was informing the physician of the weights weekly via a faxed list, but it was being sent to the wrong physician. LVN 1 stated when Resident 1 had a significant weight loss she did not complete a change of condition and she should have.During a concurrent interview and record review on 6/15/26 at 2:28 p.m. with Director of Nursing (DON), DON reviewed Resident 1's clinical record. DON was unable to provide evidence that a change of condition was completed to notify the physician of Resident 1's significant weight losses. DON stated that when Resident 1 had significant weight changes a change of condition should have been completed.During a review of the facility's policy and procedure (P&P) titled Change in a Resident's Condition or Status undated, the P&P indicated, The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-call Physician when there has been.a significant change in the resident's physical/emotional/mental condition.a significant change of condition is a decline or improvement in the resident's status that.will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions.impacts more than one area of the resident's health status.requires interdisciplinary review and/or revision to the care plan.During a review of the facility's policy and procedure (P&P) titled, Weight Assessment and Intervention undated, the P&P indicated, any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation.The threshold for significant unplanned and undesired weight loss will be based on the following criteria.1 month - 5% weight loss is significant; greater than 5 % is severe.3 months - 7.5% weight loss is significant; greater than 7.58 % is severe.6 months - 10% weight loss is significant; greater than 10% is severe.The physician and the multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss.

Based on interview and record review, the facility failed to:1. Develop a care plan when one of three sampled residents (Resident 1) experienced significant weight loss;2. Implement interventions when significant weight loss was identified for one of three sampled residents (Resident 1).These failures resulted in the potential for Resident 1 to have continued weight loss and unmet nutritional needs.Findings:1. During a review of Resident 1's IDT (Interdisciplinary Team-group of medical professionals from diverse specialties who work together to address a patient's complex needs) - Weight Variance Assessment (WVA) dated 2/16/26, the WVA indicated, Problem weight (lb-pound) -18 lbs.weight loss/gain (%) -9.6 %.in (x) number of weeks.2.Interventions/Implementations.Diet is liberalized for max (maximum) diet variety.(2/4) SLP (speech language pathologist) following for safest, least restrictive diet. Clear protein drink BID (twice a day).Appetite stimulant in place. Continue weekly NAR (nutritional at risk) monitoring.During a review of Resident 1's WVA dated 2/23/26, the WVA indicated, Root cause analysis.26 lb/13% wt. (weight) loss x 3 weeks since admit.Interventions/Implementations.Add magic cup (high-calorie, high-protein nutritional supplement) QD (every day) at lunch. Continue weekly NAR monitoring.During a review of Resident 1's WVA dated 3/2/26, the WVA indicated, Root cause analysis.29 lb/15 % wt loss x4 weeks since admit.Interventions/Implementations.Magic cup QD trialed but poorly accepted. Will d/c (discontinue) IV (intravenous administered through a vein) provided. Banatrol (medical food and dietary supplement used to naturally manage and thicken loose stools) in place for loose stools. Continue weekly NAR monitoring.During a review of Resident 1's WVA dated 3/9/26, the WVA indicated, Root cause analysis.36 lb/19% wt loss x 5 weeks since admit.interventions/Implementations.Care conference to discuss POC (plan of care) w/ (with) RP (responsible party). Continue weekly NAR monitoring.During a review of Resident 1's WVA dated 3/16/26, the WVA indicated, Root cause analysis.37 lb/20% wt loss x 6 weeks since admit.Interventions/Implementations.Continue weekly NAR monitoring.During a concurrent interview and record review on 6/16/26 at 9:24 a.m. with Assistant Director of Nursing (ADON), ADON reviewed Resident 1's clinical record. ADON was unable to provide evidence that a care plan was developed when Resident 1 experienced significant weight loss. ADON stated it was the responsibility of the weight committee to develop the care plan.2. During a review of Resident 1's WVA dated 3/9/26, the WVA indicated, Root cause analysis.36 lb/19% wt loss x 5 weeks since admit.interventions/Implementations.Care conference to discuss POC (plan of care) w/ (with) RP (responsible party).During an interview on 6/3/26 at 2:40 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated there was a care plan conference recommended to discuss Resident 1's weight loss with the responsible party on 3/9/26 but she did not know if the care plan conference was held.During an interview on 6/15/26 at 1:57 p.m., with Registered Dietitian (RD), RD stated it was his responsibility to complete the weight changes and report them at the weight committee meeting. RD stated it was the responsibility of LVN 1 to reach out to Social Services (SS) to coordinate the care plan conference with the responsible party and he would attend if he was available. RD stated he did not recall participating in a meeting or know if a care plan conference was held.During a concurrent interview and review of the clinical record for Resident 1on 6/15/26 at 2:28 p.m. with Director of Nursing (DON), DON reviewed Resident 1's clinical record. DON was unable to provide documentation for the care plan conference.During an interview on 6/15/26 at 2:49 p.m. with Social Service Assistant (SSA), SSA stated she was unaware of a care plan conference regarding Resident 1's significant weight loss needing to be scheduled with Resident 1's responsible party.During a review of the facility's policy and procedure (P&P) titled, Weight Assessment and Intervention undated, the P&P indicated, Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the Physician, nursing staff, the Dietitian, the Consultant Pharmacist, and the resident or resident's legal surrogate.Individualized care plans shall address, to the extent possible.the identified causes of weight loss; goals and benchmarks for improvement; and time frames and parameters for monitoring and reassessment.

Based on interview and record review, the facility failed to ensure physicians orders were followed when labs were not completed for one of three sampled residents (Resident 1). This failure resulted in a delay of care and Resident 1 experiencing lower abdomen (part of the body between the chest and pelvis) pain, requiring transfer to the hospital and being diagnosed with a urinary tract infection (UTI-infection in any part of your urinary system).Findings:During a review of Resident 1's Care Plan Report (CP) dated 2/2/26, the CP indicated, Bladder incontinence: (Resident name) has mixed bladder incontinence and is reflated to recent hospitalization, weakness.date initiated 2/2/26.interventions/tasks.labs per order. Notify physician of results.date initiated.2/2/26.During a review of the General Surgery Clinic Office Note (CSCON) dated 3/23/26, the CSCON indicated, Orders.Urinalysis (used to diagnose urinary tract infection), C/S (culture and sensitivity) if indicated.Iron Panel (group of blood tests that evaluate how much iron is circulating, moving, and stored in your body).H pylori (common bacteria that infects the lining of your stomach and the upper part of your small intestine) stool ag (antigen) (stool sample that checks for specific proteins released by H pylori bacteria).During a review of Resident 1's Progress Notes (PN) dated 3/23/26 at 3:30 p.m., the PN indicated, Resident came back from her app (appointment) with new orders for labs in 2 weeks.UA with C&S, H Pylory [sic].iron studies. Orders in place.During a review of Resident 1's Order Summary Report (OSR) dated 6/3/26, the OSR indicated, .UA with C&S/H pylory [sic].iron studies.Start date 4/2/26.During a review of Resident 1's PN dated 4/18/26 (16 days after the labs were ordered to be collected) at 4:30 a.m., the PN indicated, Resident had a large amount of dark red urine and had discomfort from spasms in her rectum. Resident says her lower abdomen comes and goes with pain.Recommendations.Send to ED (emergency department) for further evaluation.During a review of Resident 1's Imaging Report (IR) dated 4/18/26, the IR indicated, CT (computed tomography- x-ray procedure that takes slices of the body to help diagnose diseases or injuries) abdomen with intravenous (administered through the vein) contrast (substance used during imaging tests to highlight specific organs, blood vessels, or tissues).CT pelvis with intravenous contrast.indications.hematuria (blood in urine) today.Impression.Minimal right hydronephrosis (the swelling of one or both kidneys that occurs when urine cannot drain properly and builds up) without ureteral (carry urine from kidneys to bladder) calculi (stone like deposits that form inside the body), consider urinary tract infection.During a review of Resident 1's emergency room Note dated 4/18/26 at 6:42 a.m. reevaluated patient noted that patients Foley catheter (a thin tube inserted into the bladder to drain urine) containing gross blood, patient feels she has had a UTI for a while has made her facility aware, patient feels nothing has been done to address the UIT [sic].7:57 a.m. after a brief course of continuous bladder rogation [sic], patient's urine cleared completely without any complications. Patient received antibiotics for urinary tract infection.During a review of Resident 1's PN dated 4/20/26 at 2:33 p.m., the PN indicated, IDT (Interdisciplinary Team-group of medical professionals from diverse specialties who work together to address a patient's complex needs).On 4/18/26 resident was noted to have hematuria with suprapubic (above the pubic bone) pain noted. MD (Doctor of Medicine) notified and received order to send to ER (Emergency room) for evaluation and treatment. Resident returned from (hospital name) on 4/18/26 with dx (diagnosis).UTI (urinary tract infection). Received order for ciprofloxacin (antibiotic used to treat infection) .During an interview on 6/3/26 at 11:55 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated a couple of months ago she provided care to Resident 1 and there was blood in her urine. CNA 1stated she reported it to the nurse and the nurse wanted to get a urine sample, but she didn't know if it was ever collected.During a concurrent interview and record review, on 6/15/26 at 2:28 p.m. with Director of Nursing (DON), DON reviewed Resident 1's clinical record. DON was unable to provide evidence of the labs being completed as ordered. DON stated the labs were not completed and they should have been. During a review of the facility's policy and procedure (P&P) titled, Physician orders, accepting, transcribing and implementing (noting) undated, the P&P indicated, Licensed nursing personnel will ensure that telephone and verbal orders will be recorded and implemented.During a review of the facility's policy and procedure (P&P) titled, Lab and Diagnostic Test Results - Clinical Protocol dated 11/18, the P&P indicated, The physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs.the staff will process test requisitions and arrange for tests.

Based on observation, interview, and record review, the facility failed to provide nail care for one of four sampled residents (Resident 1). This failure resulted in Resident 1 having approximately one-inch fingernails and potential for nail disfigurement and accidental scratches, potentially leading to skin infections.Findings:During a concurrent observation and interview on 4/2/26 at 11:41 a.m. in Resident 1's room, Resident 1 was lying in bed with the head of bed elevated, watching on his personal laptop. Resident 1's right hand fingernails were approximately one inch long beyond fingertips. Resident 1's left hand was contracted (fingers permanently bent towards palm) with fingernails approximately one inch long beyond fingertips. Resident 1 stated he asked several staff members for his nails to be trimmed but no staff members ever returned to trim his fingernails.During a concurrent observation and interview on 4/2/26 at 11:45 a.m. with Certified Nursing Assistant (CNA), in Resident 1's room, CNA confirmed Resident 1's fingernails were long and should be trimmed.During an interview on 4/2/26 at 11:56 a.m. with Licensed Vocation Nurse (LVN) LVN stated nail care was provided daily, but Sundays were dedicated for staff to offer and trimmed residents nails. LVN was unable to provide documented evidence Resident 1 was offered nail care for the past one and half months.During an interview on 4/2/26 at 12:10 p.m. with Director of Nurses (DON), DON stated Resident 1's fingernails were too long and required trimming.During a review of Resident 1's care plan dated 7/21/25 indicated Resident 1 had ADL (Activities Daily Living): Function-Self Deficit: Dependent on staff for bathing, personal hygiene, dressing, grooming . During a review of the facility policy and procedures (P&P) titled, Activities of Daily Living (ADL), Supporting, dated 3/2018, the P&P indicated, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

Based on observation, interview, and record review, the facility failed to ensure that pain management interventions were safely implemented and monitored for one of thirty sampled residents (Resident 71). Specifically, licensed nurses failed to appropriately monitor and reassess the resident following administration of prescribed opioid pain medication (morphine sulfate) and failed to identify and respond to adverse effects related to pain treatment. As a result of these failures, Resident 71 experienced opioid-induced over-sedation and respiratory depression, requiring emergency transfer to a general acute care hospital (GACH), treatment for opioid overdose including administration of Narcan (reverses opioid overdose), intubation (insertion of a tube to aid in breathing) for respiratory support, and a seven-day hospitalization beginning 12/12/25. This resulted in actual harm to the resident.Findings:During a concurrent observation and interview on 1/15/26 at 8:41 a.m., with Resident 71, in her room, Resident 71 was lying in bed, receiving two liters (unit of measure) of oxygen via nasal cannula (plastic tube delivering oxygen). Resident 71, who was alert and oriented, stated she was taking morphine medication at times because she had severe left shoulder blade pain. Resident 71 also stated she did not remember why she went to the hospital on [DATE], but her son told her she had slept for three days. During a review of Resident 71's admission Record, the admission Record indicated Resident 71 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD, a condition caused by damage to the airways or other parts of the lung and fibromyalgia (chronic condition causing widespread musculoskeletal pain, fatigue, sleep problems, and cognitive difficulties).During a review of Resident 71's Nursing Progress Notes (NPN), written by LVN 3, dated 12/11/25, the NPN indicated, on 12/11/25 at 7:35 a.m., Resident 71 went out on a leave of absence to an appointment. Resident 71 was transported in facility van along with staff. Resident was in good spirits and is in stable condition. Resident 71 complained of pain before leaving and PRN (as needed) morphine was administered.During a review of Resident 71's Nursing Progress Notes (NPN), written by LVN 3, the NPN indicated on 12/11/25 at 10:40 a.m., Resident 71 returned to the facility after not receiving care and services at her ophthalmology appointment because she was over-sedated on arrival. Resident 17's physician was notified of Resident 71's status, and he changed the morphine order to oral tablet 15 mg, give 0.5 (7.5mg) tablet by mouth every 12 hours as needed for moderate to severe pain. Upon returning to the facility, Resident 71 refused all scheduled medications. During a review of Resident 71's Medication Administration Record (MAR), dated 12/11/25, the MAR indicated Resident 71 refused her scheduled medications at 1 p.m., 2 p.m., 8 p.m., and 9 p.m. During a review of Resident 71's Nursing Progress Notes (NPN), dated 12/12/25, the NPN indicated on 12/12/25 at 2:56 a.m., Resident 71 had a change in condition. Resident 71 began throwing up green liquid repeatedly and it was hard to arouse Resident 71. Resident 71's physician was notified and ordered her to be transferred to GACH for evaluation. During a review of Resident 71's GACH Progress Notes, dated 12/12/25, the GACH PN indicated, on admission, per Emergency Medical Services (EMS), Resident 71 had pinpoint pupils for which she was given 1 dose of Narcan (reverses opioid overdose). Resident 71 was on high doses of morphine that may have caused the opioid induced respiratory depression. The GACH PN, indicated In setting of opioid induced acute encephalopathy [brain dysfunction], she aspirated [inhaled] sputum. Do not send patient home on same pain regimen as on admission given her presentation concerning for opioid overdose requiring intubation (insertion of a tube to aid in breathing). During an interview on 1/15/26 at 9:44 a.m., with LVN 3, who was Resident 71's assigned nurse on 12/11/25, LVN 3 stated she did not monitor Resident 71 for sedation (morphine adverse effects) on 12/11/25 when she returned to the facility from her medical appointment. LVN 3 stated Resident 71 was sedated the rest of her shift, and that Resident 71 refused her scheduled medications because she was so sedated. During a review of Resident 71's Order Summary Report, (OSR), the OSR, dated 12/5/25, indicated an order since 6/3/25 for morphine 15 mg (milligram-unit of measure) one tab every four (4) hours as needed for moderate to severe pain (level 4-9), hold if respirations less than 12 and/or oxygen saturation less than 90%.During a concurrent interview and record review on 1/15/26 at 10:06 a.m., with the Assistant Director of Nursing (ADON), Resident 71's Medication Administration Record (MAR) indicated Resident 71 received a morphine 15 mg tablet on 12/11/25 at the following times:a. 4 a.m.b. 7:19 a.m. (41 minutes early)ADON stated the second dose should have been administered every four hours as needed, and as a result the second dose of morphine was given too early.During Resident 71's medical record review, ADON confirmed Resident 71 was over sedated when she returned to the facility from her ophthalmology appointment on 12/11/25 at 10:40 a.m. ADON was unable to locate documented evidence to show the licensed nurses monitored Resident 71 for over sedation (a change in condition) starting on 12/11/25, upon her return to the facility. ADON confirmed Resident 71 was repeatedly vomiting green liquid, and she was hard to arouse on 12/12/25 at approximately 3 a.m. ADON stated the licensed nurses identified a change in Resident 71's condition at that time, and she was transferred to the GACH for evaluation. During an interview on 1/15/26 at 11:13 a.m., with the Director of Nursing (DON), the DON stated that licensed nurses should have implemented the facility's policies and procedures (P&P) for Administering Pain Medication and Change in a Resident's Condition or Status on 12/11/25 when Resident 71 returned to the facility over sedated from the 12/11/25 at 7:19 a.m. morphine administration. The DON stated there should have been monitoring to prevent adverse reactions (morphine black box warning) sedation, respiratory depression, coma, and death.During an interview on 1/15/26 at 11:55 a.m., with Pharmacy Consultant (PC), the PC stated monitoring for morphine adverse effects was a nursing measure. The PC stated licensed nurses should monitor residents receiving morphine for adverse reactions sedation, respiratory depression, coma, and death.During a review of the facility policy titled Administering Pain Medication, dated 4/2025, the policy indicated .When opioids are used for pain management, the resident is monitored for medication effectiveness, adverse effects, and potential overdose. a. Any resident who uses opioids for long-term management of chronic pain is at risk for opioid overdose .Administer pain medication as ordered .During a review of the facility policy titled Change in a Resident's Condition or Status, dated 2/2021, the policy indicated .The nurse will notify the resident's attending physician.when .adverse reaction to medication .The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition .

Based on observation, interview, and record review, the facility did not comply with its policy for securely disposing of controlled medications on two of four medication carts. This failure poses a risk of diversion, where legally prescribed controlled substances could be transferred to individuals other than those for whom they were prescribed for illegal use.Findings:During a concurrent observation and interview on 1/13/26 at 2:48 p.m., with Licensed Vocational Nurse (LVN) 3, the bottom drawer of the South 1 Medication Cart contained a pharmaceutical waste container with a removable lid. The pharmaceutical waste container contained multiple intact pills. LVN 3 stated that there were multiple medications in the container which included any wasted medications including narcotics. LVN 3 stated if a narcotic was not given in an event the resident refused, or if the medication was dropped on the floor, she would discard the narcotic in the waste container after verifying with another nurse.During a concurrent observation and interview on 1/13/26 at 2:58 p.m., with LVN 4, the bottom of the North 2 Medication Cart contained a pharmaceutical waste container with a removable lid. The pharmaceutical waste container contained multiple intact pills. LVN 4 stated that there were multiple medications in the container which included any wasted medications including narcotics. LVN 4 stated if a narcotic was not given in an event the resident refused, or if the medication was dropped, she would discard the narcotic in the waste container after verifying with another nurse. LVN 4 also stated she would take the full pharmaceutical waste container to the biohazard room.During an interview on 1/14/25 at 9:09 a.m., with the Pharmacy Consultant (PC), the PC stated when a narcotic medication was wasted, the Licensed Nurses would dispose of the medication with other non-controlled medications in the pharmaceutical waste container with a removable lid. The PC stated if a staff member wanted to take medication out of the container they could and that there could be a safer way to discard narcotics to reduce the risk. During a concurrent observation and interview on 1/14/26 at 9:26 a.m. with the Director of Nurses (DON), South 1 and North 2 Medication Carts were observed. The DON opened the removable lid of the pharmaceutical waste container and stated there was a risk for diversion. The DON validated that both containers contained multiple intact medications.During a review of the facility policy and procedure (P&P) titled, Disposal of Medications and Medication-Related Supplies, dated 2019, the P&P indicated, .Controlled substances are retained in a securely locked area with restricted access until destroyed by Director of Nursing and Consultant Pharmacist. Controlled medications given to the Director of Nursing for destruction shall be recorded in a perpetual inventory log.non-controlled medications destruction occurs only in the presence of (two) individuals .

Based on observation, interview, and record review, the facility failed to implement appropriate infection control measures when:1. Resident 57's oxygen humidifier bottle was not changed weekly. 2. Clean linen and clean diapers were stored on the floor in a resident's room.3. Certified Nursing Assistant (CNA) 2 did not wash her hands before and after resident care in room [ROOM NUMBER]. These failures could contribute to the spread of infectious diseases among residents, staff, and visitors. Findings: 1. During a review of Resident 57's admission Record (AR), the AR indicated Resident 57 was admitted to the facility on [DATE] with diagnoses that included shortness of breath. During an observation on 1/12/26 at 2:05 p.m., in Resident 57's room, Resident 57 was receiving two liters of oxygen via a nasal canula (flexible plastic tube). The oxygen humidifier bottle was dated 12/28/25. During an interview on 1/12/26 at 4:16 p.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated Resident 57's oxygen humidifier bottle was dated 12/28/25 and should have been changed weekly. During a concurrent interview and record review on 1/14/26 at 10:00 a.m., with the Infection Preventionist (IP) the policy and procedure titled, Respiratory Therapy-Prevention of Infection, dated 11/2011, the policy indicated, .The purpose of this procedure is to guide prevention of infection associated with respiratory therapy .Use distilled water humidification per facility protocol .Mark bottle with date upon opening and discard according to the MD orders . The IP stated the humidifier should be changed weekly to prevent infection and ensure sufficient water was in the bottle. 2. During a concurrent observation and interview on 1/13/26 at 8:58 p.m. with Licensed Vocational Nurse (LVN) 1 and Certified Nurse Assistant (CNA) 1, one bag of clean linen and clean diapers were observed on the floor in resident's room. LVN 1 stated clean linen, and clean diapers should not be on the stored on the floor. CNA 1 stated she should not have left the clean linen and clean diapers on the floor. During a review of the facility's policy and procedure (P&P) titled, Departmental (Environmental Services) - Laundry and Linen, version 2.2(H5MAPR0097) undated, indicated under 7. 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 . 3. During a concurrent observation and interview on 1/13/26 at 10:10 p.m., with Certified Nurse Assistant 2 (CNA 2), CNA 2 was observed entering and exiting room [ROOM NUMBER] to respond to a call light. CNA 2 did not perform handwashing before entering and exiting the resident's room. CNA 2 confirmed she was in the resident's room to perform bedside care and stated she should have performed handwashing before entering and exiting the resident's room. During a review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene dated October 2023, indicated, 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. Indications: Hand hygiene is indicated:a. immediately before touching a residentd. after touching a residente. after touching the resident's environmentg. immediately after glove removal

Based on observation, interview, and record review, the facility failed to meet professional standards of quality for two of thirty sampled residents (Resident 51 and Resident 98) when Licensed Vocational Nurse (LVN) 2 did not follow the policy and procedure titled, Insulin Pen Administration. This failure placed Resident 51 and Resident 98 at risk for insulin dosing errors and had the potential to result in adverse side effects such as hypoglycemia or hyperglycemia.Findings:1.During a review of Resident 51's admission Record, indicated Resident 51 had diagnoses which included Type 2 Diabetes (body's inability to produce enough insulin).During a review of Resident 51's Physician Order (PO), dated 12/5/25, the PO indicated, Insulin Lispro (fast acting insulin]) inject as per sliding scale before meals.During medication pass observation on 1/14/26 at 11:13 a.m., LVN 2 administered Lispro 4 units (unit of measurement) SQ (subcutaneous injection given in the fatty tissue, just under the skin) to Resident 51 using an insulin pen. LVN 2 did not prime (remove bubbles from the needle) the insulin pen before administering the insulin to Resident 51. 2. During a review of Resident 98's admission Record, indicated Resident 98 had diagnoses which included Type 2 Diabetes (body's inability to produce enough insulin).During a review of Resident 98's Physician Order (PO), dated 12/5/25, the PO indicated, Insulin Lispro inject as per sliding scale before meals.During medication pass observation and interview on 1/14/26 at 11:24 a.m., LVN 2 administered Lispro 4 units SQ to Resident 98 using an insulin pen. LVN 2 did not prime the insulin pen before administering the insulin to Resident 98. LVN 2 inaccurately described the process of priming the insulin pen.During a concurrent interview and record review on 1/15/26 at 11:32 a.m. with the Director of Nursing (DON) the facility policy and procedure titled, Insulin Pen Administration, dated 2019 was reviewed. The policy indicated .To provide for the safe and accurate administration of Insulin Pen medications .Before each injection, do a safety test as follows:a. Turn dose selector to select 2 unitsb. Hold insulin pen upright, tap the cartridge gently a few times.c. Press the push-button all the way ind. The dose selector returns to 0 .The DON stated the insulin pen should be primed before each use to ensure the resident does not receive too much or too little insulin.

Based on observation, interview, and record review, the facility did not adhere to its policy and procedures for one of the 30 sampled residents (Resident 57) when:Resident 57's fingernails and toenails were not trimmed.Resident 57 had untreated lacerations on the right great toe of unknown origin.The physician was not informed about the resident's change in condition.These failures resulted in substandard quality of care for Resident 57.Findings:During a review of Resident 57's admission Record, the admission Record indicated Resident 57 was admitted to the facility on [DATE], with diagnoses of Parkinsonism (neurological disorder that cause movement problems), muscle weakness and dependence on wheelchair.During a concurrent observation and interview on 1/12/26 at 2:21 p.m., with Resident 57, in Resident 57's room, Resident 57 was lying in bed with his feet exposed. Resident 57 had untrimmed fingernails and toenails. Resident 57's inner area of the right great toe had three scabs (forms over a cut or wound during healing) Resident 57, who was alert and oriented, stated about a week ago when he was transferred from his bed, his left foot nail dug into his right great toe causing a cut. Resident 57 stated licensed nurses did not treat his cut. Resident 57 also stated his nails were too long, and he wished for somebody to cut his nails.During a concurrent observation and interview on 1/14/26 at 10:29 a.m., with Licensed Vocational Nurse (LVN) 5, in Resident 57's room, Resident 57 was lying in bed with his feet exposed. LVN 5 confirmed Resident 57 fingernails and toenails were untrimmed. LVN 5 confirmed Resident 57's inner right great toe had scabs. LVN 5 stated he was unaware of Resident 57's injury of unknow origin prior to the current observation and there was no treatment ordered. LVN 5 stated that Resident 57's untrimmed toenails and movement disorder could have caused the injury of unknown origin. LVN 5 also stated it was the Certified Nurse Assistants (CNA) responsibility to trim fingernails, and toenails should have been trimmed by podiatry services.During a review of Resident 57's physician current orders for 1/2026, the physician orders indicated, Podiatry care for nail treatment as indicated.During an interview on 1/14/26 at 10:42 a.m., with Social Worker (SW), SW stated the process of scheduling podiatry was for licensed nurses to verbally tell her or place note in her in-box. SW stated that she was not informed by the LVNs that Resident 57 needed podiatry services.During an interview on 1/15/26 at 11:33 a.m., with the Director of Nursing (DON), the DON stated it was CNAs responsibility to trim resident fingernails and podiatry services trim toenails. The DON stated while staff were providing care they should do skin assessments. The DON stated there should have been a change in condition completed and physician notification to monitor and treat Resident 57's right great toe laceration.During a review of the facility policy and procedure titled, Fingernails/Toenails, Care of, dated February 2018. The policy indicated, .The purpose of this procedure is to clean the nail bed, to keep nails trimmed, and to prevent infections .Nail care includes daily cleaning and regular trimming .Proper nail care can aid in the prevention of skin problems around the nail bed .Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin .During a review of the facility policy and procedure titled, Podiatry Services undated. The policy indicated, .to ensure residents receive proper treatment and care .Employees should refer any identified need for foot care to the social worker or designer .During a review of the facility policy and procedure titled, Change in a Resident's Condition or Status, dated February 2021. The policy indicated, .Our facility notifies the resident .attending physician .where there has been .accident or incident involving the resident .discovery of injuries of an unknown source .

Based on observation, interview, and record review, the facility failed to ensure a sanitary environment when one soiled dish towel was placed on the surface of a table tray that contained clean cups. This failure had the potential to result in cross-contamination.Findings: During a concurrent observation and interview on 1/12/26 at 2:25 p.m., with the Dietician in the kitchen, one soiled dish towel was observed on the surface of a table tray that contained clean cups. The Dietitian stated the soiled dish towel should have been disposed of in the soiled linen container. During a review of the facility's policy and procedure (P&P) titled, Sanitation Section 8, dated 2023, the P&P indicated,16. Kitchen staff is responsible for all the cleaning with the exception of ceiling vents, light fixtures and the hood over stove, which will be cleaned by the maintenance staff.22. Do not use cleaning products or sanitizers in the food preparation or food storage areas in any way that could result in contamination of exposed food items. This includes spraying or pouring cleaning products near food items during preparation or cooking.

Based on interview and record review, the facility failed to ensure the physician's order was followed for one of three sampled residents (Resident 1). This failure resulted in the physician's order being incorrect and the potential for Resident 1's wound to worsen.Findings:During a review of Resident 1's Progress Notes Details (PND-completed by the wound doctor) dated 12/4/25, the PND indicated, Wound #2 right shin is a vascular wounds [sic] and has received a status of not healed.Wound Care Orders.Cleanse wound with ns (normal saline), pat dry, apply Dakin's (antiseptic [substance used to prevent the growth of disease-causing organisms] used to clean skin and infected chronic wounds) flush with betadine to eschar qd (everyday) and prn (as needed).During a review of Resident 1's Order Summary Report (OSR) undated, the OSR indicated, venous wound (chronic, shallow and slow-healing open sore) to right lower leg; cleanse area with wound cleanser, pat dry, betadine (antiseptic used to kill bacteria) soaked gauze to wound bed, cover with dry dressing, wrap with kerlex [sic], QD (every day) or PRN (as needed) if soiled or falls off, notify MD (doctor of medicine) of any changes.start date 11/26/25. The treatment order was not updated with the new order received on 12/4/25.During a concurrent interview and record review on 1/28/26 at 10:23 a.m. with Assistant Director of Nursing (ADON), Resident 1's clinical record was reviewed. ADON was unable to provide evidence of the 12/4/25 treatment order being implemented. ADON stated the treatment order for the venous wound to the right lower leg was not updated with the new order on 12/4/25 and it should have been. During a review of the facility's policy and procedure (P&P) titled Medication Orders dated 11/2014, the P&P indicated, A current list of orders must be maintained in the clinical record of each resident.treatment orders-when recording treatment orders, specify the treatment, frequency and duration of the treatment.

Based on observation, interview, and record review, the facility failed to provide care and services for one of three sampled residents (Resident 1) who was high risk for falls, had history of falls, and had a diagnosis of Dementia (decline in memory and thinking, severe enough to interfere with daily life) when Resident 1 was left waiting in the room to be toileted for approximately 30 minutes. This failure resulted in Resident 1 falling, sustaining laceration (cut) to the top of the head requiring three staples (little wire), and compression fracture (a type of broken bone that can cause the spine to collapse) of T (thoracic- middle section of spine) 5 (T5- is the fifth bone of the thoracic spine located in the middle of the back). Findings: During a review of Resident 1 ' s Admission Record (AR), dated 4/8/25, the AR indicated, Resident 1 was initially admitted on [DATE]. The AR indicated, Diagnosis. Repeated Falls.Muscle Weakness.Dementia. During a review of Resident 1 ' s annual Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 2/17/25, the MDS indicated Resident 1 had a BIMS (Brief Interview for Metal Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 6 (0-7 severely impaired [decline in one or more mental abilities that affects a person ' s daily functioning]). The MDS section GG-Functional Abilities (a person ' s capacity to perform everyday activities) F. Toilet transfer: The ability to get on and off a toilet or commode (furniture shaped like a chair). indicated Resident 1 was 01. Dependent-Helper does ALL the effort, Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. During a review of Residents 1 ' s Post Fall Review (PFR-assessment after a fall to identify factors contributing to the fall to determine the necessary course of care), dated 6/15/24, 7/5/24, 7/26/24, 2/24/25, 3/1/25 and 3/30/25, the PFR ' s indicated Resident 1 was High Risk for falls. During a review of Resident 1 ' s Care Plan ([current] CP) titled, Falls date initiated 5/24/24, the CP indicated, Resident 1 had 6/15/24 un-witness fall, 7/5/24 un-witness fall, 7/25/24 un-witness fall, 7/26/24 un-witness fall, 2/24/25 un-witness fall, 3/1/25 un-witness fall, 3/30/25 un-witness fall. Resident 1 ' s CP titled, ADL (Activities of Daily Living)/Mobility dated 2/18/25 indicated, Resident 1 has actual at risk for ADL/mobility decline and requires assistance related to cognitive impairment, fluctuating (constant changing) ADLs, medical conditions, weakness. Goal included Will have needs anticipated and met by staff. Intervention included, Toileting: Assist of total dependence. During a review of Resident 1 ' s Change of Condition (COC) dated 3/30/25 at 6:24 p.m., the COC indicated, .resident (Resident 1) had fallen while she was attempting to use the bathroom.sent out (acute hospital) due to having neck and back pain along with the bleeding that was coming from her head. During a review of the facility investigative report titled, Facility Reported Event (FRE), undated, the FRE indicated, on 3/30/25 at 5:20 p.m. Resident 1 had an unwitnessed fall in her bathroom. The FRE indicated a full investigation was completed and indicated at approximately 4:40 p.m. Resident 1 had asked for help to be taken to the bathroom by Certified Nursing Assistant (CNA 3). At approximately 5:10 p.m. (30 minutes later) CNAs nearby heard a noise and found Resident 1 on the bathroom floor. During a concurrent observation and interview on 4/8/25 at 1:47 p.m. with Resident 1, Resident 1 was noted lying in bed. Resident 1 stated on 3/30/25 I had to pee, but nobody came.I told a couple of people I had to pee, and they walked in and left.I took myself to the bathroom because no one came when I scream and holler. I fell out. I have three staples on my head. It feels like I broke everything. During an interview on 4/8/25 at 1:57 p.m. with Licensed Vocational Nurse (LVN), LVN 1 stated Resident 1 was admitted to the acute hospital (3/30/25) for observation and readmitted to the facility on [DATE] with three staples on top of the head, with T5 compression fracture (broken bone) and a back brace (a device fitted to something, in particular a weak or injured part of the body, to give support). During an interview on 4/8/25 at 2:05 p.m. with Certified Nursing Assistant (CNA 1), CNA 1 stated Resident 1 was alert with confusion (lack of understanding). CNA 1 stated Resident 1 had a history of falling and required assistance (total) in toileting. During an interview on 4/8/25 at 2:09 p.m. with LVN 2, LVN 2 stated on 3/30/25 at approximately 5:30 p.m., Resident 1 had slipped and fell while taking herself to the bathroom. LVN 2 stated Resident 1 was found lying on the bathroom floor up against the wall, bleeding from her head. LVN 2 stated Resident 1 was sent to the acute hospital (3/30/25) and stated the fall and fracture could have been prevented if Resident 1 was assisted right away to the toilet. LVN 2 stated right away is within two minutes. During an interview on 4/8/25 at 2:18 p.m. with CNA 2, CNA 2 stated on 3/30/25 during dinner time, she heard Resident 1 yelling. CNA 2 stated Resident 1 was found on the floor in the bathroom with her pants down. CNA 2 stated, It looked like she (Resident 1) tried to go use the bathroom. CNA 2 stated Resident 1 was a fall risk and required assistance for toileting. CNA 2 stated the fall could have been prevented if Resident 1 was taken to the bathroom. During a concurrent interview and record review on 4/8/25 at 4 p.m. with Director of Nurses (DON), the FRE was reviewed. DON stated on 3/30/25 at 5:20 p.m. Resident 1 had an unwitnessed fall in the bathroom. DON confirmed Resident 1 was left waiting to be assisted to the bathroom for approximately 30 minutes. DON stated 30 minutes was a long time to wait for assistance. During an interview on 4/10/25 at 2:10 p.m. with CNA 3, CNA 3 stated on 3/30/25 at approximately 4:40 p.m. Resident 1 requested to be taken to the bathroom. CNA 3 stated he left Resident 1 in the room without assisting Resident 1 to the bathroom. CNA 3 stated at approximately 5:10 p.m. (30 minutes later) Resident 1 was heard yelling and was found on the bathroom floor. CNA 3 stated Resident 1 was a high fall risk for falls and cannot take herself to the bathroom. CNA 3 stated the fall could have been prevented if Resident 1 was taken to the bathroom right away. During a review of acute hospital Resident 1 ' s Emergency Department (ED) note, dated 3/30/25 at 7:22 p.m., the ED note indicated, Chief Complaint.unwitnessed fall from (facility name) . staff heard fall and checked on her. Neck pain, back pain, left thumb swelling, lac (laceration) to head. Attempted to self-transfer to bathroom. During a review of Resident 1 ' s MRI (Magnetic resonance imaging-test that produces detailed images including bones), dated 3/31/25 at 11:12 a.m., the MRI result indicated, acute (recent) compression fracture of T5. During a review of the facility ' s policy and procedure (P&P) titled, Activities of Daily Living (ADL), Supporting, dated 3/18, the P&P indicated, 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: .c. elimination (toileting).

null Based on observation, interview, and record review, the facility failed to implement the care plan (CP) for two of two sampled residents (Resident 6 and Resident 7) on Falling Star Program (fall prevention program) when:1. The call light, the remote control, and water pitcher were not within one of one sampled resident's (Resident 6) reach.2. The bowel and bladder (toileting) program every two hours was not implemented for one of one sampled resident's (Resident 7).These failures had the potential to place Resident 6 and Resident 7 at a greater fall risk. Findings:1. During a concurrent observation and interview on 6/17/25 at 10:10 am, in Resident 6's room with Assistant Director of Nursing (ADON), there was a gold star on Resident 6's name plate by the entry door. Resident 6 was in bed. Resident 6's call light and remote control were on the floor. The water pitcher was on the over bed table out of Resident 6's reach. ADON stated, I seeDuring a concurrent observation and interview on 6/17/25, at 10:25 am, in Resident 6's room with Certified Nursing Assistant (CNA) 4, Resident 6 was in bed. Resident 6's call light and remote control were on the floor. The water pitcher was on the over bed table out of Resident 6's reach. CNA 4 stated, I don't know why the call light and remote control are on the floor. The table needs to be near him [Resident 6] because he needs the water. He [Resident 6] cannot see well.During an interview on 6/17/25, at 11:03 am, with the Director of Nursing (DON), DON stated each station has a Falling Star Program binder with the list of residents' names that had two falls in the last 30 days on the outer cover. DON stated, The updated care plan for each resident is posted in the binder for all the staff to focus on.During a concurrent interview and record review on 6/17/25, at 2:50 pm, with ADON, Resident 6's CP was reviewed, the CP indicated, Focus Falls: Resident [6] had an unwitnessed fall and is at risk for pain, recurring falls. Goal Will be compliant with fall interventions to reduce risk for additional falls. Date initiated: 2/28/2024 Revision on: 02/11/2025 Target Date: 08/17/2025. Will minimize risk for additional falls to the extent possible. Date Initiated: 2/28/2024 Revision on: 02/11/2025 Target Date: 08/17/2025 . Keep call light within reach. Date Initiated: 02/28/2024Keep personal items frequently used within reach. Date initiated: 02/28/2024ADON stated, I know, saw that.2. During a concurrent observation and interview on 6/17/25, at 9:50 am, with DON, in Resident 7's room, there was a gold star on Resident 7's name plate by the entry door. Resident 7 was not in the room. DON stated, [Resident 7] is in the activity room. DON stated, [Resident 7] is on falling star program.During a concurrent observation and interview on 6/17/25, at 3:20 p.m., in Resident 7's room with CNA 5, Resident 7 was not in his bed and stated, [Resident 7] may be in the rest room. CNA 5 stated, [Resident 7] is not on toileting bowel and bladder program every 2 hours.During a concurrent interview and record review on 6/17/25, at 3:56 pm, with ADON, Resident 7's CP was reviewed, the CP indicated Focus Fall: Resident had an unwitnessed fall and is at risk for injury. 5/8/25, Resident 7 had an unwitnessed fall no injury. Goal Will minimize for additional falls to the extent possible date initiated: 04/29/2025 Target date: 07/21/2025. Interventions/Tasks . Bowel and Bladder Q [every] 2H [hours] Date Initiated: 05/09/2025. ADON was unable to find documentation of bowel and bladder every two hours. DON stated, I cannot find it.

Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was scheduled and on duty eight hours a day, seven days a week. This failure had the potential for resident care to be negatively impacted. Findings: During a concurrent interview and record review on 1/8/25 at 9:09 a.m. with Director of Staff Development (DSD), the Nursing Staff Assignment and Sign-in Sheet (NSASS) dated July 2024 was reviewed. The NSASS indicated, there was no RN for 8 hours a day on 7/1/24, 7/2/24, 7/3/24, 7/4/24, and 7/5/24. DSD stated there was not an RN on duty for 8 hours a day on those days. During a concurrent interview and record review on 1/8/25 at 11:07 a.m. with DSD, the NSASS dated August 2024 was reviewed. The NSASS indicated, there was no RN for 8 hours a day on 8/5/24, 8/6/24, 8/7/24, 8/8/24, and 8/9/24. DSD stated there was not an RN on duty for 8 hours a day on those days. During a concurrent interview and record review on 1/8/25 at 11:50 a.m. with DSD, the NSASS dated September 2024 was reviewed. The NSASS indicated, there was no RN for 8 hours a day on 9/2/24, 9/3/24, 9/4/24, 9/5/24, 9/6/24, and 9/30/24. DSD stated there was no RN on duty for 8 hours a day on those days. During a concurrent interview and record review on 1/8/25 at 11:55 a.m. with DSD, the NSASS dated October 2024 was reviewed. The NSASS indicated, there was no RN for 8 hours a day on 10/1/24, 10/2/24, 10/3/24, and 10/4/24. DSD stated there was no RN on duty for 8 hours a day on those days. During a concurrent interview and record review on 1/8/25 at 12:05 p.m. with DSD, the NSASS dated November 2024 was reviewed. The NSASS indicated, there was no RN for 8 hours a day on 11/4/24, 11/5/24, 11/6/24, and 11/8/24. DSD stated there was no RN on duty for 8 hours a day on those days. During a concurrent interview and record review on 1/8/25 at 12:10 p.m. with DSD, the NSASS dated December 2024 was reviewed. The NSASS indicated, there was no RN for 8 hours a day on 12/2/24, 12/3/24, 12/4/24, 12/5/24, 12/6/24, 12/30/24, and 12/31/24. DSD stated there was no RN on duty for 8 hours a day on those days. During a concurrent interview and record review on 1/8/25 at 12:15 p.m. with DSD, the NSASS dated January 2025 was reviewed. The NSASS indicated, there was no RN for 8 hours a day on 1/1/25, 1/2/25, and 1/3/25. DSD stated there was no RN on duty for 8 hours a day on those days. During a review of the facility's policy and procedure (P&P) titled, Staffing, Sufficient and Competent Nursing, 8/2022, the P&P indicated, A registered nurse provides services at least (8) consecutive hours every 24 hours, seven (7) days a week.

Based on interview and record review, the facility failed to ensure the resident's representative and the state long term care ombudsman (representatives who assist residents in long-term care facilities with issues related to day-to day care, health, safety, and personal preferences) were notified, in writing, when two of seven sampled residents (Resident 52 and Resident 82) were transferred to the hospital. This failure resulted in the resident representative and the ombudsman to not be aware of resident's healthcare status and location. Findings: During an interview on 1/7/25 at 2:37 p.m. with Resident 52, Resident 52 stated he had been to the hospital several times because of his diabetes (disorder characterized by difficulty in blood sugar control and poor wound healing) and high blood pressure. During a concurrent interview and record review on 1/8/25 at 3:36 p.m. with Minimum Data Set (MDS - a federally mandated resident assessment tool) Consultant (MDSCL), Resident 52's medical record was reviewed. MDSCL stated Resident 52 was transferred to the hospital on 3/27/24 for GI [Gastro (stomach)-intestinal) bleeding and nausea and vomiting. Resident 52's History & Physical (H&P) dated 4/12/24 indicated, Resident 52 was discharged from the hospital and readmitted to the facility with a diagnosis of GI bleed. MDSCL stated Resident 52's family member was not notified because the nurse listed Resident 52 as his own representative. Resident 52's Admission Record was reviewed. MDSCL stated Resident 52's family member was listed as his Responsible Party (RP) and should have been notified. MDSCL stated Resident 52 was transferred to the hospital on 10/9/24 due to a fall but his family member was not notified because the Voicemail box was full. The facility H&P dated 10/11/24 indicated, Resident 52 was discharged from the hospital and readmitted to the facility with diagnoses of altered mental status, chronic kidney disease, high blood acid levels, high levels of potassium in his blood. During an interview on 1/8/25 at 4:01 p.m. with Social Services Designee (SSD), SSD stated she did not notify RPs in writing when residents were transferred to the hospital, and she did not send notification to the ombudsman when a resident was discharged /transferred to the hospital. 46958 During a review of Resident 82's, Transfer Form (TF), dated 11/12/24, the TF indicated, Resident 82 was transferred to the hospital on 11/12/24. During an interview on 1/9/25 at 9 a.m. with SSD, SSD stated she did not notify the ombudsman about Resident 82's transfer to the hospital. During a review of the facility's policy and procedure (P&P) titled, Transfer or Discharge, Facility-Initiated, dated 10/2022, the P&P indicated, Once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy . 1. When a resident is transferred or discharged from the facility, the following information is documented . b. That an appropriate notice was provided to the resident and/or legal representative . 3. A copy of the notice is sent to the office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative.

Based on observation, interview and record review, the facility failed to ensure individualized, person-centered care plans were developed and implemented for three of six residents (Resident 46, Resident 52, and Resident 79). This failure had the potential for care needs to not be met. Findings: a. During an observation on 1/7/25 at 10:41 a.m. in Resident 46's room, Resident 46 was in her wheelchair, and she was speaking in short clips of gibberish with no discernable words. During an interview on 1/8/25 at 3:46 p.m. with Certified Nursing Assistant (CNA) 6, CNA 6 stated she can understand Resident 46's needs from having cared for her for the past year. During a concurrent interview and record review on 1/8/25 3:36 p.m. with Minimum Data Set (MDS - a federally mandated resident assessment tool) Consultant (MDSCL), Resident 52's medical record was reviewed. MDSCL stated Resident 52 was transferred to the hospital on 3/27/24 for GI [gastro (stomach)-intestinal] bleeding and nausea and vomiting. Resident 52's History & Physical (H&P) dated 4/12/24 indicated Resident 52 was discharged from the hospital and readmitted to the facility with a diagnosis of GI bleed. MDSCL was not able to find a care plan for GI bleeding. b. During a concurrent interview and record review on 1/9/25 at 10:41 a.m. with MDSCL, Resident 79's medical record was reviewed. The Bowel and Bladder Observation/assessment dated [DATE] indicated, Incontinence [inability to control bladder and/or bowel] Assessment 1. Length of incontinence 1. Days and 3. Needs assistance getting to toilet. MDS Section H indicated, Urinary continence 3. Always incontinent and Bowel Continence 3. Always incontinent. MDSCL stated she was unable to find a care plan for incontinence. c. During a concurrent interview and record review on 1/9/25 at 2:11 p.m. with MDSCL, Resident 46's medical record was reviewed. The Minimum Data Set (MDS- Assessment tool) Section B indicated, Speech Clarity 1. Unclear speech. Makes Self Understood 3. Rarely/never understood. MDSCL stated she was unable to find a care plan for a speech deficit. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, 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 . 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making . 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition, b. when the desired outcome is not met, c. when the resident has been readmitted to the facility from a hospital stay.

Based on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Anti-coagulation [medication used to thin blood] Clinical Protocol to monitor for possible complications for two of two sampled residents (Resident 10 and Resident 57) on an anti-coagulant. This failure had the potential for Resident 10 and Resident 57 to have adverse effects. Findings: During a concurrent interview and record review on 1/9/25 at 2:03 p.m. with Assistant Director of Nursing (ADON), Resident 10's Medication Administration Record (MAR) dated 12/1/24 - 12/31/24 and 1/1/25 - 1/9/25 were reviewed. The MARs indicated, Give Eliquis [medication to prevent blood clots] 2.5 mg [milligram] Give 1 tablet by mouth two times a day for DVT [deep vein thrombosis - blood clot] prevention. ADON stated there was no documentation that the blood thinning medication was monitored for adverse effects and there should be. 46958 During a concurrent interview and record review on 1/9/25 at 11:12 a.m. with Minimum Data Set (MDS - a federally mandated resident assessment tool) Consultant (MDSCL), Resident 57's Order Summary Report (OSR), dated 1/9/25 was reviewed. The OSR indicated, Xarelto [medicaton to prevent blood clots] oral [NAME] 20 MG . give 1 tablet by mouth one time a day for DVT. MDSCL stated there was no documentation that the blood thinning medication was monitored for adverse effects and there should be. During a review of the facility's P&P titled Anticoagulation- Clinical Protocol, dated 11/2018, the P&P indicated, The staff and physician will monitor for possible complications in individuals who are being anticoagulated, and will manage related problems. a. If an individual on anticoagulation therapy shows sign of excessive bruising, hematuria [blood in the urine], hemoptysis [coughing up blood], or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant.

Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 79) was assessed for a Bowel and Bladder Training program (structured plan designed to help residents regain control over their bowel and bladder functions). This failure had the potential for Resident 79 to be unable to maintain toileting abilities. Findings: During a concurrent interview and record review on 1/9/25 at 10:41 a.m. with Minimum Data Set (MDS - a federally mandated resident assessment tool) Consultant (MDSCL), Resident 79's medical record was reviewed. Resident 79's Bowel and Bladder Observation/Assessment (BBOA) dated 12/12/24 indicated, Incontinence [inability to control bladder and/or bowel] Assessment 1. Length of incontinence 1. Days and 3. Needs assistance getting to toilet. MDS Section H indicated, Urinary continence 3. Always incontinent and Bowel Continence 3. Always incontinent. MDSCL stated she was unable to find a care plan for incontinence and no documentation of Resident 79 being placed on a bowel and bladder training program. During an interview and record review on 1/9/25 at 10:48 a.m. with Minimum Data Set Coordinator (MDSC), MDSC stated the information on the BBOA might not be correct, but there was no other documentation to clarify Resident 79's continence status prior to admission to the facility. MDSC stated that if Resident 79 had only been incontinent for a matter of days she would have expected him to be placed on a bowel and bladder training program. A bowel and bladder training program policy was requested, none was provided.

Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Repositioning, for three of three sampled residents (Resident 71, and Resident 52) who were dependent on staff to change position or transfer. This failure had the potential to result in further loss of mobility and skin breakdown. Findings: a. During an interview on 1/7/25 at 9:10 a.m. with Resident 71, Resident 71 stated she does not get out of bed or do any exercising because it might interfere with her brittle bones. During a concurrent interview and record review on 1/8/25 at 10:55 a.m. with Assistant Director of Nursing (ADON), Resident 71's medical record was reviewed. The Minimum Data Set (MDS- Assessment tool) Section GG Functional Abilities indicated, Resident 71 was Dependent on facility staff to A. Roll left and right: B. Sit to lying: C. Lying to sitting on side of bed: D. Sit to stand: E. Chair/bed-to-chair transfer . FF. Tub/shower transfer. The Task: Turn and Reposition (TTR) dated 12/26/24 to 1/8/25 was reviewed and the following was noted: 12/26/24 Resident 71 was turned at 1:59 p.m., and 4:52 p.m. 12/27/24 Resident 71 was turned at 1:59 a.m., 10:37 a.m., 5:33 p.m., and 11:03 p.m. 12/28/24 Resident 71 was turned at 8:48 a.m., 2:50 p.m., and 11:42 p.m. 12/29/24 Resident 71 was turned at 6:35 a.m., and 3:17 p.m. 12/30/24 Resident 71 was turned at 1:38 a.m., 7:35 a.m., 3:24 p.m., and 10:47 p.m. 12/31/24 Resident 71 was turned at 9:43 a.m. and 2:59 p.m. 1/1/25 Resident 71 was turned at 5:49 a.m., 8:14 a.m., and 5:17 p.m. 1/2/25 Resident 71 was turned at 1:42 a.m., 9:28 a.m., 4:04 p.m., and 11:55 p.m. 1/3/25 Resident 71 was turned at 9:42 a.m., 3:10 p.m., and 4:52 p.m. 1/4/25 Resident 71 was turned at 1:43 p.m., 2:14 p.m., and 11:07 p.m. 1/5/25 Resident 71 was turned at 6:38 a.m., 2:32 p.m., and 10:44 p.m. 1/6/25 Resident 71 was turned at 1:59 p.m., and 10:28 p.m. 1/7/25 Resident 71 was turned at 3:45 a.m., 9:09 a.m., and 5:12 p.m. 1/8/25 Resident 71 was turned at 1:31 a.m. and 9:49 a.m. b. During a concurrent observation and interview on 1/7/25 at 2:30 p.m. with Resident 52, in his room, Resident 52 was in a wheelchair. Resident 52 was unable to use his left arm. Resident 52 stated he relies on the nursing staff to turn him when he was in bed. During a review of Resident 52's, Admission Record (AR), the AR indicated, a diagnosis of Hemiplegia [inability to use one side of the body] and Hemiparesis [muscle weakness on one side of the body] following Cerebral Infarction [loss of blood flow to a part of the brain, causing brain tissue to die] affecting left non-dominant side. During a concurrent interview and record review on 1/9/25 at 11:47 a.m. with Minimum Data Set Consultant (MDSCL), Resident 52's medical record was reviewed. MDS Section GG Functional Abilities dated 12/3/24 indicated Resident 52 was dependent on staff for mobility. The Care Plan dated 11/23/24 indicated an ADL [activities of daily living] Self Care Deficit r/t [related to] Activity Intolerance, Confusion, Hemiplegia, Stroke [blood flow to brain is interrupted, causing damage to brain tissue]. MDSCL stated the care plan does not indicate Resident 52 is dependent on staff for mobility and that the MDS is more accurate. The TTR dated 12/27/24 to 1/9/25 was reviewed and the following was noted: 12/27/24 Resident 52 was turned at 12:30 a.m., 8:51 a.m., 5:08 p.m., and 10:57 p.m. 12/28/24 Resident 52 was turned at 8:53 a.m., 2:40 p.m., and 11:13 p.m. 12/29/24 Resident 52 was turned at 6:29 a.m. and 3:12 p.m. 12/30/24 Resident 52 was turned at 1:32 a.m., 1:43 p.m., 2:24 p.m., and 10:40 p.m. 12/31/24 Resident 52 was turned at 9:49 a.m. and 2:46 p.m. 1/1/25 Resident 52 was turned at 2:30 a.m., 8:08 a.m., and 2:23 p.m. 1/2/25 Resident 52 was turned at 5:59 a.m., 9:18 a.m., and 3:59 p.m. 1/3/25 Resident 52 was turned at 3:05 a.m., 9:32 a.m., and 2:54 p.m. 1/4/25 Resident 52 was turned at 5:36 a.m., 11:14 a.m., and 2:08 p.m. 1/5/25 Resident 52 was turned at 3:41 a.m., 6:35 a.m., and 2:30 p.m. 1/6/25 Resident 52 was turned at 3:58 a.m., 1:59 p.m., and 8:23 p.m. 1/7/25 Resident 52 was turned at 1:46 a.m., 9:48 a.m., and 5:07 p.m. 1/8/25 Resident 52 was turned at 4:27 a.m., 9:48 a.m., and 3:21 p.m. 1/9/25 Resident 52 was turned at 5:59 a.m. MDSCL stated the only information documented when a resident is turned, is the time. During an interview on 1/9/25 at 10:11 a.m. with Minimum Data Set Coordinator (MDSC), MDSC stated a lack of documentation makes it seem like the dependent residents are not being turned. MDSC stated a difference in the MDS assessment coding and a resident's individualized care plan could result in a resident injury, if the care plan does not accurately reflect the actual degree of resident needs. During a review of the facility P&P titled, Repositioning dated 5/2013, the P&P indicated, The purpose of this procedure is to provide guidelines for the evaluation of resident repositioning needs, to aid in the development of an individualized care plan for repositioning, to promote comfort for all bed-or chair-bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents. Interventions 3. Residents who are in bed should be on at least an every-two-hour. repositioning schedule. 5. Residents who are in a chair should be on a every one hour. repositioning schedule. Documentation The following information should be recorded in the resident's medical record: 1. The position in which the resident was placed. This may be on a flow sheet. 2. The name and title of the individual who gave the care. 3. Any changes in the resident's condition. 4. Any problems or complaints made by the resident related to the procedure. 5. If the resident refused the care and the reason(s) why. 6. Observations of anything unusual exhibited by the resident. 7. The signature and title of the person recording the data.

Based on observation interview and record review, the facility failed to ensure a communication tool was used for one of one sampled resident (Resident 46) with a speech impairment. This failure had the potential for Resident 46's concerns and needs to be unmet and for her psychosocial health to be negatively impacted. Findings: During an observation on 1/7/25 at 10:41 a.m. in Resident 46's room, Resident 46 was in her wheelchair, and she was speaking in short clips of gibberish with no discernable words. During an interview on 1/8/25 at 3:46 p.m. with Certified Nursing Assistant (CNA) 6, CNA 6 stated she can understand Resident 46's needs from having cared for her for the past year. During a concurrent interview and record review on 1/9/25 at 2:11 p.m. with Minimum Data Set Consultant (MDSCL), Resident 46's medical record was reviewed. The Minimum Data Set (MDS- Assessment tool) Section B indicated, Speech Clarity 1. Unclear speech. Makes Self Understood 3. Rarely/never understood. During an interview on 1/9/25 at 2:26 p.m. with Minimum Data Set Coordinator (MDSC), MDSC stated not using a communication tool for Resident 46 would make it difficult for newer staff assigned to care for her, to understand her, and meet her needs. During a review of the facility's policy and procedure (P&P) titled, Effective Communication, dated 2/2018, the P&P indicated, Staff will assist hearing impaired residents and residents with language barriers to maintain effective communication with clinicians, caregivers, other residents and visitors.

Based on interview and record review, the facility failed to follow its policy and procedure (P&P) on Change in a Resident ' s Condition or Status when the facility failed to notify the physician of a non-healing bruise (an injury appearing as an area of discolored skin on the body) and blister (a small bubble on the skin filled with serum and caused by friction, burning or other damage) for one of three sampled residents (Resident 1), left lateral shin sustained after a fall incident. This resulted in Resident 1 developing cellulitis (bacterial infection involving the inner layers of the skin), requiring hospitalization and the need for surgical intervention. Findings: During a review of Resident 1's Admission Record (AR), undated, the AR indicated, Resident 1 diagnoses included encephalopathy (disease in which the functioning of the brain is affected by some agent or condition), weakness, other symptoms and signs involving the musculoskeletal system (consists of the body's bones, muscles, tendons, ligaments, joints, and cartilages) morbid obesity (clinically severe obesity-overweight) due to excess calories. During a review of Resident 1's Minimum Data Set (MDS-clinical assessment of resident), dated 5/25/23, the MDS indicated, Resident 1 had a BIMS (Brief Interview for Mental Status) score of 11 (moderately impaired cognition). During an interview on 5/24/23, at 4:31 a.m., with Licensed Vocational Nurse (LVN 3), LVN 3 stated, she was working when Resident 1 fell and hit her left leg on the Hoyer lift (assistive device that allows residents to be lifted between bed and chair) on 4/5/23. Resident 1 was sent to the emergency room (ER) for evaluation and returned from theER on [DATE]. LVN 3 stated, Resident 1 sustained a bruise and a blister to the left lateral shin after the fall incident and was being monitored (regularly checking for the development or progress) for 72-hours (4/6/23-4/9/23). LVN 3 stated, the 72-hour monitoring was completed on 4/9/23. On 4/26/23, (16 days later) Resident 1 ' s left lateral shin was noted with swelling and noticed draining. LVN 3 stated, the facility should have notified the physician after the 72-hour monitoring was completed on 4/9/23, because the bruise and the blister were still present, and the monitoring for the bruise and blister should have been continued until there was an improvement. During a review of Resident 1 ' s Progress Notes (PN), dated 4/5/23, at 11:23 a.m., the PN indicated, While doing med [medication] pass at around 8:35 p.m., this writer was notified by CNA [Certified Nursing Assistant] that resident fell .She [Resident 1] stated ' I hit my left leg on the base of the Hoyer lift, and it is hurting a lot. I don ' t think it ' s broken but I ' m sure it will be bruised tomorrow ' . MD [Medical Doctor] was notified and gave an order to send resident to ER [emergency room ] for evaluation and x-ray. During a review of Resident 1's ER [emergency room ] General RME [Rapid Medical Evaluation]/HPI [History of Present Illness] dated, 4/5/23 (day of the fall), the RME/HPI indicated, Chief complaint: Fall.lower left leg pain s/p [status post] fall.Extremities: Ecchymosis (a discoloration of the skin resulting from bleeding underneath, typically caused by bruising) to the lateral (towards the side) shin.she does have a contusion (injured tissue or skin in which blood capillaries have been ruptured) on her leg [left] and was returned to the nursing home for management of bruise.Referrals: [Primary Physician] -in 1 week.Additional Instructions: Follow-upy [sic] our primary doctor as need. [sic] During a review of Resident 1 ' s PN, dated 4/6/23, at 5:53 a.m., the PN indicated, Resident came back from ER visit. Resident has a contusion to L [left] leg (left lateral shin) with blister.Resident to follow up with MD. During a review of Resident 1 ' s Care Plan (CP), dated 4/6/23, the CP indicated, [Resident 1] had an actual fall [4/5/23] with minor injury.contusion to left leg (left lateral shin).Goal. [Resident 1] ' s contusion to left leg will resolve without complications.Interventions.Monitor/document/report PRN (as needed) x (times) 72h [hour] to MD for s/sx [signs and symptoms]: bruises. During a review of Resident 1 ' s PN, dated 4/8/23, at 8:51 a.m., the PN indicated, IDT [Interdisciplinary Team-group of healthcare professionals that create an individualized plan of care] met in regards to resident having a staff assisted fall on 4/5/23.resident was sent to the ER [DATE]] for eval [evaluation]. Resident returned from ER @ [at] 4/6/23 @ approx [approximately] 5:53 a.m., no fracture noted to resident, resident noted to have a contusion to left leg (left lateral shin) with blister. During a review of Resident 1 ' s PN, dated 4/26/23, at 5:46 a.m., [16 days later] the PN indicated, Resident noted.wound to L lower leg (left lateral shin) noted to have non-purulent (drainage without pus) drainage. Redness around site with discoloration observed, skin is warm to touch. During a review of Resident 1 ' s Order Summary Report (OSR), dated 5/1/23, the OSR indicated, Keflex [antibiotic] Oral Capsule 500 MG [milligrams-unit of measurement] [Cephalexin-generic name for Keflex] Give 1 capsule by mouth three times a day for Cellulitis (bacterial infection involving the inner layers of the skin) to L.L.E. [left lower extremity] (left lateral shin) for 10 days until finished.start date 4/26/23. During a review of Resident 1 ' s PN, dated 5/1/23, at 10:59 a.m., the PN indicated, [Wound MD] was made aware of wound to left lower leg (left lateral shin). [Wound MD] stated it is a DTI [Deep Tissue Injury-persistent non-blanchable (skin does not turn white when touched with finger) purple or maroon area of intact skin or blood-filled blisters caused by damage to under lying tissue]. During a review of Resident 1 ' s Integumentary [body ' s outer layer] Assessment Sheet (IAS), dated 5/1/23, completed by [Wound MD], the IAS indicated, Pt [patient] s/p fall mid-March [sic] with ER Eval [Evaluation] & dx [diagnosis] of contusion to left lateral calf [left lateral shin] area. End of April Pt developed cellulitis to area.I was consulted May 1st. During a concurrent interview and record review, on 5/10/23, at 1:10 p.m., with LVN 2, Resident 1 ' s PN dated 4/9/23, at 12:20 PM, documented by LVN 2, was reviewed. There was no documentation of physician notification and monitoring of the bruise and blister between 4/10/23 and 4/25/23 (16 days), in the clinical record. LVN 2 stated, Resident 1 had a bruise and a blister to the left lateral shin, and it was being monitored from 4/6/23-4/9/23. LVN 2 confirmed the findings there was no evidence the physician was notified of the non-healing bruise and blister after the 72-hour monitoring which ended on 4/9/23. LVN 2 stated, when the 72-hour monitoring was completed (4/9/23) and the bruise and blister were still present, the physician should have been notified, and the monitoring for the bruise and blister should have been continued. During a concurrent interview and record review, on 5/10/23, at 1:28 p.m., with Director of Nursing (DON), Resident 1 ' s PN ' s were reviewed. There was no documentation noted on Resident 1 ' s bruise or blister between 4/10/23-4/25/23. DON confirmed the findings and stated, Resident 1 sustained a bruise and a blister to her left lateral shin after a fall incident (4/5/23) and were never resolved. DON stated, Resident 1 developed cellulitis to the same area (left lateral shin) on 4/26/23 (16 days later). DON stated, After the 72-hour monitoring was completed (4/9/23) and the bruise and the blister were still present, the physician should have been notified and the monitoring should have been continued due to a potential change in condition. During a concurrent interview and record review, on 6/8/23, at 8:28 AM, with Assistant Director of Nursing (ADON), ADON reviewed Resident 1 ' s OSR (Order Summary Report), dated 5/1/23. The OSR indicated, DTI to left outer ankle (left lateral shin): Cleanse area with wound cleanser, pat dry, apply Medi honey (wound and burn gel) to wound bed, cover with ABD (abdominal gauze pad), wrap with Kerlex [sic] (a white gauze dressing), QD [every day] or PRN [as needed] if soiled or falls off. Notify Md [sic] of any changes.order date 4/27/23. ADON stated, the left lateral shin wound (bruise and blister) was discovered on 4/26/23. ADON stated, Resident 1 ' s physician classified the wound as a DTI due to the wound being caused from Resident 1 ' s fall incident (4/5/23) and gave treatment orders for the wound. During a review of Resident 1 ' s PN dated, 5/2/23, at 1 p.m., the PN indicated, resident requested to be sent out to hospital, resident c/o [complain of] . not feeling right.resident sent to [acute hospital] ER for evaluation. During a review of Resident 1 ' s History of Present Illness (HPI), dated 5/2/23, from [acute hospital], the HPI indicated, Chief complaint: Left lower leg pain.Per patient ' s [Family Member 1 and Family Member 2].she has not received proper care for left lower leg (left lateral shin) wound sustained after sling fall [4/5/23] during patient ' s stay.Extremities: 6x8cm [centimeter-unit of measurement] LLE [left lower extremity] tender, necrotic (death of most or all the cells in tissue due to disease, injury, or failure of the blood supply), open wound with serous [thin watery fluid]/clotted drainage noted.Assessment and Plan.LLE [left lower extremity] necrotic ulcer.LLE cellulitis.Reason for hospitalization .cellulitis During a review of Resident 1 ' s History of Present Illness (HPI), dated 5/3/23, from [acute hospital], the HPI indicated, Consult details.Left leg open wound.[Resident 1] noted to have a large open wound with skin necrosis.Left leg with large open wound and skin necrosis with underlying hematoma [localized bleeding outside of blood vessels due to either disease or trauma including injury and may involve blood continuing to seep from broken capillaries] but continues to be unstable medically.Plan.will require medical optimization prior to debridement (the removal of damaged tissue or foreign objects from a wound). During a review of Resident 1 ' s Wound Care Note (WCN) dated 5/5/23, at 11:56 a.m., from [acute hospital], the WCN indicated, [Hospital MD] rounding. Per MD pt [patient] needing surgical debridement of hematoma. During a review of the facility policy and procedure (P&P) titled, Change in a Resident's Condition or Status dated, 2/2021, the P&P indicated, The nurse will notify the resident's attending physician or physician on call when there has been a(an).significant change in the resident's physical/emotional/mental condition; need to alter the resident's medical treatment significantly.A significant change of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions.b. impacts more than one area of the resident's health status; c. requires interdisciplinary review and/or revision to the care plan.

Based on observation, interview, and record review, the facility failed to ensure safe resident smoking practices were provided for 18 of 18 sampled residents who smoked (Resident 4, Resident 7, Resident 10, Resident 12, Resident 23, Resident 27, Resident 30, Resident 42, Resident 43, Resident 49, Resident 56, Resident 72, Resident 76, Resident 79, Resident 81, Resident 83, Resident 391, and Resident 392) when: 1. One Smoking Observation/Assessment (SOA) was not completed on admission for one sampled resident (Resident 30). 2. 11 sampled residents (Resident 79, Resident 72, Resident 4, Resident 76, Resident 30, Resident 42, Resident 43, Resident 49, Resident 10, Resident 391, and Resident 392) who smoked were allowed to keep their lighters and cigarettes/cigars in their possession. 3. A smoking apron was not provided for one sampled resident (Resident 76) who was required to wear a smoking apron when smoking, according to the resident's SOA. 4. Smoking aprons were not easily accessible to 18 of 18 sampled residents who smoked (Resident 4, Resident 7, Resident 10, Resident 12, Resident 23, Resident 27, Resident 30, Resident 42, Resident 43, Resident 49, Resident 56, Resident 72, Resident 76, Resident 79, Resident 81, Resident 83, Resident 391, and Resident 392). These failures had the potential to compromise the safety of the 18 sampled residents who smoked and had the potential to compromise the safety of all 92 residents who resided in the facility. This resulted in a situation of Immediate Jeopardy (IJ) which was called on 7/13/21 at 4 PM with the facility Administrator and the Regional Administrator. Findings: 1. During an interview, on 7/13/21 at 11:20 AM, with Minimum Data Set Coordinator (MDSC), MDSC stated, a smoking assessment was done for all smokers upon admission and quarterly thereafter. MDSC stated, based on the SOA, a resident who smoked was designated as a supervised or unsupervised smoker. For those residents who were assessed to require staff supervision, the residents would always require staff or family with them at all times while smoking and only would smoke during designated smoking times. For those residents who were assessed to not require supervision; therefore, were unsupervised these residents would not require anyone to be with them outside and could smoke whatever time they wanted to. During a concurrent interview and record review on 7/13/21, at 2:37 PM, with MDSC, Resident 30's care plans and assessments were reviewed. MDSC stated, Resident 30 smokes and after reviewing the resident's clinical record, stated Resident 30 does not have a smoking assessment (SOA) completed or a care plan for smoking. MDSC stated, a SOA and a care plan should be completed for any resident who smokes. MDSC stated that a smoking assessment should be done for all residents who smoke during admission and quarterly. 2a. During a concurrent observation and interview on 7/12/21, at 8:53 AM, with Resident 79, inside her room, Resident 79 had a box of cigarettes and a lighter at her bedside table. Resident 79 stated she keeps her cigarettes and lighter with her at all times. During a concurrent observation and interview on 7/13/21, at 8:47 AM, with Activities Director (AD), in Resident 79's room, cigarettes and lighter were observed at the resident's bedside table. AD stated for unsupervised smokers, they are allowed to keep their cigarettes and lighters with them and can smoke outside anytime. 2b. During a concurrent observation and interview on 7/12/21, at 8:55 AM, with Resident 72, inside her room, Resident 72 had a box of cigarettes and a lighter at her nightstand. Resident 72 stated, I smoke whenever I want and I go outside as I please. During a concurrent observation and interview on 7/13/21, at 8:48 AM, with Activities Director (AD), in Resident 72's room, cigarettes and lighter were observed on her bedside table. AD stated for unsupervised smokers, they can keep their cigarettes and lighters with them and can smoke outside anytime. 2c. During a concurrent observation and interview on 7/12/21, at 10:02 AM, with Resident 4, in Resident 4's room, Resident 4 had a cigarette lighter in the pocket of his hospital gown and a pack of cigarettes were observed on his bedside table. Resident 4 stated, he keeps the cigarette lighter with him and smokes whenever he wants. During a concurrent observation and interview on 7/13/21, at 9:51 AM, with Certified Nursing Assistant (CNA) 1, in Resident 4's room, Resident 4 had his lighter in his pocket. CNA 1 stated, he keeps his lighter on him at all times and is an unsupervised smoker. 2d. During an observation on 7/12/21, at 10:30 AM, in Resident 76's room, cigarettes were on his bedside table. During a concurrent observation and interview on 7/13/21, at 9:55 AM, with CNA 1, in Resident 30's room, there were multiple packs of cigars at the bedside. CNA 1 stated, yes those cigars belong to Resident 30. CNA 1 stated, Resident 30 should be supervised when smoking. During a concurrent observation and interview on 7/13/21, at 1:27 PM, with Resident 76 and Resident 30 (roommate of Resident 76), in Resident 76's and Resident 30's room, a cigarette lighter was found between Resident 76's legs. Resident 76 stated he did not realize the lighter was there and stated, It belongs to my roommate [Resident 30]. Resident 30 stated, I smoke and I lost my lighter. I am not sure if I dropped it or someone picked it up. During a concurrent observation and interview on 7/13/21, at 1:28 PM, with CNA 1, in Resident 76's and Resident 30's room, CNA 1 observed the lighter in between Resident 76's legs in bed and stated, she did not know who the lighter belonged to. CNA 1 stated Resident 30 is confused and should not have access to a lighter. During a review of Resident 30's Admission Record (AR), dated 4/22/21, the AR indicated, Resident 30 has a diagnosis of Dementia (a group of conditions characterized by loss of memory and judgement). During a review of Resident 30's Minimum Data Set (MDS - a comprehensive assessment tool), dated 5/5/21, Resident 30's BIMS (Brief Interview for Mental Status - a screening tool used to assess cognition) score was 3 (a score of 3 indicates the resident has severe cognitive impairment). During a review of Resident 76's AR, dated 3/12/21, the AR indicated, Resident 76 is a quadriplegic (affected by or relating to paralysis of all four limbs) and has limited range of motion to all four of his extremities. 2e. During an observation on 7/12/21, at 10:33 AM, in Resident 42's room, Resident 42 had a cigar sitting by his bed. Resident 42 was sitting in a wheelchair. During an interview on 7/13/21, at 2:42 PM, with CNA 1, CNA 1 stated, the cigar in Resident 42's room belonged to Resident 42. 2f. During a concurrent observation and interview on 7/12/21, at 11:29 AM, with Resident 43, in Resident 43's room, a pack of cigarettes were observed at the bedside. Resident 43 stated, he keeps his own cigarette lighter. During a concurrent observation and interview on 7/12/21, at 1:18 PM, with Activities Assistant (AA), in the designated smoking area in the back of the building, Resident 43 was smoking a cigarette and showed AA his lighter. AA stated, Resident 43 can smoke unsupervised and all residents who are considered unsupervised smokers can keep their own lighters. 2g. During an interview on 7/12/21, at 3:28 PM, with Resident 49. Resident 49 stated she is a smoker and keeps her cigarette and lighter with her at all times and is allowed to smoke at night unsupervised. During an interview on 7/12/21 at 4:11 PM, with the Director of Nursing (DON), DON stated all cigarette lighters are kept at the nurse's station. For unsupervised smokers, residents can get the lighter at the nurse's station. For supervised smokers, the facility staff will light the cigarettes for them. No lighters are kept with the residents. 2h. During a concurrent observation and interview on 7/13/21, at 9 AM, with CNA 5, in Resident 10's room, Resident 10 had his cigarette and lighter inside a bag. CNA 5 verified the cigarette and lighter were inside the bag and stated, [Resident 10] keeps his lighter with him. Most of [the residents who smokes] have their own lighters with them. During an interview on 7/13/21, at 9:10 AM, with Licensed Vocational Nurse (LVN) 3, LVN 3 stated, We don't keep any cigarettes or lighters at the nurse's station. The residents who smoke keeps their lighter with them or the Activity Department. During an interview on 7/13/21, at 4:03 PM, with Registered Nurse (RN) 1, RN 1 stated, We don't keep any cigarettes or lighters in the [medication room] or our [medication cart]. During a review of Resident 10's AR, undated, the AR indicated the facility admitted Resident 10 to the facility on [DATE], with admitting diagnosis of Muscle Weakness. During a concurrent interview and record review on 7/13/21, at 12:21 PM with MDSC, Resident 10's MDS assessment dated [DATE] and SOA, dated 6/17/21 were reviewed. The MDS indicated Resident 10 had Functional Limitation in Range of Motion (ROM). The MDS coded the ROM as 2 (2 - impairment to right and left side) for upper extremity (shoulder, elbow, wrist, and hand). The SOA indicated the following: 1. Dexterity (skill in performing tasks, especially with hands): problems, 2. Unable to light his own cigarette, 3. Smokes with supervision, 4. Has a potential for injury related to smoking. MDSC verified the MDS assessment and the SOA and stated Resident 10 should not have a lighter in his possession and must be supervised when he smokes. 2i. During a concurrent observation and interview on 7/13/21, at 2:30 PM, with Licensed Vocational Nurse (LVN) 6, in Resident 391's room, Resident 391 had his cigarette lighter kept inside a bag on his bed. Resident 391 stated, I go out to smoke in either smoking areas in the back patios anytime I want to. I go out to smoke late at night or early morning. 2j. During an interview on 7/13/21, at 4:15 PM, with AD, in Resident 392's room, Resident 392 stated he had his cigarette lighter kept in his pocket. Resident 392 stated, another resident was the one providing him with his cigarettes. 3. During a review of Resident 76's SOA, dated 3/16/21, the SOA indicated, Apron should be worn due to him not having the ability to grab the cigarette if it falls on him while smoking. Resident 76 has limited range of motion in all four of his extremities and utilizes a motorized wheelchair. During an interview on 7/13/21, at 2:23 PM, with Resident 76. Resident 76 stated, he does not wear a smoking apron outside when he is smoking. During an interview on 7/13/21, at 2:25 PM, with AD, AD stated, the smoking aprons were in her office and that none of the residents at the facility required one. 4. During a concurrent observation and interview on 7/13/21, at 3:57 PM, with AD, inside AD's office, two smoking aprons were observed on a shelf. AD stated, there are two more smoking aprons in central supply (A designated space to store medical supplies and equipment). AD stated, there are no residents assigned to use a smoking apron at this facility. AD stated, her office was not accessible after 5 PM every day. No residents who smoked (Resident 4, Resident 7, Resident 10, Resident 12, Resident 23, Resident 27, Resident 30, Resident 42, Resident 43, Resident 49, Resident 56, Resident 72, Resident 76, Resident 79, Resident 81, Resident 83, Resident 391, and Resident 392) have access to the AD's office after 5 PM every day. During a review of the facility's policy and procedure (P&P) titled, Smoking Policy-Residents, dated 2017, the P&P indicated, This facility shall establish and maintain safe resident smoking practices. 6. The resident will be evaluated by a licensed nurse on admission to determine if he or she is a smoker or non-smoker. 12. Residents who are supervised/unsupervised will have all cigarettes, e-cigarettes, pipes, tobacco, and other smoking articles, and disposable safety lighters in locked boxes at each nurse station. All other forms of lighters, including matches, are prohibited. 14. Residents without independent smoking privileges may not have or keep any smoking articles. While onsite and through observation, interview and record review, the IJ was removed on 7/14/21, at 4:10 PM, with facility Administrator and Regional Administrator.

Based on interview and record review, the facility failed to provide [CONDITION(S)] (process of purifying blood of a person whose kidneys are not working normally) care and services according to professional standards of care for one of one sampled [CONDITION(S)] resident (Resident 14) when: 1. Dressing changes were not provided to the CVC (Central Venous Catheter - a small flexible tube that is inserted into a large vein for the purpose of providing [CONDITION(S)]) [CONDITION(S)] site. 2. A care plan (CP) was not revised after Resident 14 refused [CONDITION(S)] treatments. 3. The physician was not notified when Resident 14 refused his [CONDITION(S)] treatments on 6/30/21, 7/5/21 and 7/9/21. These failures resulted in Resident 14 developing an infection to the CVC [CONDITION(S)] site (presence of pus and blood to the [CONDITION(S)] site) which required antibiotic therapy for seven days and had the potential to result in a change in the resident's condition to go untreated by the physician. Findings: 1. During a review of Resident 14's Order Summary Report (OSR), dated 5/13/21, the OSR indicated, [CONDITION(S)] Schedule: 3 x/week (three times per week at an offsite [CONDITION(S)] clinic) on M-W-F (Monday, Wednesday, Friday) . Rt (Right) [MEDICATION(S)] (vessel that lies just below the clavicle [collarbone]) . During a concurrent interview and record review, on 7/15/21, at 10:10 AM, with Director of Nursing (DON), Resident 14's Progress Note (PN), dated 7/13/21, was reviewed. The PN indicated, on 7/13/21, Resident was noted to have pus and blood to his [CVC] site to right side of chest. resident to start on [MEDICATION(S)] [antibiotic used to treat bacterial infections] 1 gm [gram - a unit of measurement] IM [intramuscular injection - used to deliver a medication deep into the muscles] daily x 7 days [for seven days] and [MEDICATION(S)] [antibiotic used to treat bacterial infections] 100 mg bid [two times a day] x 7 days. DON stated, Resident 14 was on antibiotic for an infection to the CVC site. DON stated, [[CONDITION(S)] Center] is doing the dressing during his [CONDITION(S)] days but that he's refusing to go to [CONDITION(S)] for approximately two weeks now. DON stated the dressing to the CVC [CONDITION(S)] site has not been changed since his last [CONDITION(S)] treatment [6/28/21]. DON stated dressing changes have not been done since the resident's last [CONDITION(S)] treatment which was on 6/28/21. During an interview on 7/19/21, at 8:04 AM, with Assistant Director of Nursing (ADON), ADON stated, We never do the dressing for the [CONDITION(S)] site. We monitor the dressing site to check if it has any drainage. During an interview on 7/19/21, at 8:31 AM, with Nurse Consultant (NC), NC stated, We don't manipulate the [CONDITION(S)] dressing change. If a dressing change is needed, the resident needs to be transferred to the [CONDITION(S)] center or ER [emergency room ]. [Facility] should have asked for some directions from the [CONDITION(S)] center and should have documented that they referred the resident for dressing changes on the [CONDITION(S)] site [CVC site] when he refused [[CONDITION(S)]] treatments [6/30/21, 7/5/21 and 7/9/21]. During an interview on 7/19/21, at 11:20 AM, with DON, DON stated, We could have sent him to the [CONDITION(S)] center or ER for the dressing changes on the [CONDITION(S)] site when he refused treatments. During a review of the facility's policy and procedure (P&P) titled, End-Stage [CONDITION(S)] (kidney failure), Care of a Resident with, dated 9/10, the P&P indicated, Residents with end-stage [CONDITION(S)] ([CONDITION(S)]) will be cared for according to currently recognized standards of care. 1. Agreements between this facility and the contracted [CONDITION(S)] facility include all aspects of how the resident's care will be managed, including. b. How information will be exchanged between the facilities. 2. The resident's comprehensive care plan will reflect the resident's needs related to [CONDITION(S)]/[CONDITION(S)] care. During a review of the National Institutes of Health / U.S. National Library of Medicine (NIH/USNLM) dated 9/28/20, the NIH/USNLM indicated, Central venous catheter - dressing change. This is a tube that goes into a vein in your chest and ends at your heart. Dressings are special bandages that block germs and keep your catheter site dry and clean. You'll need to change your dressing often, so that germs don't get into your catheter and make you sick. You should change the dressing about once a week. You will need to change it sooner if it becomes loose or gets wet or dirty. 2. During an interview on 7/12/21, at 11:30 AM, with Resident 14, Resident 14 stated, I'm not on [CONDITION(S)]. I don't feel good. I feel tired and dizzy. I don't want [any]more [CONDITION(S)]. During a concurrent interview and record review, on 7/15/21, at 10:10 AM, with Director of Nursing (DON), Resident 14's CP, dated 4/15/21 was reviewed. DON was unable to find a plan of care for Resident 14's refusal to do his [CONDITION(S)] treatment. DON stated, a care plan should have been revised to reflect Resident 14's refusal to go to for his [CONDITION(S)] treatment. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, dated 12/16, the P&P indicated under the Policy Statement, 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 . 7. The care planning process will . Include an assessment of the resident's strengths and needs . 8. The comprehensive, person-centered care plan will . Include measurable objectives and timeframes . Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment . Incorporate identified problem areas . Reflect the resident's expressed wishes regarding care and treatment goals . Aid in preventing or reducing decline in the resident's functional status and/or functional levels . Reflect currently recognized standards of practice for problem areas and conditions . 10. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident . 14. The Interdisciplinary Team [IDT-group of health care professional who meets to plan residents care needs] must review and update the careplan: a. When there has been a significant change in the resident's condition . 3. During a concurrent interview and record review, on 7/19/21, at 8:31 AM, with NC, Resident 14's Progress Notes (PN), dated 6/28/21 to 7/15/21 were reviewed. NC was unable to find documented evidence, the physician was notified when resident refused his [CONDITION(S)] treatments on the following dates: 6/30/21, 7/5/21, and 7/9/21. NC stated the physician should have been notified consistently on the days when Resident 14 refused his [CONDITION(S)] treatments. During a review of the facility's P&P titled, Change in a Resident's Condition or Status, dated 5/17, the P&P indicated, Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. 1. The nurse will notify the resident's Attending Physicians or physician on call when there has been a(an): f. refusal of treatment or medications two (2) or more consecutive times) .

Based on observation, interview, and record review, the facility failed to provide pain management in a timely manner for one of 19 sampled residents (16) and one of three random residents (22). 1. For Resident 22, the facility failed to administer pain medication as ordered by the physician which resulted in unrelieved pain for over seven hours and left Resident 22 unable to participate in his normal activities of daily living. 2. For Resident 16, the facility failed to advocate for the resident to ensure pain management was adequate which had the potential to result in prolonged pain and negatively impact her activities of daily living. Findings: 1. During a concurrent observation and interview with Resident 22, on 1/3/17, at 10:16 AM, Resident 22 was seen in bed, uncovered, with a grimace facial expression (a facial expression that shows disgust, disapproval, or pain). Resident 22 stated I have severe pain 10 out of 10 (a scale that measures a resident's pain intensity with 0 being no pain and 10 being the worst pain). He stated I need something stronger . I told a staff (Certified Nursing Assistant) member this morning. During an interview with the Director of Nursing (DON), on 1/3/17, at 4:57 PM, the DON stated Resident 22 had not received any PRN (as needed) pain medication today as of yet, only his routine medications . During an interview with Resident 22, on 1/3/17, at 5:08 PM, Resident 22 stated My pain is still 10/10 . I still haven't received my pain medication yet and I have told 2 staff members so far, someone from therapy and the nursing assistant . I can't get a hold of the nurse. During an interview with Licensed Vocational Nurse (LVN) 5, on 1/3/17, at 5:10 PM, she stated Yes the Certified Nursing Assistant told me when I got back from lunch at 2:45 PM that Resident 22 had pain . During an interview with Resident 22, on 1/3/17, at 5:12 PM, Resident 22 stated I have been in pain most of the day . I can't get up, it makes me not want to do anything . During an interview with Certified Nursing Assistant (CNA) 2, on 1/3/17, at 5:15 PM, she stated Resident 22 told me around 11:30 AM if I could tell the nurse to bring him his pain medication . I told the nurse right after. During a review of the clinical record for Resident 22, the Clinical physician's orders [REDACTED]. The Medication Administration Record dated 1/2017, indicated the medication [MEDICATION NAME]-[MEDICATION NAME] 5-325 was not administered until 5:13 PM. No other administration times were noted on the record. The Clinical Care Plan Detail dated 1/4/17, indicated Resident 22 has pain . Alert staff of need for PRN (As needed) medication . Give [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 MG every six hours as needed for pain severe. 2. During an interview with Resident 16, on 1/6/17, at 11:50 AM, Resident 16 stated I'm good . I would like something stronger for my pain . I have Aspirin and sometimes I have to ask for more aspirin but would like something stronger . I do need it at times and the nursing staff keeps telling my they would call the doctor but that's the last I hear of it . During an interview with LVN 2, on 1/6/17, at 2:55 PM, he stated Yes I have called the doctor about the issue but he denies it and states its not about what the resident wants . I have called a few times already to try and get something stronger but its the doctor. During an interview with the DON, on 1/6/17, at 3:17 PM, the DON stated The doctor is very difficult. I will talk to the resident to see if she would like a new doctor that could better manage her pain . During a review of the clinical record for Resident 16, the Clinical Care Plan Detail dated 1/6/17, indicated Resident 16 has potential for pain related to medical and physical condition . During a review of the clinical record for Resident 16, the Medication Administration Record dated 1/6/17, indicated Monitor pain level on a scale of 0-10 (0= No Pain, 1-3= Mild Pain, 4-5= moderate pain, 6-9= severe pain, 10= Excruciating Pain) A pain scale of 6 was documented on 1/1/17, and a pain score of 7 was documented on: 1/4/17, and 1/5/17 which indicated severe pain. The facility policy and procedure titled Pain Assessment and Management revised 3/2015, indicated Pain management is a multi-disciplinary care process that includes the following: b. Effectively recognizing the presence of pain . Observe the resident (during rest and movement) for physiologic and behavioral (non-verbal) signs of pain . Implement the medication regimen as ordered.

NOTE: A "pressure sore" (also known as bed sores, decubitus ulcers, pressure ulcers) is any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s). Pressure sores are measured in "Stages" and grouped by their severity. Stage 1 is the earliest stage. Stage 4 is the most advanced. Stage 1: A reddened area on the skin that, when pressed, does not turn white. This is a sign that a pressure sore is starting to develop. Stage 2: The skin blisters or forms an open sore. The area around the sore may be red and irritated. Stage 3: The skin now develops an open, sunken hole called a crater. Stage 4: The pressure sore has become so deep that there is damage to the tissue below the skin, damage to the muscle and bone, and sometimes to tendons and joints. Unstageable: Full thickness loss in which actual depth of the sore is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (necrotic, or dead, tissue that appears tan, brown, or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be considered a Stage 3 or Stage 4. Based on observation, interview, and record review, the facility failed to provide pressure pads to the ear area of one of 20 sampled residents (6). This resulted in the oxygen tubing coming into contact with the resident's skin at his left ear, causing an unstageable pressure sore to Resident 6's left ear. Findings: During an initial facility tour and observation on 3/9/15, at 11:50 AM, Resident 6 was observed laying in his bed. The head of his bed was elevated at a 30 degree angle, his chin was to his chest, oxygen via a mis-placed nasal cannula was flowing to his right upper cheek under his right eye, instead of to his nostrils. The oxygen tubing was wrapped around his right and left ears and secured under his chin. On his left ear was a black and blue, flat darkened line down the left ear crease, semi-circling the left ear. His left ear had pieces of necrotic skin peeling. Licensed Vocational Nurse (LVN) 1 entered the room and indicated Resident 6 had wounds on his left ear. She stated, "He is suppose to have pressure pads on the oxygen tubing around his ears to protect them." During an interview with the Hospice Licensed Nurse (HLN) on 3/9/15, at 4:10 PM, she stated, "The ear wounds were not diagnosed during transfer to hospice care on 2/28/15. The wounds have grown the past two weeks. The HLN did not know how long he had the left ear wound since it was not being measured nor treated. The HLN stated, "I remember the Left ear wound was about one centimeter long." She indicated the left ear wound was now two centimeters long. The HLN indicated that Resident 6 needed a physician's orders [REDACTED]. During the HLN's measuring of the left ear crevice wound, Resident 6 winced, and said 'Ouch.' The HLN assessed him for his pain level and stated he could have "[MEDICATION NAME] (a strong, narcotic, prescription pain reliever), ordered for 'moderate to severe pain as needed', because Resident 6 indicated his pain was severe, level 10 of 10." During an observation and interview with the Assistant Director of Nursing and Wound Care Specialist (ADON) on 3/10/15, at 3:40 PM, she stated, "I was just informed about his left ear (pressure ulcer) yesterday by the hospice nurse." The ADON stated, "This left ear wound has developed necrotic tissue and the inner ear crease is black." She measured the wound as two centimeters long and .5 centimeters in width. During the assessment, Resident 6 winced. The ADON assessed his pain on two different pain scales: first, 0 to 10 pain scale 10 being severe, and a second time using a 'Mild to Moderate to Severe' rating scale. On both assessments Resident 6 indicated his left ear pain was severe. The ADON administered Resident 6 his prescribed dose of [MEDICATION NAME]. During an interview with the ADON on 3/12/15, at 8:40 AM, she stated the sore on Resident 6's left ear was "From the pressure of the oxygen tubing. We didn't stage it, we called the doctor, and just called it an open wound." The ADON then provided an untitled document, dated 3/12/15, at 8:50 AM, which read Resident 6 had a physician's treatment order to "Cleanse Unstageable wound to left ear..."

Based on observation, interview, and record review, the facility failed to ensure a hot beverage was served at a safe temperature and failed to supervise Resident A and Resident B which resulted in Resident B suffering burns from Resident A's hot beverage. Findings: On 7/16/14, Resident A's clinical record was reviewed. A care plan, dated 11/10/13, indicated Resident A was "at potential risk for injuries due to behaviors of wandering and no regard of safety...secondary to late effects of CVA (stroke) (the late effects include problems with cognitive function, such as remembering, thinking, concentrating, and solving problems), Alzheimer's (a type of dementia that causes problems with memory, thinking and behavior)." The goal for this care plan indicated she would "be assisted and monitored by staff to minimize any injuries r/t (related to) wandering and behavioral symptoms daily..." On 7/16/14, the clinical record for Resident B was reviewed. Resident B was admitted to the facility with intellectual disabilities (problems in adaptive behaviors in social situations and learning disabilities) and bipolar disorder (mood swings). Resident B's care plan for bipolar disorder, dated 6/6/13, indicated: " (Resident B) is showing increase behaviors; throwing objects at staff, continuous crying and screaming, attempting to strike at staff and other resident-goal is to keep resident stable and reduce/prevent resident from danger to self and others." Resident B had another care plan for "impaired cognitive functions" related to a [DIAGNOSES REDACTED]." During an interview on 7/16/14, at 11:15 AM, the Director of Nursing stated Resident A had a [DIAGNOSES REDACTED]. The cup of hot cocoa had been prepared by Activities Director (AD) 1. During an observation on 7/16/14, at 11:35 AM, Resident A was seated in the dining room. She was alert and confused and her speech was garbled. During an observation on 7/16/14, at 11:30 AM, at the request of the surveyor, Food Server 1 poured hot water from a container used to make hot cocoa into a Styrofoam cup and placed a thermometer in the Styrofoam cup. The hot water temperature registered 184 degrees Fahrenheit. During a record review on 7/16/14, the nurse's notes dated 7/12/14 indicated Resident B suffered burns on bilateral inner thighs. The physician was notified and ordered treatment with silvadene ointment which is an antibacterial cream used to treat burns. During an interview on 7/31/14, at 11 AM, Licensed Vocational Nurse (LVN) 1 stated she observed Resident A throw her hot cocoa at Resident B's lap. LVN 1 stated Resident B was immediately taken for a cool shower and "his skin was peeling off as soon as we got him in the shower." LVN 1 stated Resident A was "not coherent enough to know what's going on." LVN 1 stated she was not aware of any policy about supervising demented residents with hot drinks but stated "There's a policy that drinks have a certain temperature when leaving the kitchen" but did not know the correct temperature. During an interview on 7/31/14, at 11:50, AD 1 stated Resident A was drinking a hot beverage and "(Resident A) freaks out if anyone touches her. (Resident B) touches everybody. No staff was in there; we went in when we heard yelling." AD 1 stated she was not aware of any facility policy regarding safe temperatures of hot beverages and "We just serve what the kitchen fixes." During an interview on 8/13/14, at 12:35 PM, Day Program Staff (DPS) stated the day after the incident she observed bandages on Resident B's thighs. She stated she observed blisters "in more than one area." DPS was asked if Resident B was in pain, she stated, "It's hard to tell if he is in pain; he's always tense. But he looked more uncomfortable than usual." The facility policy and procedure titled, "Food Preparation", dated 2012, indicated in part, "12. Prepared food will be stored at proper temperature until serving time. B. Hot beverages >140 degrees F and < ( below)160 F." An article, "Scalds: A Burn Issue," published in 2000 by American Burn Association has identified older adults and people with any type of disability are at high risk to be scalded by hot water. The severity of injury with scalds depends on two factors - the temperature to which the skin is exposed and the length of time that the hot liquid is in contact with the skin. At 120 degrees Fahrenheit/48 degrees Celsius, skin requires five minutes of exposure for a full thickness burn to occur. Coffee, tea, hot chocolate and other hot beverages are usually served at 160 to 180 degrees Fahrenheit, resulting in almost instantaneous burns that require surgery to heal. The same article also described people with disabilities or special needs may have physical, mental or emotional challenges or require some type of assistance from caregivers are at high risk for all types of burn injuries including scalds. The disability may be permanent or temporary due to illness or injury and vary in severity from minor to total dependency on others.

Based on observation, interview, and record review, the facility failed to ensure three (13, 16 and 4) of 18 sampled residents and one random resident (21) received the necessary comprehensive assessments to direct the residents' care, to enable them to attain their highest practicable physical, mental and psychosocial well being. 1. For Resident 16 the facility failed to address pain in a timely fashion, which caused unnecessary pain. 2. For Resident 13, the facility failed to provide an interdisciplinary comprehensive assessment to determine the underlying cause of the self inflicted wounds throughout his body and failed to develop appropriate interventions to prevent further injury. These failures resulted in the resident sustaining multiple self inflicted wounds throughout his body. 3. For Resident 21, the facility failed to provide an interdisciplinary comprehensive assessment to determine the underlying cause of the self inflicted scratches to her eyes and failed to develop appropriate interventions to prevent further injury. These failures resulted in the resident causing herself discoloration and scratches around her eyes. 4. For resident 4 the facility failed to provide an interdisciplinary comprehensive assessment to determine the underlying cause of the resident's refusal to bath and change her clothing. This failure had the potential to cause social isolation of the resident. Findings: 1. During an observation of the Medication Pass on 2/26/13, at 11 AM, in Resident 16's room, Licensed Vocational Nurse (LVN) 1 took the resident's blood sugar, and then drew up [MEDICATION NAME]in an insulin syringe. When LVN 1 went to give the injection to the resident, she refused and was agitated. For the next 15-20 minutes, LVN 1 tried to give the injection without success. No assessment of resident's agitation was made by LVN 1. Then, she called for LVN 2 to come and assist her (LVN 1). LVN 2 approached the resident and asked her if she was in pain and Resident 16 said, "Yes." LVN 2 asked what her pain level was on a scale of 1-10 with 10 being the worst pain. Resident 16 stated her pain was 9-10. LVN 1 gave the resident her ordered pain medication and after a few minutes, the resident allowed LVN 1 to give the insulin injection. 2. During an observation and interview, with Resident 13, on 2/26/13, at 11:15 AM, he was noted to have open sores on his face. Resident 13 stated he felt "itchy" all over. During an observation with Certified Nursing Assistant (CNA) 2 of Resident 13, on 2/26/13, at 11:20 AM, he was noted with multiple sores throughout his body. The sores extended from his face, back of his neck, chest, arms, upper back, legs and buttock area. The sores varied in stages of healing; from scarred to open areas. CNA 2 stated, he was noncompliant with showers and the nurse was treating the areas with Vitamin "A and D" ointment. During an interview with the LVN 4, on 2/26/13, at 11:30 AM, she stated, the Minimum Data Set (MDS) Coordinator had the wound doctor (MD 1) look at it and they thought it was "a behavior". During an interview with the MDS Coordinator, on 2/26/13, at 11:45 AM, she stated she thought MD 1 looked at the wounds on Resident 13, and MD 1 thought it was a "behavior and hygiene". During a concurrent record review of Resident 13's electronic medical record (EMR), she was unable to find documented evidence MD 1 examined the extensive wounds on Resident 13. During a concurrent interview and record review, with Registered Nurse (RN) 1, on 2/26/13, at 1:05 PM, she indicated the resident was offered a daily shower but he often refused and his nails were trimmed down. RN 1 stated, he had the sores because he was "dirty". She further stated it was a behavior that started in January 2013 and they were treating the areas with A and D ointment. She was asked if a psychiatric evaluation was performed to determine the underlying cause of the behavior or appropriate interventions to prevent the resident from further picking and scratching himself. The resident's record was reviewed with RN 1 and it was noted the treatment to the self inflicted wounds started on 1/9/13. A continued review of the clinical record was conducted and she was unable to find documented evidence a psychiatric consultation was performed after the behavior began and she was unable to find documentation a dermatology consultation was performed to determine if any other contributing physical factors to the picking and scratching of his body could be determined. The care plan problem list was reviewed and a problem dated, 1/9/13 "(Resident 13) has episodes of picking/scratching himself." The goal for this problem, "Will have no episodes of scratching/picking himself through review date." The interventions included to shower the resident at least twice a week to prevent itchy skin and trim fingernails, and apply lotion to his entire body daily. There were no other interventions noted to redirect the behavior of picking and scratching. During a concurrent interview and record review, with the Director of Nursing (DON), on 2/27/13 at 11 AM, she was unable to find documented evidence professional medical experts were consulted to assist in ruling out any underlying factors to the picking and scratching. During a review of the clinical record for Resident 13, on 2/27/13, the nursing notes were reviewed. From 1/9/13 to current the nurses documented the wounds were self inflicted and they were monitoring the areas for infection. There was lack of documentation a comprehensive interdisciplinary assessment was conducted to determine if more could be done to minimize the scratching and picking which resulted in the wounds throughout his body. There was also lack of documentation the licensed nurses were routinely attempting to redirect the behavior of picking and scratching. The facility policy and procedure titled, "Behavior Assessment and Monitoring" revised April 2007, was reviewed. Under the Assessment subheading it read in part, "2. The nursing staff will identify, document, and inform the physician about an individual's mental status, behavior, and cognition, including...a. Onset, duration and frequency of problematic behaviors or changes in behavior, cognition..." Under the monitoring subheading it read in part, "1. If the resident is being treated for [REDACTED]. 2. The staff will document...the following information about specific problem behaviors: a. Number and frequency of episodes; b. Preceding or precipitating factors; c. Interventions attempted... d. Outcomes associated with interventions." 3. During the initial tour on 2/25/13 at 11:05 AM, Random Sampled Resident 21 was noted lying in bed with large discolored pinkish areas around both her eyes and scratch marks. During an interview with the Facility Manager (FM), on 2/25/13 at 3:30 PM, she stated Resident 21 scratches her own eyes. During a concurrent interview and record review, with the Director of Nursing (DON), on 2/27/13 at 11 AM, she indicated the reddened eyes and scratches to Resident 21 was self inflicted and the areas are being monitored for signs and symptoms of infection. The clinical record was reviewed and a physician's orders [REDACTED]. to air. A second physician's orders [REDACTED]. After further review with the DON, she could find no documented evidence a comprehensive interdisciplinary assessment was conducted by other professionals to determine the underlying cause of why the resident was scratching her eyes to the extent of causing discolored pinkish to reddish area around both her eyes and scratches or to assist the staff in developing appropriate consistent interventions/redirection to assist the resident from scratching the area around the eyes. A further review of the clinical record was conducted. A nursing note dated 1/11/13 was noted which read in part, "treatment continues as ordered to self inflicted scratch to forehead..." There was lack of documented evidence the nursing staff were redirecting the self inflicted injury to the area around her eyes. 4. During an observation on 2/25/13 at 2:45 PM, in the front main entrance area, Resident 4 was observed wearing a matching checked top and pants. On 2/26/13, at 11:30 AM , Resident 4 was observed ambulating in her room wearing the same clothing. On 2/27/13 at 9 AM Resident was observed in the main entrance nursing station wearing the same clothing. During an interview with LVN 3 on 2/27/13 at 6:40 AM, she stated it was not unusual for Resident 4 to refuse to shower or change her clothing. At that time the shower log dated 2/12/13 through 2/27/13 (17 days) was reviewed. The log indicated Resident 4 had showered only twice during that time period. Upon further review of the record, with LVN 3, there was no documented evidence that a comprehensive interdisciplinary assessment had been completed to determine the cause of Resident 4's refusals to shower or change her clothing.

Based on observation, interview, and record review, the facility failed to ensure two of 18 sampled residents (13 and 4) and one random resident (21) were provided comprehensive assessments to attain their highest practicable physical, mental and psychosocial well being. 1. For Resident 13, the facility failed to provide an interdisciplinary comprehensive assessment to determine the underlying cause of the self inflicted wounds throughout his body and failed to develop appropriate interventions to prevent further injury. These failures resulted in the resident sustaining multiple self inflicted wounds throughout his body. 2. For Resident 21, the facility failed to provide an interdisciplinary comprehensive assessment to determine the underlying cause of the self inflicted scratches to her eyes and failed to develop appropriate interventions to prevent further injury. These failures resulted in the resident causing herself discoloration and scratches around her eyes. 3. For Resident 4, the facility failed to provide an interdisciplinary comprehensive assessment to determine the underlying cause of the resident's refusals to shower and change her clothing. This failure had the potential to cause the resident social isolation. Findings: 1. During an observation and interview with Resident 13, on 2/26/13, at 11:15 AM, he was noted to have open sores on his face. Resident 13 stated he felt "itchy" all over. During an observation with Certified Nursing Assistant (CNA) 2 of Resident 2, on 2/26/13, at 11:20 AM, he was noted with multiple sores throughout his body. The sores extended from his face, back of his neck, chest, arms, upper back, legs and buttock area. The sores varied in stages of healing; from scarred to open areas. CNA 2 stated, he was noncompliant with showers and the nurse was treating the areas with Vitamin "A and D" ointment. During an interview with Licensed Vocational Nurse (LVN) 4, on 2/26/13, at 11:30 AM, she stated the Minimum Data Set (MDS) Coordinator had the wound doctor (MD 1) look at it and they thought it was "a behavior". During an interview with the MDS Coordinator, on 2/26/13, at 11:45 AM, she stated she thought MD 1 looked at the wounds on Resident 13 and MD 1 thought it was a "behavior and hygiene". During a concurrent record review of Resident 13's electronic medical record (EMR), she was unable to find documented evidence MD 1 examined the extensive wounds on Resident 13. During a concurrent interview and record review with Registered Nurse (RN) 1, on 2/26/13 at 1:05 PM, she indicated the resident was offered a daily shower but he often refused and his nails were trimmed down. RN 1 stated, he had the sores because he was "dirty". She further stated it was a behavior that started in January 2013 and they were treating the areas with A and D ointment. She was asked if a psychiatric evaluation was performed to determine the underlying cause of the behavior or appropriate interventions to prevent the resident from further picking and scratching himself. The resident's record was reviewed with RN 1 and it was noted the treatment to the self inflicted wounds started on 1/9/13. A continued review of the clinical record was conducted and she was unable to find documented evidence a psychiatric consultation was performed after the behavior began and she was unable to find documentation a dermatology consultation was performed to determine if any other contributing physical factors to the picking and scratching of his body could be determined. The care plan problem list was reviewed and a problem dated, 1/9/13 "(Resident 13) has episodes of picking/scratching himself." The goal for this problem, "Will have no episodes of scratching/picking himself through review date." The interventions included to shower the resident at least twice a week to prevent itchy skin and trim fingernails, and apply lotion to his entire body daily. There were no other interventions noted to redirect the behavior of picking and scratching. During a concurrent interview and record review, with the Director of Nursing (DON), on 2/27/13 at 11 AM, she was unable to find documented evidence professional medical experts were consulted to assist in ruling out any other underlying factors to the picking and scratching. During a review of the clinical record for Resident 13, on 2/27/13, the nursing notes were reviewed. From 1/9/13 to current the nurses documented the wounds were self inflicted and they were monitoring the areas for infection. There was lack of documentation a comprehensive interdisciplinary assessment was conducted to determine if more could be done to minimize the scratching and picking which resulted in the wounds throughout his body. There was also lack of documentation the licensed nurses were routinely attempting to redirect the behavior of picking and scratching. 2. During the initial tour on 2/25/13 at 11:05 AM, Random Resident 21 was noted lying in bed with large discolored pinkish areas around both her eyes and scratch marks. During an interview with the Facility Manager (FM), on 2/25/13 at 3:30 PM, she stated Resident 21 scratches her own eyes. During a concurrent interview and record review, with the DON, on 2/27/13 at 11 AM, she indicated the reddened eyes and scratches to Resident 21 was self inflicted and the areas are being monitored for signs and symptoms of infection. The clinical record was reviewed and a physician's orders [REDACTED]. to air. A second physician's orders [REDACTED]. There was no documented evidence a comprehensive interdisciplinary assessment was conducted by other professionals to determine the underlying cause of why the resident was scratching her eyes to the extent of causing discolored pinkish to reddish area around both her eyes and scratches or to develop appropriate consistent interventions/redirection to assist the resident from scratching the area around the eyes. A further review of the clinical record was conducted on 3/7/13. A nursing note was noted which indicated the resident had been inflicting these scratches to her forehead since 1/11/13. 3. During an observation on 2/25/13 at 2:45 PM, in the front main entrance area, Resident 4 was observed wearing a matching checked top and pants. On 2/26/13, at 11:30 AM , Resident 4 was observed ambulating in her room wearing the same clothing. On 2/27/13 at 9 AM Resident 4 was observed in the main entrance nursing station wearing the same clothing. During an interview with LVN 3 on 2/27/13 at 6:40 AM, she stated it was not unusual for Resident 4 to refuse showers or change her clothing. At that time the shower log dated 2/12/13 through 2/27/13 (17 days) was reviewed. The log indicated Resident 4 had showered only twice during that time period. Upon further review of the record with LVN 3, there was no documented evidence that a comprehensive interdisciplinary assessment had been completed to determine the cause of Resident 4's refusals to shower or change her clothing.