Every finding on record at Sharon Care Center

Based on interview and record review, facility failed to report a serious allegation of suspected sexual abuse for one of three sampled residents (Resident 1), when such concern was brought to the facility's attention by Resident 1's roommate (Resident 2)'s responsible party (RP) on 5/18/2026 involving sexual conduct by Certified Nursing Assistant (CNA) 3 toward Resident 1 on 5/17/2026.This deficient practice resulted in a delayed investigation of the allegation and inadequate implementation of protective measures, which negatively affect Resident 1's care. Cross Reference F610.During a review of nursing staffing assignments on 5/16/2026 11:00 pm to 5/17/2026 7:00 am, CNA 3 was assigned to take care of Resident 1 and Resident 2 on that shift. During a review of facility grievances logs on 5/2026 and 6/2026, the grievances log did not indicate any suspect sexual abuse was reported. During a phone interview on 8/19/2026 at 12:28 pm with Resident 2's RP, Resident 2's RP stated, she reported to facility administrator on Monday, 5/18/2026 that she suspects CNA 3 had sexually abused Resident 1 on Sunday 5/17/2026. During an interview on 8/19/2026 at 12:44 pm with CNA 4, CNA 4 stated facility Administrator is the abused coordinator, any suspicion of abuse should be reported to the administrator immediate, and facility should report the suspect abuse allegation to related agency no more than 2 hours. During an interview on 8/19/2026 at 12:56 pm with the Administrator, the Administrator stated he is the abuse coordinator; he acknowledged he had conversation with Resident 2's RP about she reported suspect sexual abuse. He stated there should be a facility report incident (FRI). During an interview on 8/19/2026 at 1:15 pm with Director of staff development (DSD). DSD stated for any suspect abuse, facility needed to report to related agency immediately, filed a grievance as needed, and started facility inside investigation. During an interview on 8/19/2026 at 2:30 pm with the Administrator, Administrator confirmed no FRI was found on 5/2026 related to Resident 1. He also acknowledged facility did not report suspect sexual abuse on 5/17/2026 and no inside investigation has been carried out yet. Administrator further stated any suspect abuse, including sexual abuse, facility must have reported, and completed the facility inside investigation to protect the resident. Failed to report will delay the investigation and negatively impact Resident 1's care. During a review of the facility's policy and procedures (P&P) titled, Abuse, Neglect. dated 12/18/2025, the P&P indicated all reports of resident abuse, neglect.are reported to local, state and federal agencies and thoroughly investigated by facility management.all investigations are documented and reported.

Based on interview and record review, facility failed to initiate and complete the inside investigation of a serious allegation of suspected sexual abuse for one of three sampled residents (Resident 1) per facility's policy, when such concern was brought to the facility's attention by Resident 1's roommate (Resident 2)'s responsible party (RP) on 5/18/2026 involving conduct by Certified Nursing Assistant (CNA) 3 toward Resident 1 on 5/17/2026. This deficient practice resulted in a delayed investigation of the allegation and inadequate implementation of protective measures, which negatively affect Resident 1's care. Cross Reference F609.During a review of nursing staffing assignments on 5/16/2026 11:00 pm to 5/17/2026 7:00 am, CNA 3 was assigned to take care of Resident 1 and Resident 2 on that shift. During a review of facility grievances logs on 5/2026 and 6/2026, the grievances log did not indicate any suspect sexual abuse was reported. During a phone interview on 8/19/2026 at 12:28 pm with Resident 2's RP, Resident 2's RP stated, she reported to facility administrator on Monday, 5/18/2026 that she suspects CNA 3 had sexually abused Resident 1 on Sunday 5/17/2026. During an interview on 8/19/2026 at 12:44 pm with CNA 4, CNA 4 stated facility Administrator is the abused coordinator, any suspicion of abuse should be reported to the administrator immediate, and facility should report the suspect abuse allegation to related agency no more than 2 hours. During an interview on 8/19/2026 at 12:56 pm with the Administrator, the Administrator stated he is the abuse coordinator; he acknowledged he had conversation with Resident 2's RP about she reported suspect sexual abuse. He stated there should be a facility report incident (FRI). During an interview on 8/19/2026 at 1:15 pm with Director of staff development (DSD). DSD stated for any suspect abuse, facility needed to report to related agency immediately, filed a grievance as needed, and started facility inside investigation. During an interview on 8/19/2026 at 2:30 pm with the Administrator, Administrator confirmed no FRI was found on 5/2026 related with Resident 1; He also acknowledged facility did not report suspect sexual abuse happened on 5/17/2026 and no inside investigation has been carried out yet. Administrator further stated any suspect abuse, including sexual abuse, facility must have reported, and completed the facility inside investigation to protect the resident. Failed to initiate and complete the facility inside investigation will increase the risk of further harm to Resident 1 and inadequate implementation of protective measures. During a review of the facility's policy and procedures (P&P) titled, Abuse, Neglect. dated 12/18/2025, the P&P indicated all reports of resident abuse, neglect.are reported to local, state and federal agencies and thoroughly investigated by facility management.all investigations are documented and reported .

Based on interview and record review, facility failed to ensure physician' orders were implemented for three of three sampled residents (Resident 1, Resident 2, and Resident 3). These deficient practices negatively affect residents' care, placing Residents 1, 2 and 3 at risk for unmet clinical needs and potential decline.1.During a review of Resident 1's admission record dated 8/11/2026, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included but not limited to sepsis (your body's extreme reaction to an infection, If not treated quickly, sepsis can lead to organ failure and become life threatening), hypertension (high blood pressure), cerebral infarction (a condition when blood can't reach part of the brain, usually because a blood vessel is blocked. Without blood, the brain cells don't get oxygen, so they begin to die within minutes) and muscle weakness. During a review of Resident 1's minimum data set (MDS, a resident assessment tool) dated 8/10/2026, the MDS indicated Resident 1 had moderate cognition (ability to think, remember and reason for daily decision making) impairment. During a review of Resident 1's care plan (CP) titled Resident is newly admitted . dated 8/7/2026, the CP indicated facility will administer medications, treatment, and other services in accordance with physician orders. During a review of Resident 1's physician order dated 8/8/2026, the order indicated the following: Monitor for signs and symptoms. No blood pressure (BP) on left arm or venipuncture (using a needle to go into a vein to draw blood or give medication. It always involves a vein). During a review of Resident 1's medication administration record (MAR) dated 8/2026, the MAR indicated the following: Monitor for signs and symptoms . including vital signs (basic measurements that show how your body is working, it includes: temperature, pulse, respiratory rate and blood pressure) were not done on 8/10/2026 at 6:00 am.b. During a review of Resident 1's weights and vitals summary report from 8/7/2026 to 8/10/2026, the report indicated on 8/8/2026 at 4:32 pm and 8/8/2026 at 9:18 pm, Nurses used Resident 1's left arm for blood pressure. 2.During a review of Resident 2's admission record dated 8/13/2026, the admission record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included but not limited to diabetes (a condition where your body has trouble handling sugar), hypertension, muscle weakness, chronic kidney disease (a condition kidneys are slowly getting damaged and can't clean your blood as well as they should). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 is cognition (ability to think, remember and reason for daily decision making) intact. During a review of Resident 2's CP titled Resident is newly admitted . dated 4/9/2026, the CP indicated facility will administer medications, treatment, and other services in accordance with physician orders. During a review of Resident 2's physician order dated 4/8/2026, the order indicated the following: Monitor for signs and symptoms.During a review of Resident 2's physician order dated 4/10/2026, the order indicated the following: b. Levothyroxine sodium (a medicine that replaces a hormone your body should make naturally) tablet. c. Protonix (a medicine that reduces the amount of acid your stomach makes) tablet. d. Metoprolol succinate (a heart medicine, use for High blood pressure, Heart failure) .hold for Systolic Blood Pressure (SBP, it is the top number in a blood pressure) less than 110 or heart rate (HR) less than 60. During a review of Resident 2's MAR dated 8/2026, the MAR indicated the following: Monitor for signs and symptoms. including vital signs were not done on 8/4/2026 at 6:00 am and 8/8/2026 at 6:00 am. Levothyroxine sodium tablet. was not given on 8/8/2026 at 5:00 am. Protonix tablet. was not given on 8/8/2026 at 6:00 am. Metoprolol succinate.hold for SBP less than 110 or HR less than 60. was given on 8/10/2026 at 9:00 am but SBP was 100. 3.During a review of Resident 3's admission record dated 8/13/2026, the admission record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included but not limited to diabetes, dialysis (a medical treatment that uses a machine to clean your blood when your kidneys can't do the job anymore), heart failure (a condition when the heart is not pumping blood as strongly as it should), and depression (a condition that affects your mood. It's more than feeling sad or having a bad day. It is a long lasting feeling of being down, hopeless, or not interested in things you used to enjoy). During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3 had mild cognition (ability to think, remember and reason for daily decision making) impairment. During a review of Resident 3's CP titled, Resident is newly admitted . dated 5/12/2026, the CP indicated facility will administer medications, treatment, and other services in accordance with physician orders. During a review of Resident 3's physician order dated 5/12/2026, the order indicated the following: Levothyroxine sodium tablet.During a review of Resident 3's MAR dated 8/2026, the MAR indicated the following: Levothyroxine sodium tablet. was not given on 8/8/2026 at 6:30 am. During a phone interview with Registered Nurse (RN) 1 on 8/12/2026 at 1:48 pm, RN 1 acknowledged he worked on 8/9/2026 night shift and assigned to take care Resident 1. He did not check Resident 1's vital signs as order during that shift. During an interview with RN 2 on 8/12/2026 at 2:16 pm, RN 2 stated, nurses should follow physician's order. If physician ordered not to use Resident 1's left arm for BP, nurses should have implemented that. if physician order to check vital signs, nurses should also follow the order every shift. During a concurrent phone interview and record review with Assistant Director of Nursing (ADON) on 8/21/2026 at 1:53 am, Resident 1, Resident 2 and Resident 3's missing monitoring and medications on 8/2026 were reviewed. ADON acknowledged multiple times all Resident 1, Resident 2 and Resident 3's physician orders were not followed and implemented. ADON continued stated, failed to follow physician's order is unacceptable, it will result negative affect Resident 1, Resident 2 and Resident 3s' care. During a review of the facility's policy and procedure (P&P) titled care plan comprehensive dated 12/18/2025, the P&P indicated, facility must develop and implement care plan for each resident. During a review of the facility's P&P titled, Licensed Practical (Vocational) Nurse (LVN), dated 12/18/2025, the P&P indicated, LVN will provide nursing service to residents in accordance with scope of practice, facility policies and professional standard of care, LVN should administer medication within the scope of practice and according to physician order. During a review of the facility's P&P titled, Registered Nurse, dated 12/18/2025, the P&P indicated RN will provide nursing services to residents in accordance with scope of practice, facility policies and professional standards of care, RN should administer medication according to physician order.

Based on observation, interview, and record review, facility failed to provide and maintain a safe and sanitary environment for residents, when Director of Nursing (DON) brought her dog into resident's room, and let it roam freely in the patio area. These deficient practices increase risk of transmission of microorganisms and compromised the facility's ability to maintain a safe, sanitary, and infection controlled environment for its residents.Findings:During an observation on 8/5/2026 at 12:05 pm, DON's dog was observed walking and sitting by itself in the facility's patio un-attended. During an interview with Resident 3 on 8/5/2026 at 11:50 am in the dining area, Resident 3 stated he witnessed DON having carried her dogs and went into other resident's room. He had concern for other residents. During an interview with Resident 4 on 8/5/2026 at 12:45 pm in Resident 4's room, Resident 4 stated she witnessed DON carry her dog into her room while DON were having conversation with her roommates. During an interview with Certified Nursing Assistant (CNA) 1 on 8/5/2026 at 12:55 pm, CNA 1 stated she had witnessed DON carry her dog into residents' room. During an interview with Infection Prevention Nurse (IPN) on 8/5/2026 at 2:30 pm, IPN stated that she knows DON bring her dog to the facility, but she did not know the reason, no risk assessment was done, and currently there is no policy regarding with staff's service animal. IPN stated staff's service dog should not enter resident's room and should not be left un-attended in the patio where resident could be around, it could cause infection control issue and increase the risk of transmission of microorganisms. During an interview with DON on 8/5/2026 at 4:20 pm, DON acknowledged facility did not have a policy for staff's service animal and she did carry her dog into other residents' room. During an interview with Administrator on 8/11/2026 at 5: 45 pm, Administrator acknowledged facility did not have DON's dog's vaccination records. During a review of the facility's policy and procedure (P&P) titled, infection prevention and control. Dated 5/6/2026, the P&P indicated facility adopted infection prevention and control policies and procedures are intended to help maintain a safe, sanitary and comfortable environment and to help prevent and manage.infection prevention and control policies and procedures apply to all personnel, consultants, contractors, residents, visitors and volunteers.

Based on interview and record review, the facility failed to develop and implement an individualized care plan addressing one of three sampled residents (Resident 1) when Resident 1 was identified at risk for pressure injury.This deficient practice increased the risk for Resident 1 develop for pressure injury. During a review of Resident 1's admission record dated 8/6/2026, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included but not limited to Atherosclerosis of the Aorta (a condition that biggest artery [a blood vessel, a long, tube like path inside your body, that carries blood away from your heart] in the body (called the aorta) is getting clogged or hardened inside), hypertension (high blood pressure), depression (a mental health condition that makes a person feel very sad, empty, or hopeless for a long time), and muscle weakness. During a review of Resident 1's Minimum Data Set (MDS- resident assessment tool) dated 7/24/2026, the MDS indicated Resident 1 had moderate cognition (ability to think, remember and reason for daily decision making) impairment; Resident 1 need maximal assistance from staffs for toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene; Resident 1 is at risk for pressure ulcers/injuries. During a review of Resident 1's Braden Scale (a checklist nurses use to see whether a person might get pressure injuries, also called bedsores [when someone sites or lies in one position too long, and their skin get damaged]) assessment dated [DATE] and 7/25/2026. Braden Scale assessments were scored 17, Resident 1 was at risk for developing pressure injury. During a review of Resident 1's Body Check (a head to toe skin check. nurses and CNAs do it to make sure a resident's skin is healthy and to find problems early) assessment dated [DATE], the Body Check indicated resident had blanchable redness (when you press gently on the red spot with your finger: the skin turns white (pales) for a moment, then turns red again after you let go. This means the skin still has working blood flow, it has not turned into a pressure injury yet. It's an early warning sign) at coccyx (a small bone at the very bottom of your spine, often called tailbone), and interventions to prevent pressure ulcer include pillow, offloading, and turning and positioning. During a review of Resident 1's care plan (CP) date 7/17/2026, the CP did not indicate Resident 1 had a care plan addressing resident's risk for pressure injury. During an interview on 8/5/2026 at 1:42 pm with Treatment Nurse (TN), TN stated, she did the skin assessment for Resident 1 on 7/18/2026, upon her assessment, Resident 1 is at risk for pressure injury. During an interview on 8/5/2026 at 3:23 pm with Registered Nurse (RN), RN acknowledged Resident 1's MDS assessment, Body Check assessment, Bradon Scale assessment (a widely used clinical tool to predict a patient's risk of developing pressure injuries (bedsores). 0 all indicated resident was at risk for pressure injury, and Resident 1's CP did not address Resident 1 was at risk for pressure injury. RN stated, Resident's care plan should be individualized, Resident 1 is at risk for pressure injury, the care plan needed to address that, failed to develop and implement the care plan will increase the risk of pressure injury for Resident 1. During a review of the facility's policy and procedures (P&P) titled, care plan comprehensive, dated 12/18/2025, the P&P indicated facility must develop and implement a comprehensive person-centered care plan for each resident.to meet a resident's medical, physical and mental and psychological needs.

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 2) who required assistance with activities of daily living (ALDs) received timely incontinence care. This deficient practice increased Resident 2 at risk for compromised skin integrity, discomfort, and avoidable decline in quality of care.During a review of Resident 2's admission record dated 7/17/2026, the admission record indicated Resident 2 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with the diagnoses that included stroke (a condition happens when the brain suddenly can't get enough blood, a stroke will cause a person to have trouble speaking, one side of the face drooping, weakness in an arm or leg), seizure (a condition when the brain suddenly sends out a burst of fast, mixed up electrical signals. During a seizure, a person might shake or jerk uncontrollably, stare blankly and stop responding and collapse), diabetes (a condition where the body has trouble controlling its blood sugar), and muscle wasting and atrophy (a condition a person's muscles start to get smaller, weaker, and thinner, and losing its strength). During a record review of Resident 2's Minimum Data Set (MDS- resident assessment tool) dated 5/15/2026, the MDS indicated Resident 2 had mild cognition (ability to think, remember and reason for daily decision making) impairment. Resident 2 need maximal assistance from staff for Toileting hygiene and shower bathe; Resident 2 need moderate assistance from staff for upper body dressing and oral hygiene; and Resident 2 dependent on staff for lower body dressing and putting on/taking off footwear. In addition, MDS indicated Resident 2 is always incontinent. During a review of Resident 2's care plan (CP) titled Resident is incontinent of bowel and bladder. dated 2/14/2026, the CP indicated staffs should assist Resident 2 with perineal care as needed and provide privacy and comfort for Resident 2. During an interview on 7/16/2026 at 12:10 PM with Certified Nursing Assistant (CNA) 1, CNA 1 stated, Resident 2 did not get change last night, Resident 2 told her he pressed call light, night shift CNA went into the room and cancelled the call light but did not help him. She changed Resident 2 this morning. During an interview on 7/16/2026 at 1:20 PM with Resident 2 in his room. Resident stated that CNA from last night did not help him change, he was wet and waited until the morning being changed by the day shift CNA. During an interview on 7/16/2026 at 1:30 PM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, she aware that sometimes night shift CNAs were not doing their job, day shift CNAs had reported to her. During an interview on 7/16/2026 at 3:46 PM with Registered Nurse (RN) 1, RN 1 stated, Resident 2 needed maximal assistance from CNA for toileting hygiene, CNA should have answered Resident 2's call light and helped him. Cancel resident's call light and walk away is unaccepted, Resident should be cleaned. Failed to do that increased the risk of skin issue for Resident 2. During an interview on 7/16/2026 at 4:50 PM with Director of Nursing (DON), the DON stated, CNA who failing to provide Resident 2's toileting hygiene request by cancelling his call light is unacceptable, Resident 2 must feel very uncomfortable and frustrated. During a review of the facility's policy and procedure (P&P) titled, ADLs, supporting, dated 12/18/2025, the P&P indicated Resident who are unable to carry out ADL independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

Based on interview and record review, the facility failed to ensure accurate and complete documentation in the medical record for one of four sampled residents (Resident 1), by failing to ensure:There was a detailed cardiopulmonary resuscitation (CPR an emergency action used when a person's heart stops beating or they stop breathing) documentation, which included the date and time the CPR was performed and by whom;Documentation of the Emergency Medical Services (EMS, encompasses the system of professionals like paramedics, ambulances, and dispatchers that respond to 911 calls and provide urgent pre-hospital medical care and transport) arrive timeThe attending physician's progress notes regarding the cause of death. Include the name and title of the individual pronouncing the resident dead.These deficient practices resulted in inaccurate documentation in Resident 1's medical record regarding his death.During a review of Resident 1's admission record dated 7/17/2026, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with the diagnoses that included failure to thrive (a condition that person's body is slowly getting weaker because they are not eating enough, losing weight, or not getting the nutrients and energy they need to stay healthy), gastrostomy (a small tube that goes straight into a person's stomach through the skin on their belly. It is used when someone cannot swallow safely, has trouble eating enough food, or needs medicine delivered directly to their stomach), stiffness of both shoulders and hypertension (high blood pressure). During a review of Resident 1's minimum data set (MDS, a resident assessment tool) dated 6/19/2026, the MDS indicated Resident 2 had severe cognition (ability to think, remember and reason for daily decision making) impairment, on feeding tube and was dependent on staff for oral hygiene, toileting hygiene, shower and bathe, upper body dressing, lower body dressing, putting on/ taking off footwear, and personal hygiene. During a review of Resident 1's physician order dated 10/13/2024, the physician order indicated, Resident 1 is full code. During a review of Resident 1's nursing progress notes on 7/10/2026 at 7:00 am, the progress notes indicated on 7/10/2026 at approximately 5:35 am Resident 1 was found unresponsive, pulseless, and not breathing. CPR initiated, activated 911, and EMS arrived, assumed cared, and pronounced the resident deceased at 5:58 AM in the facility. During a review of Resident 1's nursing progress notes on 7/10/2026 at 8:59 am, the progress notes indicated Resident 1 had no family, conservator (a person chosen by a court to make important decisions for someone who cannot make decisions on their own) was called and left voicemail 7/10/2026 at 8:30 am and 8:40 am regarding with resident's expired. During a review of Resident 1's nursing progress notes on 7/10/2026 at 9:01 am, the progress notes indicated Resident 1 expired early this morning has not been removed from PointClickCare (PCC, a computer system that nursing homes and healthcare facilities use to keep track of important information about their residents.) During a review of Resident 1's nursing progress notes on 7/10/2026 at 1:19 pm, the progress notes indicated Resident 1's body released to mortuary at 11:30 am. During a review of Resident 1's nursing progress notes on 7/10/2026 at 2:01 pm, the progress notes indicated Resident 1's physician notified at time of pick up from mortuary. During a review of Resident 1's medical record, no other documentation was found regarding with Resident 1's death. During a phone interview on 7/16/2026 at 4:19 pm with Certified Nursing Assistant (CNA) 2, CNA 2 stated, she found Resident 1 unresponsive and called for help on 7/10/2026 around 5;30 am. She and another CNA were instructed by the charge nurse to do CPR for Resident 1 while the charge nurse was calling 911. She does not remember exact time when the CPR initiated, and when EMS arrived. During a phone interview on 7/16/2026 at 4:36 pm with Licensed Vocational Nurse (LVN) 2, LVN 2 stated she documented what happen with Resident 1's death in nursing progress notes on 7/10/2026 at 7:00 am. LVN 1 stated she did not remember when the 911 call was made, and it was not documented in the nursing notes. During a phone interview on 7/21/2026 at 10:47 am with Registered Nurse (RN) 1, RN 1 acknowledge facility documentation on Resident 1's death was too general, not specific enough. RN 1 further stated the following:staff members who initiate CPR, and when, and how long the CPR continue if it was effective or not were not documented.EMS arrive time was missing.The EMS personal's name who pronounced Resident 1's death was missing.Physician's progress notes regarding of resident's death was also missing.The death investigation report number by police was not documented in nursing notes as well.RN 1 explained for documentation should be accurate and completed. With Resident 1's death, nursing documentation should be specific, detail and follow facility policy of documentation and death documenting. Failed to do that would compromise the integrity of Resident 1's medical record. During a phone interview on 7/21/2025 at 11;37 am with Director of Nursing (DON), DON stated, facility should have follow their policy of documentation and death documenting. During a review of facility policy and procedure (P&P) titled charting and documentation, dated 12/18/2025, the P&P indicated documentation in the medical record will be objective, complete and accurate. During a review of facility policy and procedure (P&P) titled death of a resident, documenting, dated 12/18/2025, the P&P indicated all information pertaining to a resident's death (i.e., date, time of death, the name and title of the individual pronouncing the resident dead, etc.) must be recorded on the nurses' notes.the attending physician must record the cause of death in the progress notes, and must complete and file a death certificate with appropriate agency within 24 hours of the resident's death or as may be prescribed by state law.

Based on interview and record review, the facility failed to provide dental visits per regulations for one of three sampled residents (Resident 2).This deficient practice resulted in Resident 2 experiencing discomfort while eating, potentially leading to malnutrition, weight loss, and hospitalization.During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted on [DATE], with diagnoses including but not limited to type 2 diabetes (uncontrolled elevated blood sugar), right leg below the knee amputation (surgical removal of the lower leg) and hypertension (elevated blood pressure).During a review of Resident 2's minimum data set (MDS - a resident assessment tool) dated 4/15/2026, the MDS indicated Resident 2 had a brief interview for mental status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 13 (the resident is cognitively intact) and required assistance with activities of daily living (ADL) and mobility.During a review of Resident 2's care plan report, the care plan indicated the resident is at risk for cardiovascular (refers to the heart [cardio] and the blood vessels [vascular]) symptoms or complications.During an interview on 6/10/2026, at 10:45a.m. Resident 2 stated they (Resident 2) would like to see the dentist and have dental hygiene performed and have a broken tooth looked at. Resident 2 stated the broken tooth had been causing some discomfort. Resident 2 stated they (Resident 2) informed a staff member but did not remember the name. Resident 2 stated they (staff) must have forgotten about the request since they (staff) have not mentioned anything since the request.During an interview on 6/10/2026, at 1:08p.m. with the Director of Nursing (DON), the DON stated dental comes to the facility every three to six months and performs routine exams on the residents. If a resident has a concern, then a referral is submitted and they have dental come in sooner if they are available.During a phone interview on 6/15/2026, at 4:12p.m. with the Social [NAME] Director (SSD), the SSD stated that the facility's dental provider visits one to two times per month and requests the facility census to ensure newly admitted residents receive a baseline dental exam. The SSD reported that a resident admitted for two months should have been seen at least once. The SSD stated they were not aware that Resident 2 had requested a dental referral and confirmed Resident 2 had not been seen by dental despite being in the facility for two months. Dental was on-site on 4/29/2026 but did not see Resident 2 due to insurance coverage issues. The SSD stated they were not informed of this and that no follow up occurred regarding which residents were seen on 4/29/2026. The SSD emphasized that timely dental care is important to maintain oral hygiene and prevent pain, poor intake, weight loss, psychosocial isolation, and potential hospitalization.During a review of the facility's policy and procedure (P&P) titled, Dental Services, dated 12/18/2025, the P&P indicated that emergency and routine dental services will be provided to residents in accordance with their assessment and plan of care. The P&P indicated that social services is to facilitate dental appointments for residents at the facility.

Based on interview, and record reviews, the facility did not accurately document the administration of insulin for one of three sampled residents (Resident 1) This deficient practice had the potential to compromise Resident 1's safety by causing confusion among staff who administrate medications and potentially result in a medication error that could harm Resident 1.During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted on [DATE] to the facility with diagnoses including but not limited to heart failure, hyperlipidemia (elevated cholesterols levels), Type 2 diabetes mellitus (DM-elevated blood sugar levels).During a review of Resident1's Minimum Data Set (MDS- a resident assessment tool), dated 4/9/2026, the MDS indicated Resident 1 had a brief interview for mental status(BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 14 ( score of 13-14 cognitively intact).During a review of Resident 1's History and Physical (H&P - document detailing a resident's current and past medical history), dated 1/7/2026, the H&P indicated Resident 1 is not having memory loss and has capacity to make medical decisions.During a review of Resident 1's Care Plan Report (CP), dated 1/17/2025, it was noted that the resident has a diagnosis of diabetes and is prescribed Novolog insulin (type of insulin to control blood sugar). The care plan indicated that Resident 1 is to remain free of signs and symptoms of both hypoglycemia and hyperglycemia (low/high blood sugar), with the intervention identified as, administering medication as ordered.During a review of resident 1's Order Summary Report (OSR), dated 5/28/2026, the OSR stated: NovoLog Injection Solution 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale: if 0 - 150 = 0 (if blood glucose is less than 70, call MD) give a glass of juice; 151 - 200 = 2; 201 - 250 = 4; 251 - 300 = 6; 301 - 350 = 8; 351 - 399 = 12 and (if glucose is greater than 400, call MD immediately for further instruction), subcutaneously before meals for sliding scale insulin coverage for diabetes Rotate injection site. Order date/start date is 1/23/2026During a review of Resident 1's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 5/2026, the MAR indicated on May 24th at 6:30a.m. and May 26th at 11:30 a.m. the medication Novolog was not documented as given or refused by the resident.During an interview on 5/28/2026, at 10:04a.m. with Resident1, Resident 1 stated that their medications were not given on time and were sometimes missed when a particular staff member was not working. Resident 1 stated that insulin is not administered on time and that blood glucose finger sticks are completed after meals instead of before meals. Resident 1 further stated that their 9:00 a.m. medications were given one to two hours late.During an interview on 5/28/2026 at 11:10 a.m., with Licensed Vocational Nurse (LVN 1), LVN 1 stated that Resident 1 is knowledgeable about their daily medications and promptly voices any concerns if something is missing. LVN 1 stated they ensure medications and care tasks are completed correctly because Resident 1 is particular about their care and aware of their medication regimen. LVN 1 further stated that Resident 1 has complained on several occasions that other nursing staff did not give medications on time, could not locate medications, or failed to administer medications all together.During an interview on 5/28/2026 at 1:17 p.m. with the director of nursing (DON), the DON stated that the insulin administration process requires blood sugar to be checked before meals. If insulin is needed, it is to be administered with food or shortly after to prevent a drop in blood sugar. The DON stated that if a resident refuses the blood sugar check or the insulin administration, the refusal must be documented on the Medication Administration Record (MAR) and in the progress notes. The DON further stated that any medication not given must always be documented as a refusal on the MAR. The DON acknowledged that the MAR for Resident 1 does not indicate whether insulin was administered on May 24 and May 26, noting that the entries were left blank. The DON stated that leaving MAR entries blank can cause confusion among staff and potentially result in a medication error that could harm Resident 1.During a review of the facility's policy and procedure (P&P) titled, Insulin Administration, not dated, the P&P indicated that insulin documentation includes the residents' blood glucose, the dose and concentration and the injection site and if the resident tolerated medication. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated April 2019, the P&P indicated if a drug is withheld, refused, or given at a time other than the scheduled, document refusal.

Based on interview and record review, the facility failed to revise the care plan regarding leave of absence without notice (LAWN, leaving the facility unsupervised) for one of three sampled residents (Resident 1) by failing to: -Ensure to address Resident 1's LAWN on 5/17/2026. This failure had the potential to for Resident 1 to leave unsupervised again.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 4/22/2026 with diagnoses that included but not limited to unspecified dementia (loss of memory and other mental abilities severe enough to interfere with daily life) and hypotension (low blood pressure). During a review of Resident 1's Minimum Data Set (MDS, resident assessment tool) dated 4/20/2026, the MDS indicated Resident 1 sometimes made himself understood and sometimes understood others. The MDS indicated Resident 1 had severely impaired cognition (significant decline in a resident's mental abilities that profoundly impacts their daily life and independence). The MDS indicated Resident 1 self-propelled (maneuver) a manual wheelchair for mobility. During a review of Resident 1's Care Plan Report dated 5/11/2026, the Care Plan Report indicated Resident 1 was at risk for LAWN dated 5/11/2026. The Care Plan Report indicated there were no updated interventions for Wander Guard Elopement Device (a bracelet that sounds when near a door and alerts staff when a confused resident tries to leave unsupervised) ordered for Resident 1 on 5/17/2026 and monitor Resident 1's whereabouts on 5/20/2026. During a review of Resident 1's History and Physical dated 5/13/2026, the History and Physical indicated Resident 1 did not have the capacity to make decisions. During a review of Resident 1's Leave of Absence Without Notice (LAWN) Evaluation Form, dated 5/17/2026, the LAWN Evaluation Form indicated IDT (interdisciplinary team) determined that Resident 1 was at risk for LAWN. The evaluation form indicated reviewing and update the plan of care to address Resident 1's specific interventions and application of Wander Guard. During a review of Resident 1's Order Summary Report dated 5/20/2026, the Order Summary Report indicated Resident 1 had orders on 5/17/2026 to have Wander Guard elopement device due to poor safety awareness, on 5/20/2026 to monitor Wander Guard device for placement and function every shift and on 5/20/2026 to monitor Resident 1's whereabouts at least every hour. During an interview on 5/20/2026 at 2:50 PM, with Licensed Vocational Nurse1 (LVN 1), LVN 1 stated a care plan was a person-centered care specific to the needs of residents (in general) and updated with change of condition. LVN 1 stated Wander Guard was ordered on 5/17/2026 for Resident 1. LVN 1 stated care plan of Resident 1 on LAWN should have been updated with Wander Guard Device intervention. During a concurrent interview and record review on 5/21/2026 at 2:58 PM, with the Director of Nursing (DON), Resident 1's Order Summary Report dated 5/20/2026 and the Care Plan Report dated 5/11/2026 were reviewed. The DON stated the Care Plan Report indicated Resident1 was at risk for Leave of Absence without notice (LAWN) . The DON stated that a care plan served as a guide to address resident-centered needs and should have been updated with any change in condition. The DON stated that the care plan specifically on LAWN was not revised to include Wander Guard intervention ordered on 5/17/2026, and Monitor whereabouts interventions ordered on 5/20/2026. The DON stated it was important to update the LAWN care plan dated 5/11/2026 with interventions to prevent resident 1 from a repeat LAWN. During a concurrent interview and record review on 5/22/2026, at 3:54 PM, with the DON, the facility's policy and procedure (P&P) titled Leave of Absence Without Notice (LAWN), last review date on 1/16/2026 was reviewed. The DON stated the policy indicated to update plan of care when a resident is at risk for LAWN. During a review of the facility's recent P&P titled Care Plan Comprehensive: last reviewed on 12/18/2025, the P&P indicated: The Comprehensive care plan includes a. The services that are to be furnished to attain or maintain the residents' highest practicable physical, mental and psychological being. During a review of the facility's recent P&P titled Leave of Absence without Notice (LAWN) last reviewed on 1/16/2026, the P&P indicated: Procedural guidelines: 1.Residents will be evaluated by interdisciplinary team members (IDT) for possible leave of absence without notice /authorization upon admission, quarterly and when there is a significant change of condition. 3.A resident deemed at risk for Leave of Absence without Notice by IDT a re to consider the following measures but not limited to: Initiate/update plan of care 4. Procedural Post Leave of Absence without notice. Documentation in the medical record will include findings from nursing and social services, physician/family notification, and care plan discussions as applicable. During a review of the facility's recent P&P titled Wandering and Elopements last reviewed on 12/18/2026, the P&P indicated: Policy Statement The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Policy Interpretation and Implementation 1.If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who was confused and had a diagnosis of dementia (a progressive state of decline in mental abilities) did not elope (the act of leaving a facility unsupervised and without prior authorization) the facility on 5/17/2026 at approximately after 10:45AM by failing to: - Ensure the Interdisciplinary Team (IDT, group of diverse health care professionals from different fields) assessed Resident 1 as at risk for elopement (leaving the facility unsupervised). This failure resulted for Resident 1 to leave the facility on 5/17/2026 unsupervised and placed Resident 1 at risk for harm, injury, and/or death.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted the resident on 9/26/2025 and readmitted the resident on 11/13/2025 with diagnoses that included but not limited to unspecified dementia, hypotension (low blood pressure), and hyperlipidemia (a condition having too many lipids (fats), in the blood). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 4/20/2026, the MDS indicated Resident 1 sometimes made himself understood and sometimes understood others. The MDS indicated Resident 1 had severely impaired cognition (significant decline in a resident's mental abilities that profoundly impacts their daily life and independence). The MDS indicated Resident 1 self-propelled (steer) a manual wheelchair for mobility. During a review of Resident 1's Nursing Document Evaluation Form dated 5/11/2026, the Nursing Document Evaluation Form indicated Resident 1 was at risk for Leave of Absence Without Notice (LAWN) and Resident 1 had a history of exhibiting exit -seeking behavior while at home or from the facility without informing staff. The Nursing Document Evaluation Form did not indicate IDT considerations. During a review of Resident 1's Care Plan Report dated 5/11/2026, the Care Plan Report indicated Resident 1 was at risk for Leave of Absence without notice (LAWN). The Care Plan Report indicated to monitor the resident's location with visual checks during routine care and as needed. During a review of Resident 1's History and Physical dated 5/13/2026, the History and Physical indicated Resident 1 did not have the capacity to make decisions. During a review of Resident 1's SBAR Communication Form dated 5/17/2026, the SBAR indicated the staff (unidentified) last saw Resident 1 on 5/17/2026 at 10:45 AM. The SBAR indicated that a receptionist (unidentified) received a call from a rehab staff (unidentified) that they found Resident 1 down the street from the facility. The SBAR indicated the staff (unidentified) brought Resident 1 back to the facility at 11:24 AM. During a review of Resident 1's Interdisciplinary Care Conference document dated 5/19/2026, the Interdisciplinary Care Conference indicated the IDT determined the likely root cause to be unsupervised exit through the facility's front door. The Interdisciplinary Care Conference document indicated Resident 1 was known to walk throughout the facility as part of daily routine. During an interview on 5/20/2026 at 9:54 AM with Receptionist 1, Receptionist 1 stated her job duties included answering telephone calls and monitoring individuals entering and exiting the facility through the front entrance. Receptionist 1 stated nursing staff (in general) were aware when residents (in general) would try to leave the facility. During an interview on 5/20/2026 at 12:57 PM, with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 1 had a diagnosis of dementia and required frequent reminders and reorientation to place due to confusion and forgetfulness regarding his surroundings. CNA 1 stated Resident 1 was able to get out of bed independently and would ambulate (walk) throughout the facility without assistance or supervision at times. CNA 1 stated she (CNA1) assisted Resident 1 in a wheelchair to the activity room entrance on 5/17/2026 (unidentified time). During an interview on 5/20/2026 at 2:24 PM, with Activities Assistant1 (AA 1), AA 1 stated Resident 1 self-propelled his wheelchair into the activity room on 5/17/2026 at approximately 10 AM. AA 1 stated Resident 1 remained in the activity room for about 30 minutes. AA 1 stated Resident 1 had dementia and liked to wander throughout the facility, and frequently would go out to the patio area. AA 1 stated Resident 1's elopement could have been prevented if Resident 1 had been properly supervised. AA 1 stated that without supervision, Resident 1 was at risk of injury becoming involved in an accident due to his wandering behaviors and cognitive impairment. During an interview on 5/20/2026 at 2:50 PM, with Licensed Vocational Nurse (LVN 1), LVN 1 stated Resident 1 had a diagnosis of dementia and demonstrated significant cognitive impairment. LVN 1 stated residents with dementia (in general) may not fully understand their care needs or safety risks. LVN 1 stated based on her assessment, Resident 1 exhibited more severe dementia related behaviors compared to other residents in the facility. LVN 1 stated Resident 1 was observed ambulating in the hallway near the receptionist area and Resident 1 had a wandering behavior. LVN 1 stated Resident 1 could benefit from increased supervision to monitor wandering and maintaining resident safety. LVN 1 stated the Wander Guard device (a bracelet that sounds when near a door and alerts staff when a confused resident tries to leave unsupervised) could have been placed prior to 5/17/2026 if Resident 1's wandering behavior had been assessed as being at risk for exiting through the facility entrance. During an interview on 5/20/2026 at 3:54 PM, with Receptionist 2, Receptionist 2 stated he was aware of the Elopement Binder (book of resident's information at risk for elopement) located at the front desk. Receptionist 2 stated the elopement binder had no information of residents at risk for elopement prior to 5/17/2026. During a concurrent interview and record review on 5/21/2026 at 9:05 AM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled Leave of Absence Without Notice (LAWN) was reviewed. The DON stated the LAWN assessment replaced the facility's elopement risk evaluation approximately three months prior to 5/11/2026. The DON stated the LAWN assessment was used to identify residents at risk for leaving the facility without notice. The DON stated the P&P indicated that when a resident was identified as being at risk for elopement, the resident's physician was notified to obtain an order for a wonder guard device. The DON stated the facility failed to implement a Wander Guard intervention for Resident 1. During a concurrent interview and record review on 5/21/2026 at 9:10 AM, Resident 1's Nursing Documentation Evaluation dated 5/11/2026 was reviewed with the DON. The DON stated that the Nursing Documentation Evaluation of Resident 1 indicated Resident 1 was assessed as high risk for history of exit seeking behavior. During a concurrent interview and record review on 5/21/2026 at 9:15 AM, with the DON the facility's P&P titled Elopement of Resident dated 5/11/2026 was reviewed. The DON stated the P&P required that a photograph be obtained, an elopement identification form be completed, and the resident's information be placed in the elopement risk binder for residents identified as being at risk for elopement. The DON stated the elopement risk binder should be readily accessible to staff. The DON stated Resident 1 was assessed as being at risk for LAWN. The DON stated Resident 1's photograph and identification information were not included in the elopement risk binder on 5/11/2026 in accordance with the facilities P&P. During an interview on 5/21/2026 at 2:28 PM, with the Activities Director (AD), the AD stated Elopement risk refers to residents with wandering behaviors who required interventions to prevent them from leaving the facility and to ensure their safety. The AD stated Resident 1 had a diagnosis of dementia and exhibited wandering behaviors. The AD stated president wants LAWN on 5/17/2020 six could have been prevented with appropriate supervision. The ad stated resident one was not under direct supervision at the time of Resident 1's elopement incident on 5/17/2026. The AD stated Resident 1 should have been included in the facilities elopement risk binder to alert staff of the residents wandering and elopement risk. The AD stated that additional supervision and elopement prevention intervention should have been implemented for Resident 1. During a review of the facility's recent P&P titled Leave of Absence Without Notice last reviewed on 1/16/2026, the P&P indicated: The interdisciplinary team members (IDT) are recommended to evaluate if a resident is deemed at risk of leaving the facility without notice and identify resident-specific measures in a least restrictive environment. Procedural guidelines 1.Residents will be evaluated by the interdisciplinary team members (IDT) for possible leave of absence without notice/authorization upon admission, quarterly and when there is a significant change in condition. 2.The IDT is recommended to use the Leave of Absence without Notice flow chart as a guide to consider resident specific factors to determine if resident is at risk for elopement. 3.A resident deemed at risk for Leave of Absence without Notice by IDT are to consider the following measures but not limited to: Initiate/Update plan of care Consider application of a wander guard in collaboration with the physician and responsible party In the absence of a wander guard system the IDT to collaborate and identify measures necessary to avoid leaving the facility without notice /authorization. During a review of the facility's recent P&P titled Elopement Resident last reviewed on 12/18/2025, the P&P indicated: I.PURPOSE To provide a process for managing residents at risk for elopement. II. POLICY Residents will be evaluated for elopement risk upon admission, re-admission, quarterly and with a change in condition as part of the clinical assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. Elopement occurs when a patient leaves the premises without authorization (i.e., an order for discharge or leave of absence (LOA) and/or any necessary supervision to do so. State definitions for elopement vary; follow state definition if different. III. PROCEDURE Assessment/Evaluation: Identify patient's elopement risk by reviewing the following upon admission, re- admission, quarterly, or with a significant change in conditions as defined by [NAME] Manual criteria utilizing the nursing assessment, social services assessment, and other disciplinary assessments. For residents identified as at risk, an interdisciplinary elopement prevention person centered care plan will be developed with patient participation and patient representative when applicable. Obtain current photograph of patient. Complete the Elopement Risk Identification form for all residents at risk of elopement and place in a binder that is easily accessible to staff.

Based on interviews and record review, the facility failed to ensure the physician's order for bumetanide oral tablet (medication prescribed to treat excess fluid retention and swelling [edema]) was carried out timely for one of four sampled residents (Resident 1) per facility's policy and procedures (P&P) titled, Physician's Order.This deficient practice has the potential to result in Resident 1 in unintended complications related to the management of congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including acute on chronic diastolic CHF, acute and chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide) with hypoxia (a dangerous condition where your body's tissues and organs do not receive enough oxygen to function properly) and insomnia (trouble falling asleep or staying asleep). During a review of the Minimum Data Set (MDS - resident assessment tool) dated 8/18/2025, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 1 required maximal assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1's Medication List from General Acute Care Hospital 1 (GACH 1) indicated, continue bumetanide 0.5 mg - take 1 tablet by mouth in the morning and 1 tablet before bedtime.During a review of Resident 1's Baseline Care Plan (BCP), dated 8/12/2025, the BCP indicated interventions that included, to administer medications, treatments, and other services in accordance with physician orders.During a review of Resident 1's Order Summary Report (OSR), the OSR indicated the bumetanide oral tablet 0.5 mg - give 1 tablet by mouth every 12 hours, dated 8/12/2025.During a review of Resident 1's Medication Administration Record (MAR), the MAR indicated:On 8/12/2025, 9 p.m., - Bumetanide oral tablet 0.5 mg - not givenOn 8/13/2025, 9 a.m., - bumetanide oral tablet 0.5 mg - not givenOn 8/13/2025, 9 p.m., - bumetanide oral tablet 0.5 mg - not givenOn 8/14/2025, 9 a.m. - bumetanide oral tablet 0.5 mg - not givenOn 8/15/2025, 9 p.m. - bumetanide oral tablet 0.5 mg - not given During a review of Resident 1's Progress Notes (PN - Nurse's notes) dated 8/13/2026, the PN indicated that, Per Nurse Practitioner (NP), ok to continue bumetanide (bumex - brand name) since she (Resident 1) got it at the hospital and tolerated well.During a concurrent interview and record review with Director of Nursing (DON) on 5/6/2026 at 3:24 p.m., DON stated, upon admission, the admitting nurse should verify the medications to be continued/started with the referral facility. DON reviewed Resident 1's Medication List from GACH 1 and stated, Resident 1 should be on bumetanide oral tablet upon admission as ordered by the physician, dated 8/12/2025. DON stated, Resident 1's MAR indicated, Resident 1 did not receive bumetanide medication until 8/14/2025. DON stated, if resident did not receive the medications as ordered, they need to notify the physician and document it on resident's medical record. DON stated, staff should also call the pharmacy to deliver medications and/or follow-up if medications were not available.During a review of the facility's P&P titled, Physician Orders, reviewed on 12/2025, the P&P indicated, Purpose: This will ensure that all physician orders are complete and accurate. The Licensed urse receiving the order will be responsible for documenting and implementing the order. Medication/treatment orders will be transcribed onto the appropriate resident administration record. Supplies/medications required to carry out the physician order will be ordered.During a review of the facility's P&P titled, Medication Utilization and Prescribing - Clinical Protocol, reviewed on 12/2025, the P&P indicated that, When a medication is prescribed for any reason, the physician and staff will identify the indications, considering the resident's age, medical and psychiatric conditions, risks, health status, and existing medication regimen.

Based on interview and record review, the facility failed to provide necessary respiratory care services for one of three sampled residents (Resident 1), by failing to:Follow physician's order for bilevel positive airway pressure machine (BiPAP - a device that helps people breathe easier, especially when they have breathing difficulties like sleep apnea [a sleep disorder where breathing repeatedly stops and starts during sleep]) per facility's protocol.Ensure a complete physician's order was in place for BiPAP therapy per facility's policy and procedures (P&P) titled, CPAP (continuous positive airway pressure-a breathing machine designed to increase air pressure, keeping the airway open when the person breathes in), CPAP -Auto, BiPAP, Auto-PAP (Automatic Positive Airway Pressure) machine is a breathing device used to treat sleep apnea), & BIPAP St (Spontaneous - follows natural breathing).These deficient practices had the potential to cause complications associated with respiratory treatment.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including acute on chronic diastolic congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), acute and chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide) with hypoxia (a dangerous condition where your body's tissues and organs do not receive enough oxygen to function properly) and insomnia (trouble falling asleep or staying asleep). During a review of the Minimum Data Set (MDS - resident assessment tool) dated 8/18/2025, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 1 required maximal assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1's history and physical (H&P), dated 7/27/2025, the H&P indicated, (Resident 1) to continue BiPap at bedtime. the H&P indicated, Acute Respiratory Orders or Rehab BiPAP mode: BiPap; IPAP (inspiratory pressure - the highest level of pressure applied to the lungs during inhalation): 15; EPAP (expiratory positive airway pressure - breathing support only applies positive pressure when you are exhaling): 5; FiO2 (a comparison between the oxygen level in the blood and the oxygen concentration that is breathed) (% - unit of measure): 21 at bedtime every six hours.During a review of Resident 1's Nursing Documentation Evaluation (NDE), dated 8/12/2026, the NDE indicated the form for respiratory needs (such as Bipap, Cpap (continuous positive airway pressure-a breathing machine designed to increase air pressure, keeping the airway open when the person breathes in), Ventilator (a medical device to help support or replace breathing), Oxygen, etc) was blank. The NDE also indicated an additional comment that stated, (Resident 1) new admit from General Acute Care Hospital 1 (GACH) 1. on Bipap at nighttime.During a review of Resident 1's Order Summary Report (OSR), dated 8/13/2025, The OSR indicated, physician ordered, BiPAP: fill with sterile water at bedtime for sleep apnea.During a review of Resident 1's Treatment Administration Record (TAR), the TAR order for BiPap indicated a start date of 8/14/2025. The BiPAP order did not indicate a specific order for BiPAP mode and settings.During a review of Resident 1's Care Plan (CP) date initiated 8/14/2025, the CP indicated (Resident 1) exhibits or is at risk for respiratory complications related to asthma (respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing), acute and chronic respiratory failure with hypoxia using BiPap at nighttime.During an interview with Respiratory Therapist 1 (RT 1) on 5/6/2026 at 2:48 p.m., RT 1 stated, upon admission, if there is an order for BiPap treatment, they need to set up the machine and start the BiPAP treatment at bedtime. RT 1 stated, if the BiPAP was not started upon admission per physician's order, they need to notify the physician. RT 1 stated, registered nurses and RTs are responsible for setting up and managing the BiPAP therapy. RT 1 further stated, the RNs and RTs are the responsible staff to manage and document respiratory services that residents received. During a concurrent interview and record review with Director of Nursing (DON) on 5/6/2026 at 3:4 p.m., DON stated, if there is a physician's order for BiPAP therapy upon admission, they have to ensure that the machine was available prior to admission and set up the machine as ordered. DON reviewed Resident 1's medical record and TAR on BiPAP treatment, and stated and confirmed, the BiPAP order was incomplete and was started two days after admission. DON stated, there should be documentation and notification to the physician why the BiPap order was not started upon admission with complete documentation.During a review of the facility's policy and procedures (P&P) titled, CPAP, CPAP -Auto, BIPAP, AUTO-PAP, & BIPAP St, effective date 4/7/2026, the P&P indicated that, Verify physician's order. The Order should state the CPAP pressure. The BiPap/BiPap ST order should include the inspiratory and expiratory pressures, and a respiratory rate, if needed.During a review of the facility's P&P titled, Respiratory Treatments, effective date 4/7/2026, the P&P indicated that, The respiratory services aim to improve the quality of life, reduce complications, and manage respiratory health through comprehensive, evidence-based care, education, and support for residents and their families. The Registered Nurse (RN) or Respiratory Therapist (RT) will document the respiratory treatment administration in the resident's eMAR module. The RN or RT will document daily the summary of resident's response to treatment(s) and respiratory assessment on the Respiratory Daily Treatment Note form in the resident's electronic health record for each treatment provided. The Daily assessments should be completed during evaluation of the resident's response to treatments and overall respiratory status. During a review of the facility's P&P titled, Physician Orders, reviewed date 12/18/2025, the P&P indicated that, Purpose: This will ensure that all physician orders are complete and accurate. Physician orders will include the following: Name of the prescriber, the name of the resident, the date and time the order was received; and the signature of the Licensed Nurse receiving and documenting the order, if by telephone. Treatment orders will include the following: A description of the treatment, including the treatment site, if applicable. The frequency of treatment and duration of order; and the condition/diagnosis for which the treatment is ordered.

Based on interview and record review the facility failed to provide care and services to prevent a fall (unintentionally coming to rest on a lower-level surface) for one of three sampled residents (Resident 11) reviewed for accidents by failing to: -Ensure Certified Nursing Assistant 7 (CNA 7) provided a two-person physical assistance (help from two person) and use of a Hoyer Lift (a medical device designed to safely transfer residents with limited mobility between beds, chairs, and wheelchairs) to transfer Resident 11 from Resident 11's bed to the wheelchair on 4/20/2026 at 6:50 AM as indicated in Resident 11's care plan. As a result, on 4/20/2026 at 6:50 AM, Resident 11 sustained a fall, experience severe knee pain (disabling; unable to perform daily living activities), and inability to bear weight (unable to stand or walk). Resident 11 was transferred to the emergency room (ER) of General Acute Care Hospital 1 (GACH 1) via emergency services. At GACH 1, Resident 11 was found to have a mildly displaced comminuted extra-articular fracture of the right distal femoral meta diaphysis (an injury where the right lower thigh bone is broken into multiple pieces); and a displaced comminuted peri implant fracture involving the distal left femur (an injury where the lower thigh bone is broken into multiple pieces near an existing orthopedic implant). Resident 11 underwent surgery on her right leg on 4/23/2026 and was scheduled to have another surgery on her left leg on 4/30/2026. Cross Reference F656 Findings: During a review of Resident 11's admission Record, the admission Record indicated the facility admitted the resident on 8/17/2024 with diagnoses that included type 2 diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), End Stage Renal Disease (ESRD, irreversible kidney damage), and dependence on renal (kidney) dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). During a review of Resident 11's Minimum Data Set (MDS, a resident assessment tool) dated 2/20/2026, the MDS indicated Resident 11 was cognitively intact (had the ability to think, understand, and reason). The MDS indicated Resident 11 normally used a wheelchair. The MDS indicated Resident 11 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports the trunk or limbs, but provides less than half the effort) with sit to stand mobility, chair/bed-to-chair transfer, toilet transfer, and tube/shower transfer. During a review of Resident 11's Nursing Documentation Evaluation dated 2/22/2026 at 6:57 PM, the Nursing Documentation Evaluation indicated Resident 11 had fall risk factors (any attribute, characteristic, or exposure that increases the likelihood of developing a disease, injury, or negative outcome) that included impaired balance (a condition in which an individual feels unsteady), predisposed disease or injury (a pre-existing medication condition, physical, or genetic trait that increases an individual's susceptibility to develop a different disease or injury), and required assistance for toileting. During a review of Resident 11's Care Plan Report dated 4/19/2026, the Care Plan Report indicated Resident 11 had an Activities of Daily Living (ADLs, the basic self-care tasks such as bathing, dressing, eating, and mobility that individuals perform daily to maintain independence and hygiene) self-care performance deficit related to impaired mobility (a condition that limits a person's ability to move freely or perform activities), generalized weakness (reduced muscle strength throughout the entire body), polyneuropathy (a condition in which multiple peripheral nerves in the body become damaged and causing numbness, tingling, and pain), and the use of the wheelchair. The Care Plan Report indicated the goal for Resident11 was to maintain Resident 11's current level of mobility. The Care Plan Report indicated Resident 11 required total assistance with transfers, two staff participation, the use of the Hoyer lift machine, and a yellow color medium size sling (a supportive fabric device used with resident lifts to safely transfer residents between beds, chairs, and the floor). During a review of Resident 11's SBAR (Situation, Background, Assessment, Recommendation - a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form dated 4/20/2026, the SBAR Communication Form indicated Resident 11 had a fall. The SBAR Communication Form indicated that while the CNA (unidentified) was getting Resident 11 up to go to dialysis Resident 11 slipped from the bed to the floor and landed on her (Resident 11) knees. The SBAR Communication Form indicated Resident 11 was observed lying on the floor by the charge nurse (unidentified) when the charge nurse was informed that Resident 11 had a fall. The SBAR Communication Form indicated Resident 11 had right and left knee pain that Resident 1 rated a level five (rated on a scale of 1-10 with 10 being the worst). The SBAR Communication Form indicated Resident 11 did not show any obvious signs of injury. The SBAR Communication Form indicated Resident 11 stated her (Resident 11) knees hurt from the fall. The SBAR Communication Form indicated Resident 11 was safely put back on the wheelchair assisted by three people using a bed sheet. The SBAR Communication Form indicated Resident 11 was given Tylenol (acetaminophen, a medication used to reduce pain). The SBAR Communication Form indicated Resident 11 was taken to the lobby to wait for transportation to dialysis. The SBAR Communication Form indicated Resident 11 left the facility in stable condition. The SBAR Communication Form indicated Resident 11's Nurse Practitioner (NP, unidentified) was notified on 4/20/2026 at 7:30 AM of Resident 11's fall. The SBAR Communication form indicated Resident 11's NP ordered to monitor Resident 11 and to inform the NP if an x-ray (an imaging test that uses electromagnetic radiation to create pictures of bones and tissues) was needed when Resident 11 returned from dialysis. During a review of Resident 11's Order Summary Report, the Order Summary Report indicated the resident had a physician order dated 4/20/2026 to transfer Resident 11 to GACH 1's ER for further evaluation related to knee pain. During a review of Resident 11's GACH 1 bilateral knee x-ray report dated 4/20/2026 at 5:41 PM, the bilateral knee x-ray report indicated Resident 11 had a mildly displaced comminuted extra-articular fracture of the right distal femoral meta diaphysis. The bilateral knee x-ray report indicated Resident 11 had a displaced comminuted peri implant fracture involving the distal left femur. During a review of Resident 11's Hospitalist History and Physical from GACH 1 dated 4/21/2026, the Hospitalist History and Physical indicated Resident 11 presented to GACH 1 on 4/20/2026 for a fall. The Hospitalist History and Physical indicated Resident 11 had a mechanical fall (a fall caused by an external, physical force. such as tripping, slipping, or stumbling rather than an internal medical issue like fainting or dizziness) while trying to get back into the wheelchair and landed on her (Resident 11) knees. The Hospitalist History and Physical indicated Resident 11 had severe pain, was unable to bear weight, and was found to have bilateral distal femur fractures. During a review of Resident 1's Orthopedic Arthroplasty (a physician who focuses on replacing, repairing, or reconstructing damaged joints) Progress Note from GACH 1 dated 4/22/2026 at 6:08 AM, the Orthopedic Arthroplasty Progress Note indicated Resident 11 sustained bilateral distal femur fractures after an accident at the resident's care facility. The Orthopedic Arthroplasty Progress Note indicated Resident 11 was informed that it was best to address treatment for Resident 11's legs one leg at a time given Resident 11's comorbidities (the presence of more than one disease or disorder) and the risks of anesthesia (is the use of medications to block pain during medical procedures or surgery) and surgery. The Orthopedic Arthroplasty Progress Note indicated the intended plan was for Resident 11 to have an Open Reduction and Internal Fixation (ORIF, a surgical procedure to repair severe bone fractures) of the right femur first. The Orthopedic Arthroplasty Progress Note indicated surgery was planned for Resident 11's right femur on 4/23/2026. During a telephone interview on 4/28/2026 at 10:29 AM with Resident 11, Resident 11 stated she (Resident 11) was at the GACH (unidentified). Resident 11 stated that on 4/20/2026 at almost 7 AM, CNA 7 was assisting her (Resident 11) to get to the wheelchair so the resident could go to dialysis. Resident 11 stated CNA 7 stood behind the wheelchair and grabbed the resident by her (Resident 11) sweatpants and waist. Resident 11 stated she (Resident 11) fell to the floor and landed on both knees. Resident 11 stated CNA 7 and her roommate (unidentified) were the only people in the room when she (Resident 11) fell. Resident 11 stated only CNA 7 was helping her Resident 11 during the resident's transfer. Resident 11 stated Registered Nurse 3 (RN 3) came to the room after Resident 11 had fallen. Resident 11 stated CNA 7 and RN 3 helped her (Resident 11) back to the wheelchair after the fall. Resident 11 stated she (Resident 11) was having a lot of pain. Resident 11 stated her pain level was 20, out of 10. Resident 11 stated she (Resident 11) was then taken to dialysis. Resident 11 stated she (Resident 11) was not doing good at the dialysis facility because she (Resident 11) was in a lot of pain. Resident 11 stated she (Resident 11) asked to go to the GACH (unidentified) when she (Resident 11) was at the dialysis facility. Resident 11 stated both of her (Resident 11) legs were broken. Resident 11 stated she (Resident 11) had surgery on her right leg on 4/23/2026 and was scheduled to have another surgery on her left leg on 4/30/2026. Resident 11 stated I'm so frustrated, and I am in a lot of pain. During a telephone interview on 4/29/2026 at 8:45 AM with CNA 7, CNA 7 stated that on 4/20/2026 at 6:50 AM she (CNA 7) was transferring Resident 11 from the bed to the wheelchair to get Resident 11was ready to go to dialysis. CNA 7 stated there were no other staff present in Resident 11's room at the time the CNA was assisting Resident 11 to the wheelchair. CNA 7 stated she (CNA7) was trying to get the wheelchair into position by Resident 11's bed, when Resident 11 started scooting to the edge of the bed trying to get to the wheelchair. CNA 7 stated Resident 11 started to slide to the floor. CNA 7 stated she (CNA 7) tried to grab Resident 11 under the resident's arms, but Resident 11 landed on her (Resident 11) knees. CNA 7 stated she (CNA 7) assisted Resident 11 to lay on her (Resident 11) back and called RN 3 to Resident 11's room. CNA 7 stated that Resident 11 said her (Resident 11) knees were hurting, but CNA 7 could not remember the resident's pain level. During an interview on 4/29/2026 at 9:29 AM with the Director of Nursing (DON), the DON stated RN 3 was on vacation. On 4/29/2026 at 9:29 AM an attempt to contact RN 3 by telephone was made, but RN 3 could not be reached for an interview. During a telephone interview on 4/29/2026 at 10:36 AM with Dialysis Registered Nurse 1 (DRN 1), DRN 1 stated she (DRN 1) worked at Dialysis Facility 1 (DF 1). DRN 1 stated Resident 11 received dialysis at DF 1. DRN1 stated she (DRN 1) was one of the nurses who assisted Resident 11 on 4/20/2026. DRN 1 stated Resident 11 informed DRN 1 that she (Resident 11) had fallen when she (Resident 11) was being assisted by a staff member (unidentified) at the facility during a transfer. DRN 1 stated Resident 11 informed DRN 1 that the person (unidentified) who was transferring the resident at the SNF was holding the resident from behind, when Resident 11 slipped and fell on her (Resident 11) knees. DRN 1 stated Resident 11 had a pain level of 10 out of 10 while at DF 1. DRN 1 stated that after dialysis Resident 11 stated she (Resident 11) would not be able to get back into the wheelchair, because it was too painful for Resident 11. DRN 1 stated Resident 11 wanted to go to the ER. During an interview on 4/29/2026 at 10:42 AM with Dialysis LVN 1 (DLVN 1), DLVN 1 stated that on 4/20/2026 (unidentified time), he (DLVN 1) called DRN 1 to assess Resident 11 at DF 1. DLVN 1 stated that Resident 11 had informed him (DLVN 1) that she (Resident 11) had slid and landed on both her (Resident 11) knees when a staff (unidentified) assisted Resident 11 during a transfer at the SNF. DLVN 1 stated Resident 11 had a 10 out of 10 pain level to both of her (Resident 11) knees. DLVN 1 stated that when Resident 11 finished dialysis, Resident 11 requested a gurney (stretcher) transportation to the GACH (unidentified). DLVN 1 stated Resident 11 could not bend her (Resident 11) knees because it was too painful. DLVN 1 stated the DF1 called 911 (emergency services phone number) and Resident 11 was transferred to the GACH (unidentified). On 4/29/2026 at 1:43 PM a second attempt to contact RN 3 by telephone was made. RN 3 could not be reached for interview. During a concurrent interview and record review on 4/29/2026 at 3:33 PM with the Director of Nursing (DON), Resident 11's Care Plan Report dated 4/19/2026 was reviewed. The DON stated a care plan was a guide that had interventions for the nurses (in general) and the staff (in general) to follow the care plan to provide good care for the residents (in general). The DON stated the care plan was resident centered and based on resident needs. The DON stated Resident 11 had a care plan for an ADL self-care performance deficit related to impaired mobility, generalized weakness, polyneuropathy, and use of the wheelchair. The DON stated Resident 11's ADL self-care performance deficit care plan had an intervention for transfers. The DON stated Resident 11's ADL self-care performance deficit care plan indicated Resident 11 required total assistance with transfers, two staff participation, use of the Hoyer lift machine, and a medium yellow color sling size. The DON stated staff (in general) were expected to follow Resident 11's care plan when transferring the resident. The DON stated that if Resident 11's care plan indicated the resident required total assistance with transfers, two staff participation and use of the Hoyer lift machine it was the expectation that the resident be transferred with two staff members. The DON stated Resident 11's care plan was not followed. The DON stated Resident 11 was being transferred to the wheelchair from the bed by one staff member, CNA 7, on the morning of 4/20/2026. The DON stated it was important that Resident 11's care plan be followed for safety and prevention of injury. The DON stated Resident 11's fall on 4/20/2026 could have been prevented if two staff members transferred Resident 11 from the bed to the wheelchair on 4/20/2026. During an interview on 4/30/2026 at 11:31 AM with Restorative Nursing Assistant 2 (RNA 2), RNA 2 stated she (RNA 2) was familiar with Resident 11. RNA 2 stated she (RNA 2) was often called to help transfer the resident to and from the wheelchair to the bed, especially after dialysis. RNA 2 stated she (RNA2) had just assisted Resident 11 with a transfer the week before. RNA 2 stated Resident 11 required a gait belt (a strap with a metal or plastic buckle, used by caregivers to safely assist individuals with mobility issues during walking or transfers) and assistance from two staff members with transfers. During a concurrent interview and record review on 4/30/2026 at 12:33 PM with the Director of Staff Development (DSD), Resident 11's Care Plan Report dated 4/19/2026 was reviewed. The DSD stated Resident 11's Care Plan Report indicated Resident 11 needed two-person assistance with a Hoyer lift for transfers. The DSD stated that based on Resident 11's care plan, the CNAs (in general) were expected to have two-persons with a Hoyer lift when assisting Resident 11 with transfers. The DSD stated Resident 11's care plan needed to be followed. The DSD stated the care plan was a guide that indicated what the staff (in general) needed to do for Resident 11. The DSD stated interventions on the care plan were to be followed for the safety of the residents (in general). The DSD stated injury to a resident (in general) could happen if interventions on the care plan were not followed. The DSD stated if Resident 11's care plan was followed and two staff were present and used a Hoyer lift during Resident 11's transfer, the resident's fall on 4/20/2026 could have been prevented. During a review of the facility's Policy and Procedure (P&P) titled Fall Management dated 12/18/2025, the P&P indicated Patients will be assessed for falls risk as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury .Identify patient's fall risk by reviewing the Nursing Documentation. Communicate patient's fall risk status to caregivers. Develop individualized plan of care. Review and revise care plan as indicated.

Based on interview and record review, the facility failed to attempt a gradual dosage reduction (GDR - a periodic attempt to reduce a dose of a medication in an attempt to mitigate potential side effects) or document a clinical rationale for contraindication (why the attempt would be clinically inappropriate) for risperidone (a medication used to treat mental illness) since 9/15/2022 in one of five sampled residents(Resident 4) reviewed unnecessary medications. The deficient practice of failing to attempt a GDR or document why an attempt would be contraindicated for Resident 4's risperidone increased the risk that Resident 4 could have experienced adverse effects (a harmful unintended result) related to psychotropic medication (medications that affect brain activities associated with mental processes and behavior) therapy, such as drowsiness, dizziness, constipation, movement disorders, or increased risk of fall, possibly leading to impairment or decline in his mental or physical condition or functional or psychosocial status.Findings:During a review of Resident 4's admission Record (a record containing diagnostic and demographic resident information), the admission Record indicated the facility admitted Resident 4 on 3/2/2021 and readmitted the resident on 8/26/2024 with diagnoses including schizoaffective disorder bipolar type (a mental illness characterized by seeing and/or hearing things that are not there, believing things that are untrue, and extreme mood swings). During a review of Resident 4's physician orders for risperidone, dated between 9/15/2022 and 4/29/2026, indicated Resident 4 was initially prescribed risperidone on 9/15/2022 to be given one milligram (mg - a unit of measure for mass) by mouth at bedtime. The physician orders for risperidone indicated the dose was increased on 1/26/2023 to two milligrams by mouth every evening and then increased again on 7/12/2024 to two milligrams by mouth every 12 hours. During a review of Resident 4's History and Physical (H&P - a record of a physician's comprehensive medical assessment and plan) dated 9/16/2025, the H&P indicated Resident 4 had a mildly impaired cognitive status (noticeable decline in memory or thinking skills). During a review of Resident 4's current Order Summary Report (a report of all currently active physician's orders), dated 4/29/2026, indicated he was currently taking risperidone 2 mg by mouth every 12 hours for schizoaffective disorder. During a review of Resident 4's clinical record indicated there were no attempts to use a lower dose of risperidone to manage symptoms of schizoaffective disorder since the medication was initially prescribed on 9/15/2022. During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool) Section N (medications), dated 2/20/2026, indicated Resident 4 had been receiving an antipsychotic medication (a class of medications used to treat mental illness which includes risperidone) continuously, a GDR had not been attempted for it, and there was no date in the clinical record on which the physician had documented that a GDR attempt on risperidone would be clinically contraindicated. During a review of the pharmacist's recommendation dated 3/30/2026, indicated the pharmacist recommended that the physician attempt a GDR for Resident 4's risperidone. The pharmacist's recommendation indicated the physician declined to perform the GDR citing failures from previous attempts which resulted in violent behaviors. During an interview on 4/29/2026 at 11:57 AM with the Director of Nursing (DON), the DON stated Resident 4 had been taking risperidone continuously since September 2022. The DON stated the dose was increased in January of 2023 and then again in July of 2024. The DON stated there was no record of any dosage decrease having been attempted since the risperidone was initially prescribed. The DON stated the MDS assessment dated [DATE] indicated there had been no attempt at a GDR on risperidone and no date when it was documented as contraindicated. The DON stated she (DON) could not explain why the physician's response to the pharmacist's recommendation references previously failed GDR attempts on risperidone when there was no evidence of it having been attempted in the clinical record. The DON stated the GDR must be attempted at least every year for residents (in general) on antipsychotics. The DON stated failing to attempt the GDR increased Resident 4's risk of adverse effects of antipsychotics such as drowsiness, dizziness, risk of falls, and movement disorders which could cause medical complications and a decrease in his quality of life. During an interview on 4/29/2026 at 1:03 PM with the psychiatrist (MD 1), MD 1 stated she (MD 1) had attempted a GDR on Resident 4's lithium (a medication used to treat mental illness) in the past but not on the risperidone. MD 1 stated she (MD 1) mistakenly responded to Resident 4's pharmacist recommendation from March 2026 to do a GDR on his risperidone that previous attempts have been failed as she (MD 1) confused the previous attempts with the lithium. MD 1 stated she (MD 1) understood that the clinical rationale to decline a GDR as contraindicated cannot be previous failures when no actual attempts had been made to do a GDR on that specific medication. During a review of the facility's policy titled Psychotropic Medication Use, dated June 2021, indicated .Within the first year in which a resident is admitted on a psychotropic medication or after the prescribing practitioner had initiated a psychotropic medication, the facility must attempt a GDR in two separate quarters (with at least one month between the attempts), unless clinically contraindicated. After the first year, a GDR must be attempted annually, unless clinically contraindicated. Physician/Prescriber should document the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or increase distressed behavior.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) to meet the needs of five of 18 sampled residents (Resident 2, Resident 9, Resident 11, Resident 40, and Resident 88) by failing to ensure to: 1.Implement Resident 2's care plan for at risk for skin breakdown. 2.Develop a care plan for Resident 9's language communication preference. 3.Implement Resident 11's care plan for Activities of Daily Living (ADLs, the basic self-care tasks such as bathing, dressing, eating, and mobility that individuals perform daily to maintain independence and hygiene) self-care performance deficit (when a resident cannot independently perform daily activities due to physical or mental health limitations). 4.Develop a care plan for Resident 40's flu (a respiratory virus) vaccine (medications used to prevent diseases usually given by injection or by mouth) refusal. -Develop a care plan for Resident 40's arteriovenous (AV) fistula/shunt (a surgically created connection linking an artery [a type of blood vessel that carries oxygen-rich blood the entire body] directly to a vein [a type of blood vessel that collected oxygen-poor blood and returns it to the heart] to facilitate blood flow for HD) in the right upper arm. 5. Develop a care plan for Resident 88's refusal of the pneumonia (PNA-an infection/inflammation in the lungs) vaccines. These failures had the potential for Resident 2, Resident 9, Resident 11, Resident 40, and Resident 88 to receive inadequate care causing resident injury and harm.Findings: 1.During a review of Resident 2's admission Record, the admission Record indicated the facility originally admitted Resident 2 on 7/16/2025 and re-admitted the resident on 9/17/2025 with diagnoses including gastrostomy (GT- a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration), malnutrition (lack of sufficient nutrients in the body), and generalized muscle weakness (weakening, shrinking, and loss of muscle). During a review of Resident 2's History and Physical (H&P) dated 9/3/2025, the H&P indicated Resident 2 did not have the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 3/20/2026, the MDS indicated Resident 2 had impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and maximal assistance (helper does more than half the effort) to dependent (helper does all the effort) from staff for ADLs. The MDS indicated Resident 2 was at risk of developing pressure ulcers/injuries (PI, injuries to the skin and underlying tissue resulting from prolonged pressure on the skin) with treatment for pressure reducing devices for bed. During a review of Resident 2's Braden Scale (pressure ulcer risk predictor tool) for predicting pressure ulcer risk (BSPPUR) dated 4/14/2026, the BSPPUR indicated Resident 2 was at risk for pressure ulcer development. During a review of Resident 2's Care Plan Report revised on 4/14/2026, Care Plan Report indicated Resident 2 was at risk for skin breakdown, related to advanced age (greater than 75 years), decreased activity, frail fragile skin, impaired cognition and limited mobility with intervention to provide lower extremity protectors-prevalon boots (type of heel protector to help reduce the risk of bedsores by keeping the heel floated, relieving pressure) and off load/float heels while in bed. During a concurrent observation and interview on 4/27/2026 at 9:38 AM, with Certified Nursing Assistant 9 (CNA 9) and Resident 2, inside Resident 2's room, Resident 2 was observed in bed with both heels touching the bed mattress, and without the prevalon boots. CNA 9 stated that both heels were supposed to be elevated, not touching the bed mattress. CNA 9 also stated Resident 2 was supposed to have prevalon boots. During a concurrent observation and interview on 4/28/2026 at 10:20 AM with Licensed Vocational Nurse 3 (LVN 3), inside Resident 2's room, Resident 2 was observed in bed with both heels touching the bed mattress and without prevalon boots. LVN 3 stated that since Resident 2 was on a low air loss mattress (LAL-a mattress designed to prevent and treat pressure wounds), Resident 2 did not need any offloading/floating of the heels and as well as the prevalon heels. During an interview on 4/30/2026 at 11:51 AM, with the Director of Nursing (DON), the DON stated that Resident 2 was at risk for skin breakdown and nursing staff should be following the care plan specifically for Resident 2. The DON stated and validated that Resident 2's bilateral heels should still be offloaded when in a LAL mattress and Resident 2 should be provided with prevalon boots per care plan. The DON also stated importance of implementing care plans to be able to provide proper care to Resident 2. 2. During a review of Resident 9's admission Record, the admission Record indicated the facility admitted Resident 9 on 3/21/2026 with diagnoses including atherosclerotic heart disease (build-up of fats, cholesterol, and other substances in and on the artery walls), metabolic encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood) and dementia (a chronic or persistent disorder of mental processes caused by brain disease). During a review of Resident 9's MDS, dated [DATE], the MDS indicated Resident 9 had impaired cognition for daily decision-making and maximal assistance from staff for ADLs. During a review of Resident 9's H&P dated 4/27/2025, the H&P indicated Resident 9 did not have the capacity to understand and make decisions. During an interview with Resident 9 and Activities Assistant (AS) on 4/27/2026 at 11:02 AM during initial tour, Resident 9 was speaking a different language, unable to speak English when asked if she (Resident 9) could communicate in English. The AS stated that Resident 9 mainly spoke a different language and facility staff used communication board to communicate with her (Resident 9). During a concurrent interview and record review on 4/30/2026 at 11:31 AM with the DON, Resident 9's Care Plan Report was reviewed. The Care Plan Report indicated Resident 9 did not have a care plan in regards with Resident 9's communication needs related to language barrier. The DON stated that Resident 9 was at risk for impaired verbal communication related to language barrier since Resident 9 spoke mainly spoke a different language, and facility communicated via communication board written in Resident 9's language. The DON stated it was important to have an individualized and comprehensive care plan for Resident 9's communication needs. 3. During a review of Resident 11's admission Record, the admission Record indicated the facility admitted the resident on 8/17/2024 with diagnoses that included type 2 diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), End Stage Renal Disease (ESRD, irreversible kidney damage), and dependence on renal (kidney) dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). During a review of Resident 11's MDS dated [DATE], the MDS indicated Resident 11 was cognitively intact (had the ability to think, understand, and reason). The MDS indicated Resident 11 normally used a wheelchair. The MDS indicated Resident 11 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports the trunk or limbs, but provides less than half the effort) with sit to stand mobility, chair/bed-to-chair transfer, toilet transfer, and tube/shower transfer. During a review of Resident 11's Nursing Documentation Evaluation dated 2/22/2026 at 6:57 PM, the Nursing Documentation Evaluation indicated Resident 11 had fall risk factors (any attribute, characteristic, or exposure that increases the likelihood of developing a disease, injury, or negative outcome) that included impaired balance (a condition in which an individual feels unsteady), predisposed disease or injury (a pre-existing medication condition, physical, or genetic trait that increases an individual's susceptibility to develop a different disease or injury), and required assistance for toileting. During a review of Resident 11's Care Plan Report dated 4/19/2026, the Care Plan Report indicated Resident 11 had an ADLs self-care performance deficit related to impaired mobility (a condition that limits a person's ability to move freely or perform activities), generalized weakness (reduced muscle strength throughout the entire body), polyneuropathy (a condition in which multiple peripheral nerves in the body become damaged and causing numbness, tingling, and pain), and the use of the wheelchair. The Care Plan Report indicated the goal for Resident11 was to maintain Resident 11's current level of mobility. The Care Plan Report indicated Resident 11 required total assistance with transfers, two staff participation, the use of the Hoyer lift machine, and a yellow color medium size sling (a supportive fabric device used with resident lifts to safely transfer residents between beds, chairs, and the floor). During a review of Resident 11's SBAR (Situation, Background, Assessment, Recommendation – a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form dated 4/20/2026, the SBAR Communication Form indicated Resident 11 had a fall. The SBAR Communication Form indicated that while the CNA (unidentified) was getting Resident 11 up to go to dialysis Resident 11 slipped from the bed to the floor and landed on her (Resident 11) knees. The SBAR Communication Form indicated Resident 11 was observed lying on the floor by the charge nurse (unidentified) when the charge nurse was informed that Resident 11 had a fall. The SBAR Communication Form indicated Resident 11 had right and left knee pain that Resident 1 rated a level five (rated on a scale of 1-10 with 10 being the worst). The SBAR Communication Form indicated Resident 11 did not show any obvious signs of injury. The SBAR Communication Form indicated Resident 11 stated her (Resident 11) knees hurt from the fall. The SBAR Communication Form indicated Resident 11 was safely put back on the wheelchair assisted by three people using a bed sheet. The SBAR Communication Form indicated Resident 11 was given Tylenol (acetaminophen, a medication used to reduce pain). The SBAR Communication Form indicated Resident 11 was taken to the lobby to wait for transportation to dialysis. The SBAR Communication Form indicated Resident 11 left the facility in stable condition. The SBAR Communication Form indicated Resident 11's Nurse Practitioner (NP, unidentified) was notified on 4/20/2026 at 7:30 AM of Resident 11's fall. The SBAR Communication form indicated Resident 11's NP ordered to monitor Resident 11 and to inform the NP if an x-ray (an imaging test that uses electromagnetic radiation to create pictures of bones and tissues) was needed when Resident 11 returned from dialysis. During a review of Resident 11's Order Summary Report, the Order Summary Report indicated the resident had a physician order dated 4/20/2026 to transfer Resident 11 to General Acute Care Hospital (GACH 1's) emergency room (ER) for further evaluation related to knee pain. During a review of Resident 11's GACH 1 bilateral (both) knee x-ray report dated 4/20/2026 at 5:41 PM, the bilateral knee x-ray report indicated Resident 11 had a mildly displaced comminuted extra-articular fracture of the right distal femoral meta diaphysis (an injury where the right lower thigh bone is broken into multiple pieces). The bilateral knee x-ray report indicated Resident 11 had a displaced comminuted peri implant fracture involving the distal left femur (an injury where the lower thigh bone is broken into multiple pieces near an existing orthopedic implant). During a review of Resident 11's Hospitalist History and Physical from GACH 1 dated 4/21/2026, the Hospitalist History and Physical indicated Resident 11 presented to GACH 1 on 4/20/2026 for a fall. The Hospitalist History and Physical indicated Resident 11 had a mechanical fall (a fall caused by an external, physical force. such as tripping, slipping, or stumbling rather than an internal medical issue like fainting or dizziness) while trying to get back into the wheelchair and landed on her (Resident 11) knees. The Hospitalist History and Physical indicated Resident 11 had severe pain, was unable to bear weight, and was found to have bilateral distal femur fractures. During a review of Resident 1's Orthopedic Arthroplasty (a physician who focuses on replacing, repairing, or reconstructing damaged joints) Progress Note from GACH 1 dated 4/22/2026 at 6:08 AM, the Orthopedic Arthroplasty Progress Note indicated Resident 11 sustained bilateral distal femur fractures after an accident at the resident's care facility. The Orthopedic Arthroplasty Progress Note indicated Resident 11 was informed that it was best to address treatment for Resident 11's legs one leg at a time given Resident 11's comorbidities (the presence of more than one disease or disorder) and the risks of anesthesia (is the use of medications to block pain during medical procedures or surgery) and surgery. The Orthopedic Arthroplasty Progress Note indicated the intended plan was for Resident 11 to have an Open Reduction and Internal Fixation (ORIF, a surgical procedure to repair severe bone fractures) of the right femur first. The Orthopedic Arthroplasty Progress Note indicated surgery was planned for Resident 11's right femur on 4/23/2026. During a telephone interview on 4/28/2026 at 10:29 AM with Resident 11, Resident 11 stated she (Resident 11) was at the GACH (unidentified). Resident 11 stated that on 4/20/2026 at almost 7 AM, CNA 7 was assisting her (Resident 11) to get to the wheelchair so the resident could go to dialysis. Resident 11 stated CNA 7 stood behind the wheelchair and grabbed the resident by her (Resident 11) sweatpants and waist. Resident 11 stated she (Resident 11) fell to the floor and landed on both knees. Resident 11 stated CNA 7 and her roommate (unidentified) were the only people in the room when she (Resident 11) fell. Resident 11 stated only CNA 7 was helping her Resident 11 during the resident's transfer. Resident 11 stated Registered Nurse 3 (RN 3) came to the room after Resident 11 had fallen. Resident 11 stated CNA 7 and RN 3 helped her (Resident 11) back to the wheelchair after the fall. Resident 11 stated she (Resident 11) was having a lot of pain. Resident 11 stated her pain level was 20, out of 10. Resident 11 stated she (Resident 11) was then taken to dialysis. Resident 11 stated she (Resident 11) was not doing good at the dialysis facility because she (Resident 11) was in a lot of pain. Resident 11 stated she (Resident 11) asked to go to the GACH (unidentified) when she (Resident 11) was at the dialysis facility. Resident 11 stated both of her (Resident 11) legs were broken. Resident 11 stated she (Resident 11) had surgery on her right leg on 4/23/2026 and was scheduled to have another surgery on her left leg on 4/30/2026. Resident 11 stated I'm so frustrated, and I am in a lot of pain. During a telephone interview on 4/29/2026 at 8:45 AM with CNA 7, CNA 7 stated that on 4/20/2026 at 6:50 AM she (CNA 7) was transferring Resident 11 from the bed to the wheelchair to get Resident 11was ready to go to dialysis. CNA 7 stated there were no other staff present in Resident 11's room at the time the CNA was assisting Resident 11 to the wheelchair. CNA 7 stated she (CNA7) was trying to get the wheelchair into position by Resident 11's bed, when Resident 11 started scooting to the edge of the bed trying to get to the wheelchair. CNA 7 stated Resident 11 started to slide to the floor. CNA 7 stated she (CNA 7) tried to grab Resident 11 under the resident's arms, but Resident 11 landed on her (Resident 11) knees. CNA 7 stated she (CNA 7) assisted Resident 11 to lay on her (Resident 11) back and called RN 3 to Resident 11's room. CNA 7 stated that Resident 11 said her (Resident 11) knees were hurting, but CNA 7 could not remember the resident's pain level. During an interview on 4/29/2026 at 9:29 AM with the Director of Nursing (DON), the DON stated RN 3 was on vacation. On 4/29/2026 at 9:29 AM an attempt to contact RN 3 by telephone was made, but RN 3 could not be reached for an interview. During a telephone interview on 4/29/2026 at 10:36 AM with Dialysis Registered Nurse 1 (DRN 1), DRN 1 stated she (DRN 1) worked at Dialysis Facility 1 (DF 1). DRN 1 stated Resident 11 received dialysis at DF 1. DRN1 stated she (DRN 1) was one of the nurses who assisted Resident 11 on 4/20/2026. DRN 1 stated Resident 11 informed DRN 1 that she (Resident 11) had fallen when she (Resident 11) was being assisted by a staff member (unidentified) at the facility during a transfer. DRN 1 stated Resident 11 informed DRN 1 that the person (unidentified) who was transferring the resident at the SNF was holding the resident from behind, when Resident 11 slipped and fell on her (Resident 11) knees. DRN 1 stated Resident 11 had a pain level of 10 out of 10 while at DF 1. DRN 1 stated that after dialysis Resident 11 stated she (Resident 11) would not be able to get back into the wheelchair, because it was too painful for Resident 11. DRN 1 stated Resident 11 wanted to go to the ER. During an interview on 4/29/2026 at 10:42 AM with Dialysis LVN 1 (DLVN 1), DLVN 1 stated that on 4/20/2026 (unidentified time), he (DLVN 1) called DRN 1 to assess Resident 11 at DF 1. DLVN 1 stated that Resident 11 had informed him (DLVN 1) that she (Resident 11) had slid and landed on both her (Resident 11) knees when a staff (unidentified) assisted Resident 11 during a transfer at the SNF. DLVN 1 stated Resident 11 had a 10 out of 10 pain level to both of her (Resident 11) knees. DLVN 1 stated that when Resident 11 finished dialysis, Resident 11 requested a gurney (stretcher) transportation to the GACH (unidentified). DLVN 1 stated Resident 11 could not bend her (Resident 11) knees because it was too painful. DLVN 1 stated the DF1 called 911 (emergency services phone number) and Resident 11 was transferred to the GACH (unidentified). On 4/29/2026 at 1:43 PM a second attempt to contact RN 3 by telephone was made. RN 3 could not be reached for interview. During a concurrent interview and record review on 4/29/2026 at 3:33 PM with the DON, Resident 11's Care Plan Report dated 4/19/2026 was reviewed. The DON stated a care plan was a guide that had interventions for the nurses (in general) and the staff (in general) to follow the care plan to provide good care for the residents (in general). The DON stated the care plan was resident centered and based on resident needs. The DON stated Resident 11 had a care plan for an ADL self-care performance deficit related to impaired mobility, generalized weakness, polyneuropathy, and use of the wheelchair. The DON stated Resident 11's ADL self-care performance deficit care plan had an intervention for transfers. The DON stated Resident 11's ADL self-care performance deficit care plan indicated Resident 11 required total assistance with transfers, two staff participation, use of the Hoyer lift machine, and a medium yellow color sling size. The DON stated staff (in general) were expected to follow Resident 11's care plan when transferring the resident. The DON stated that if Resident 11's care plan indicated the resident required total assistance with transfers, two staff participation and use of the Hoyer lift machine it was the expectation that the resident be transferred with two staff members. The DON stated Resident 11's care plan was not followed. The DON stated Resident 11 was being transferred to the wheelchair from the bed by one staff member, CNA 7, on the morning of 4/20/2026. The DON stated it was important that Resident 11's care plan be followed for safety and prevention of injury. The DON stated Resident 11's fall on 4/20/2026 could have been prevented if two staff members transferred Resident 11 from the bed to the wheelchair on 4/20/2026. During an interview on 4/30/2026 at 11:31 AM with Restorative Nursing Assistant 2 (RNA 2), RNA 2 stated she (RNA 2) was familiar with Resident 11. RNA 2 stated she (RNA 2) was often called to help transfer the resident to and from the wheelchair to the bed, especially after dialysis. RNA 2 stated she (RNA2) had just assisted Resident 11 with a transfer the week before. RNA 2 stated Resident 11 required a gait belt (a strap with a metal or plastic buckle, used by caregivers to safely assist individuals with mobility issues during walking or transfers) and assistance from two staff members with transfers. During a concurrent interview and record review on 4/30/2026 at 12:33 PM with the Director of Staff Development (DSD), Resident 11's Care Plan Report dated 4/19/2026 was reviewed. The DSD stated Resident 11's Care Plan Report indicated Resident 11 needed two-person assistance with a Hoyer lift for transfers. The DSD stated that based on Resident 11's care plan, the CNAs (in general) were expected to have two-persons with a Hoyer lift when assisting Resident 11 with transfers. The DSD stated Resident 11's care plan needed to be followed. The DSD stated the care plan was a guide that indicated what the staff (in general) needed to do for Resident 11. The DSD stated interventions on the care plan were to be followed for the safety of the residents (in general). The DSD stated injury to a resident (in general) could happen if interventions on the care plan were not followed. The DSD stated if Resident 11's care plan was followed and two staff were present and used a Hoyer lift during Resident 11's transfer, the resident's fall on 4/20/2026 could have been prevented. 4. During a review of Resident 40's admission Record, the admission Record indicated the facility originally admitted Resident 40 on 7/12/2023 and was readmitted on [DATE] with diagnoses including end stage renal disease (ESRD-a medical condition in which a person's kidney [organ in the body that filters waste and excess fluid from the blood] stop functioning on a permanent basis), and dependence on hemodialysis (HD-a life-sustaining treatment for kidney failure that acts as an artificial kidney, filtering waste, toxins and excess water from the person's body using a machine). During a review of Resident 40's H&P dated 2/19/2026, the H&P indicated Resident 40 had a capacity to understand and make decisions. During a review of Resident 40's MDS dated [DATE], the MDS indicated Resident 40 had intact cognition for daily decision-making and with varying needs on assistance from being independent to maximal assistance from staff for ADLs. During a review of Resident 40's vaccine consent form dated 8/18/2025, the vaccine consent form indicated Resident 40 declined flu vaccine. During a concurrent interview and record review on 4/30/2026 at 1:30 PM, with the Infection Preventionist Nurse (IPN), Resident 40's Care Plan Report was reviewed. Resident 40's Care Plan Report indicated missing refusal of flu vaccine care plan. The IPN stated that Resident 40 refused flu vaccine and was supposed to have to have a care plan for refusal of the flu vaccine. During an interview on 4/30/2026 at 2:02 PM with the DON, the DON stated it was important to develop a care plan when a resident (in general) refused medication, treatment and/or any care services provided by the facility. The DON stated that when a resident refused vaccines, the facility was supposed to develop a care plan for refusal since Resident 40 would be at risk for infection. -During a review of Resident 40's MDS dated [DATE], the MDS indicated the resident received dialysis (a medical treatment that acts as an artificial kidney, filtering waste products, toxins, and excess water from the blood when a person's kidneys can no longer perform these tasks properly). During a review of Resident 40's Order Summary Report dated 11/3/2025, the Order Summary Report indicated dialysis on Tuesday, Thursday, and Saturday using right chest Permacath (a flexible, soft tube placed into a large vein to use for short term dialysis) access site. During a review of Resident 40's Order Summary Report dated 1/26/2026, the Order Summary Report indicated HD access site monitoring location on the left arm shunt. During a review of Resident 40's Order Summary Report dated 1/26/2026, the Order Summary Report indicated to remove the dressing from Resident 40's left arm shunt post-dialysis treatment. During a review of Resident 40's Order Summary Report dated 1/30/2025, the Order Summary Report indicated Resident 40 had an external HD Permacath on the right chest. During a review of Resident 40's Order Summary Report dated 2/16/2026, the Order Summary Report indicated not to perform blood pressure (BP, the force of blood pushing against the artery walls as the heart pumps it around the body) measurements, venipunctures (blood draws), or intravenous (IV, fluids given directly into the blood stream) therapy on the access arm (unidentified arm). During a review of Resident 40's Care Plan Report dated 2/16/2026, the Care Plan Report indicated HD access site monitoring of the left arm shunt. The Care Plan Report indicated Do not perform BP measurements, venipunctures, or IV therapy on the access arm. The Care Plan Report indicated dialysis on Tuesday, Thursday, and Saturday using left chest Permacath access site. During a review of Resident 40's Body Check dated 2/19/2026, the report indicated Right medial of upper arm surgical incision with dermabond [a skin adhesive that holds wound edges together following surgical incisions]. During a review of Resident 40's Access Details undated, the report indicated Resident 40's left upper arm AV fistula was permanently unusable on 9/26/2024. The report did not indicate a removal date for the left upper arm AV fistula. The report indicated a chest Permacath actively in use starting 9/26/2024. The report indicated the previous chest Permcath was removed on 10/9/2023. The report indicated an AV fistula was placed in Resident 40's right upper arm on 2/11/2026. During a concurrent observation and interview on 4/27/2026 at 11:37 AM with Resident 40 in Resident 40's room, Resident 40 had a Permacath on the right upper chest. Resident 40 stated the left upper arm AV fistula was removed and he (Resident 40) currently would get dialysis through the temporary Permcath. Resident 40 stated the right upper arm fistula was placed a couple months ago, but it could not be used until May 2026. During a concurrent interview and record review on 4/29/2026 at 9:20 AM with Licensed Vocational Nurse 2 (LVN 2), Resident 40's Special Instructions, undated was reviewed. The instructions indicated, No BP on left arm. LVN 2 stated new orders should have been obtained to ensure staff do not take BP on the right upper arm with the AV fistula. During an interview on 4/29/2026 at 9:29 AM with Registered Nurse (RN) 1, RN 1 stated Resident 40's AV shunt site should have been updated in the chart but was not. RN 1 stated it is important for care plan interventions to be accurate because staff might take BP on the right arm which has the AV fistula. RN 1 stated pressure from the BP cuff can damage the AV fistula, cause clotting and make the HD access unusable. During an interview on 4/29/2026 at 2:39 PM with the Minimum Data Set Coordinator (MDSC), the MDSC stated the dialysis order, AV fistula location, and BP restrictions should have been clarified with the doctor. The MDSC stated orders and care plans must be updated for accuracy of care. The MDSC stated taking BP on the access site can damage the AV fistula. The MDSC stated Resident 88 could not get HD if there was no usable access site, so the toxins would build up in the body, and the resident would end up hospitalized . During a concurrent interview and record review on 4/30/2026 at 10:20 AM with the DON, the facility's policy and procedure (P&P) titled, Dialysis Care, dated August 2021 was reviewed. The P&P indicated The Interdisciplinary Team (IDT) will ensure that the resident's care plan includes documentation of the resident's renal condition and necessary precautions (e.g., shunt site, weights, dietary and fluid restrictions, no BP on affected side, lab draws, IV, injection on arm with shunt, observe for signs and symptoms of infection, etc.). The DON stated the P&P was not followed because Resident 40's orders and care plan were not updated to reflect the resident's current condition. The DON stated it was important to update care plans so staff (would know what care activities residents need. 5. During a review of Resident 88's admission record, the admission record indicated the facility originally admitted Resident 88 on 6/30/2022 and was readmitted on [DATE] with diagnoses including epilepsy (a disorder in which a nerve cell activity in the brain is disturbed causing seizure [a sudden, uncontrolled electrical disturbance in the brain]), cerebral infarction (also called stroke, a result of inadequate blood flow to the brain) and gastrostom

Based on interview and record review the facility failed to ensure two out of six sampled employees (Registered Nurse 1 [RN 1] and Licensed Vocational Nurse 1 [LVN 1]) performing medication administration had yearly annual employee evaluations (a yearly, formal check-in between an employee and their manager to discuss achievements, set goals for the coming year, and identify professional development needs) including medication administration competencies (the core skills and knowledge health providers must have to safely give medications, focusing on preventing errors and ensuring patient safety) in their employee files. This deficient practice had the potential to affect residents' (in general) safety and had the potential for unsafe medication administration. Cross reference F759Findings: During a concurrent interview and record review on [DATE] at 10:06 AM with the Director of Staff Development (DSD), RN 1 and LVN 1's employee records were reviewed. The employee records indicated RN 1 and LVN 1's license and CPR (cardiopulmonary resuscitation - an emergency, life-saving procedure performed when someone's breathing or heartbeat has stopped) were up to date. RN 1 and LVN 1's records did not indicated when RN 1 and LVN 1 had their last annual evaluation (a yearly, formal conversation between a manager and employee to look back at the past year's work, celebrate achievements, identify areas for improvement, and set goals for the year ahead) or when RN 1 and LVN 1 had their last evaluation for medication administration competency (the knowledge, skill, and judgment to safely give medicine to a patient every time). The DSD stated the Director of Nursing (DON) was responsible for monitoring the timely and proper administration of medication (the safe, precise process of giving a patient prescribed medicine) by the facility's licensed staff (LVNs and RNs in general). The DSD stated the DON had the documentation of when RN 1 and LVN 1 last received their (RN 1 and LVN 1) evaluation/education for medication administration competency and annual evaluation. During an interview on [DATE] at 12:32 PM with the DON, the DON stated the DSD, facility's pharmacy, and the DON were responsible for evaluating the licensed staff (in general) for medication administration competency. The DON stated she (the DON) asked the facility's pharmacist consultant (PC -a specialized medication safety expert who reviews patient medications in nursing homes or assisted living facilities to ensure they are safe, necessary, and effective) to evaluate RN 1 and LVN 1's medication administration competency. The DON stated she (the DON) could not recall when RN 1 and LVN 1 last received education for medication administration. The DON stated she asked the PC to train the facility's licensed staff (in general), including new hires, on medication administration three months ago because the DON stated she was preparing for survey (on-site inspection of healthcare facilities like nursing homes to ensure they follow federal safety and quality rules). The DON stated she thought RN 1 and LVN 1 received the medication administration training and stated the PC would either hand in the proof of training or email it. The DON stated she could not provide proof that RN 1 and LVN 1 received the training. The DON admitted to not having RN 1 and LVN 1's medication administration competencies readily available. The DON stated if she did not have the records for RN 1 and LVN 1, she (the DON) could not guarantee RN 1 and LVN 1 could give medications to residents (in general) safely. The DON stated RN 1 and LVN 1 would need to receive training for medication administration competency before they (RN 1 and LVN 1) would be able to give resident medications again. The DON then called the facility's consultant company and stated she (the DON) was told the PC no longer worked for the company. The DON stated she (the DON) should have performed the medication administration competencies more often to ensure the facility's nurses (in general) could give medication to residents (in general) safely. During a concurrent interview and record review on [DATE] at 1:34 PM, with the DON, RN 1's medication administration competency dated [DATE] was reviewed. RN 1's medication administration competency indicated RN 1 was last evaluated for medication administration competency on [DATE]. The DON could not provide any documentation on medication administration annual competency for RN 1 for years 2025 or 2026. The DON could not provide any documentation that LVN 1 ever had medication administration competency performed. The DON stated the facility should have done the annual medication administration competency for RN 1 and LVN 1. During a review of the facility's policy and procedure (P&P) titled, Job Descriptions and Performance Evaluations, last reviewed on [DATE], the P&P indicated Performance evaluations measure the standards against job performance. The P&P indicated performance evaluations aid management in analyzing and improving the facility's services. During a review of the facility's P&P titled, Competency of Nursing Staff , last reviewed on [DATE], the P&P indicated the following Policy Statement: 1. All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by State law.2. In addition, licensed nurses and nursing assistants employed (or contracted) by the facility will:a. participate in a facility-specific, competency-based staff development and training program; andb. demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents, as identified through resident assessments and described in the plans of care. Rhe P&P indicated its Policy Interpretation and Implementation included the following: 1. The staff development and training program is created by the nursing leadership, with input from the medical director, and is designed to train nursing staff to deliver individualized, safe, quality care and services for the residents 2. The following factors are considered in the creation of the competency-based staff development and training program (a training approach focused on mastering specific, practical job skills rather than just attending training hours ): a. An evaluation of the current program to ensure basic nursing competencies; b. Any gaps in education or training that may be contributing to poor outcomes; c. Specialized skills or training needed based on the resident population; d. A method to track, assess, plan, implement and evaluate the effectiveness of training; and e. A method to evaluate critical thinking skills and management of care in complex environments with multiple interruptions. 4. The facility assessment (a required annual check-up a nursing home performs on itself to ensure it has enough staff, equipment, and resources to safely care for its residents ) includes an evaluation of the staff competencies that are necessary to provide the level and types of care specific to the resident population. 5. Competency in skills and techniques necessary to care for residents' needs includes but is not limited to competencies in areas such as: f. Basic nursing skills i. Medication management 8. Facility and resident-specific competency evaluations will be conducted upon hire, annually and as deemed necessary based on the facility assessment. 9. Facility and resident-specific competency evaluations will include: e. Demonstrated ability to perform activities that are within the scope of practice (defines the specific procedures, actions, and processes a licensed professional is permitted to undertake, based on their training, education, and legal licensing) an individual is licensed or certified to perform. 11. Competency demonstrations will be evaluated based on the staff member's ability to use and integrate knowledge and skills obtained in training, which will be evaluated by staff already deemed competent in that skill or knowledge.

Based on observation, interview, and record review, the facility failed to ensure its medication error rate was less than five percent (%). Ten errors out of 29 total opportunities contributed to an overall error rate of 34.48 % affecting six of six (sampled) residents (Resident 44, Resident 47, Resident 86, Resident 96, Resident 97, and Resident 105) observed for medication administration.The errors noted were as follows:1. Licensed Vocational Nurse 1 (LVN1) administered the incorrect dose of thiamine (a vitamin supplement) to Resident 44 on 4/28/2026. 2.Registered Nurse 1 (RN1) omitted (medication not provided) vitamin D (a vitamin supplement) and a multivitamin (a vitamin supplement) for Resident 47 on 4/28/2026. 3.LVN 1 administered the incorrect doses of the following medications: aspirin (a medication used to prevent stroke [poor blood flow to a part of the brain causes cell death]), fish oil (a dietary supplement), vitamin D, and ferrous sulfate (an iron supplement) to Resident 86 on 4/28/2026. 4.RN1 administered carvedilol (a medication used to treat high blood pressure) late to Resident 96 on 4/28/2026. 5. RN1 omitted clopidogrel (a medication used to prevent stroke) for Resident 97 on 4/28/2026. 6. RN1 administered levothyroxine (a medication used to treat low thyroid levels) late to Resident 105 on 4/28/2026. The deficient practice of failing to administer medications in accordance with the physician's orders or professional standards increased the risk that Resident 44, Resident 47, Resident 86, Resident 96, Resident 97, and Resident 105 may have experienced medical complications possibly resulting in hospitalization.Findings: 1.During a review of Resident 44's admission Record (a document containing diagnostic and demographic information) dated 4/29/2026, the admission Record indicated the facility admitted Resident 44 on 3/12/2026 with diagnosis including paroxysmal atrial fibrillation (an irregular heartbeat due to a blood clot that increases the risk of stroke). During a review of Resident 44's History and Physical (H&P -a record of a physician's comprehensive medical assessment) dated 3/13/2026, the H&P indicated Resident 44 had a diagnosis of atrial fibrillation. During a review of Resident 44's Order Summary Report (a monthly summary report of all active physician orders) dated 4/29/2026, the Order Summary indicated Resident 44's physician prescribed the following:-Thiamine 250 milligrams (mg - a unit of measure for mass) by mouth one time a day for supplement. During an observation of medication administration on 4/28/2026 at 8:08 AM with LVN 1, LVN 1 was observed preparing the following medication for Resident 44:-One tablet of thiamine 100 mg. During an observation on 4/28/2026 at 8:13 AM, Resident 44 was observed taking the thiamine 100 mg tablet along with other medications by mouth with water. During an interview on 4/28/2026 at 11:02 AM, with LVN 1, LVN 1 stated Resident 44's order for thiamine was for 250 mg and she (LVN 1) administered 100 mg. LVN 1 stated she (LVN 1) failed to clarify with the physician if it was okay to administer a different dose prior to giving it to the resident. LVN 1 stated failing to administer the correct dose of medications could cause medical complications. LVN 1 stated she (LVN 1) failed to check the products she (LVN 1) had available in her (LVN 1) cart against the physician's orders. LVN 1 stated she (LVN 1) usually would give what she (LVN 1) had on hand out of convenience rather than trying to follow the physician's orders or to clarify the order first. LVN 1 stated she (LVN 1) failed to contact the physician to clarify the orders to see if the deviation in dosage was acceptable. LVN 1 stated failing to administer the correct dosage of medications could cause medical complications possibly resulting in a decline in health status or quality of life. 2. During a review of Resident 47's admission Record dated 4/29/2026, the admission Record indicated the facility admitted Resident 47 on 12/22/2025 with diagnoses including cerebral infarction (stroke). During a review of Resident 47's H&P dated 12/22/2025, the H&P indicated Resident 47 had a diagnosis of cerebral infarction. During a review of Resident 47's Order Summary Report dated 4/29/2026, the Order Summary Report indicated Resident 47's physician prescribed the following medications to be administered during the 9 AM medication pass:-Vitamin D 2000 International Units (IU - a unit of measure for vitamins) by mouth one time a day for supplement-Multivitamin tablet by mouth one time a day for supplement During an observation of medication administration on 4/28/2026 at 9:33 AM with RN 1, RN 1 was observed preparing the following medications for Resident 47:-One tablet of clopidogrel 75 mg.-One tablet of aspirin 81 mg chewable.-One tablet of vitamin B12 1000 micrograms (mcg - a unit of measure for mass).-One tablet of ferrous sulfate 325 mg. During an interview on 4/28/2026 at 9:40 AM with RN 1, RN 1 stated there were four total medications to administer to Resident 47 at this time. During an observation on 4/28/2026 at 9:44 AM, Resident 47 was observed taking the four medications listed above by mouth with water. During an interview on 4/28/2026 at 10:56 AM with RN 1, RN 1 stated Resident 47 was scheduled to receive Vitamin D and a multivitamin at 9 AM but she (RN1) failed to see these when reviewing the medications for Rsident1. RN 1 stated she (RN1) omitted them by accidental oversight. RN 1 stated not giving vitamins as prescribed could cause a decline in Resident 47's quality of life. 3. During a review of Resident 86's admission Record dated 4/29/2026, the admission Record indicated the facility admitted Resident 86 on 8/27/2023 with diagnoses including hypertension (high blood pressure). During a review of Resident 86's H&P dated 1/6/2026, the H&P indicated Resident 86 had a diagnosis of hypertension. During a review of Resident 86's Order Summary Report dated 4/29/2026, the Order Summary Report indicated Resident 96's physician prescribed the following medications:-Ferrous Sulfate 75 mg by mouth one time a day for supplement.-Vitamin D 1000 IU by mouth one time a day for low vitamin D. During an observation of medication administration on 4/28/2026 at 8:20 AM with LVN 1, LVN 1 was observed preparing the following medications for Resident 86:-One tablet of aspirin 81 mg chewable.-One soft gel capsule of fish oil 500 mg.-One capsule of vitamin D 400 IU.-One tablet of ferrous sulfate 325 mg. During an observation on 4/28/2026 at 8:22 AM, LVN 1 was observed crushing each medication individually in a plastic pill pouch then adding the powdered or crushed contents to a small plastic medication cup. During an observation on 4/28/2026 at 8:28 AM, LVN 1 was observed knocking over the plastic medication cup containing the powdered aspirin and spilling approximately half of the pink powder onto the top of the medication cart. LVN 1 was then observed wiping up the spilled aspirin powder with a disinfectant wipe. LVN 1 was observed placing the medication cup containing the remaining aspirin powder back onto the medication tray without replacing the contents with a new tablet. During an observation on 4/28/2026 at 8:31 AM, LVN 1 was observed placing one 500 mg fish oil soft gel capsule into a plastic medication pouch and crushing it with the pill crusher. LVN 1 was then observed trying to squeeze out the fish oil into the medication cup. The medication pouch was observed to still contain a significant amount of residual fish oil. LVN 1 was observed discarding the medication pouch containing the residual fish oil. During an observation on 4/28/2026 at 8:35 AM, LVN 1 was observed mixing each crushed medication with a small quantity of applesauce and then spoon feeding each medication mixture separately to Resident 86. During an interview on 4/28/2026 at 8:43 AM, LVN 1 stated she (LVN1) spilled some of the aspirin powder and did not replace it because she (LVN1) did not think it was very much that she (LVN1) spilled. LVN 1 stated as a result, Resident 86 did not get the full dose of aspirin. LVN 1 stated Resident 86 would take aspirin for stroke prevention and if Resident 86 missed the full dose of aspirin it may increase the risk for stroke. LVN 1 stated she (LVN1) crushed the fish oil capsule in the medication pouch rather than cutting it open. LVN 1 stated she (LVN1) thought that cutting it open might cause it to spill. LVN 1 stated she (LVN1) was not instructed to crush soft gel capsules and prepare them this way but did not know of any other way to do it. LVN 1 stated a significant amount of the fish oil remained in the medication pouch after crushing it and as a result, Resident 86 did not receive the fully intended dose of fish oil. LVN 1 stated fish oil is used for cholesterol (a fat-like substance that is found in all the cells in the body), and stroke prevention. LVN 1 stated if Resident 86 did not receive the full dose of her fish oil, it could also make her more at risk for a stroke long term. During an interview on 4/28/2026 at 11:02 AM, with LVN 1, LVN 1 stated Resident 86's order for fish oil was 1000 mg per day. LVN 1stated she (LVN1) administered one 500 mg dose. LVN 1 stated Resident 86's order for Vitamin D was for 1000 IU and she (LVN1) administered 400 IU. LVN 1 stated Resident 86's order for Ferrous Sulfate was for 75 mg and she (LVN1) administered 325 mg. LVN 1 stated she (LVN1) failed to clarify with the physician if it was okay to administer a different dose prior to giving it to the resident. LVN 1 stated failing to administer the correct dose of medications could cause medical complications. LVN 1 stated she (LVN1) failed to check the products she (LVN1) had available in her (LVN1) cart against the physician's orders. LVN 1 stated she (LVN1) usually would give what she (LVN1) had on hand out of convenience rather than trying to follow the physician's orders or to clarify the order first. LVN 1 stated she (LVN1) failed to contact the physician to clarify any of the above orders to see if the deviation in dosage was acceptable. LVN 1 stated failing to administer the correct dosage of medications could cause medical complications possibly resulting in a decline in health status or quality of life. 4. During a review of Resident 96's admission Record dated 4/29/2026, the admission Record indicated the facility admitted Resident 96 on 4/21/2026 with diagnoses including hypertension. During a review of Resident 96's H&P dated 4/22/2026, the H&P indicated Resident 96 had a diagnosis of hypertension. During a review of Resident 96's Order Summary Report dated 4/29/2026, the Order Summary Report indicated Resident 96's physician prescribed the following medication:-Carvedilol 3.125 mg by mouth two times a day at 8 AM and 5 PM for hypertension. During an observation of medication administration on 4/28/2026 at 9:47 AM with RN 1, RN 1 was observed preparing the following medications for Resident 96:-One carvedilol 3.125 mg tablet. During an observation on 4/28/2026 at 9:54 AM, Resident 96 was observed taking the carvedilol 3.125 mg tablet by mouth with water. 5. During a review of Resident 97's admission Record dated 4/29/2026, the admission Record indicated the facility admitted Resident 97 on 4/24/2026 with diagnosis including hypertensive chronic kidney disease (kidney disease caused by high blood pressure). During a review of Resident 97's H&P dated 4/28/2026, the H&P indicated Resident 97's diagnosis of hypertensive chronic kidney disease. During a review of Resident 97's Order Summary Report dated 4/29/2026, the Order Summary Report indicated Resident 97's physician prescribed the following medication to be administered during the 9AM medication pass:-Clopidogrel 75 mg by mouth one time a day to prevent blood clots. During an observation of medication administration on 4/28/2026 at 9:59 AM with RN 1, RN 1 was observed preparing the following additional medications for Resident 97:-One capsule of omeprazole (a medication used to treat heartburn) 20 mg.-Three capsules of balsalazide (an anti-inflammatory medication) 750 mg. During a concurrent observation on 4/28/2026 at 9:59 AM, RN 1 was observed leaving Resident 97's omeprazole and balsalazide unattended on the top of the medication cart when she (RN1) reentered the room to retake Resident 97's blood pressure. During an observation on 4/28/2026 at 10:03 AM, RN 1 was observed preparing the following medications for Resident 97: -One tablet of aspirin 81 mg chewable.-One tablet of ferrous sulfate 325 mg. During an observation and concurrent interview on 4/28/2026 at 10:06 AM, Resident 97 was observed taking the omeprazole, balsalazide, aspirin, and ferrous sulfate by mouth with water. RN 1 stated these four medications in addition to the four given earlier were all the medications due for Resident 97 at this time. RN 1 stated she (RN1) left Resident 97's omeprazole and balsalazide unattended on top of the medication cart when she (RN1) went into the room to retake the blood pressure. RN 1 stated she (RN1) failed to lock the medication in the medication cart to ensure resident safety per facility policy. During an observation of medication administration on 4/28/26 at 9:14 AM with RN 1, RN 1 was observed preparing the following medications for Resident 97:-One tablet of amlodipine (a medication used to treat high blood pressure) 10 mg.-One tablet of losartan (a medication used to treat high blood pressure) 100 mg.-One tablet of metoprolol succinate ER (a medication used to treat high blood pressure) 50 mg.-One tablet of hydralazine (a medication used to treat high blood pressure) 25 mg. During a concurrent interview and observation on 4/28/2026 at 9:24 AM, RN 1 stated she (RN1) would administer Resident 97's four blood pressure medications now due to a high blood pressure reading and then return in approximately 30 minutes to check the blood pressure again and administer the rest of Resident 97's medications. Resident 97 was observed taking the four medications listed above by mouth with water. During an interview on 4/28/2026 at 10:56 AM with RN 1, RN 1 stated Resident 97 was also scheduled to receive clopidogrel 75 mg at 9AM, but she (RN1) failed to administer it due to accidental oversight. RN 1 stated the resident was having episodes of high blood pressure and was distracted by this and other tasks. RN 1 stated failing to administer clopidogrel increased the risk that Resident 97 could have a stroke possibly leading to hospitalization or death. RN 1 stated the carvedilol for Resident 96 was scheduled for 8 AM, but she (RN1) gave it at 9:54 AM. RN 1 stated the latest she (RN1) could give it and still be considered on time was 9 AM. RN 1 stated giving this medication too late could cause issues with blood pressure management since it was dosed twice daily. RN 1 stated giving it too close to the next scheduled dose could cause low blood pressure possibly resulting in dizziness or falls with injury. 6. During a review of Resident 105's admission Record dated 4/29/2026, the admission Record indicated the facility admitted Resident 105 on 4/27/2026 with diagnosis including hypothyroidism (low thyroid level). During a review of Resident 105's H&P dated 4/28/2026, the H&P indicated Resident 105's diagnosis of hypothyroidism. During a review of Resident 105's Order Summary Report dated 4/29/2026, the Order Summary Report indicated Resident 105's physician prescribed the following:-Levothyroxine 125 mcg by mouth every morning at 6 AM. During an observation of medication administration on 4/28/2026 at 8:55 AM with RN 1, RN 1 was observed preparing the following medication for Resident 105:-One tablet of levothyroxine 125 mcg.During an observation on 4/28/2026 at 8:57 AM, Resident 105 was observed taking the levothyroxine 125 mcg tablet by mouth with water. During an interview on 4/28/2026 at 9:02 AM with RN 1, RN 1 stated Resident 105's levothyroxine was scheduled for a 9 AM administration, but this medication (levothyroxine) was more commonly given around 6:30 AM. RN 1 stated levothyroxine was usually scheduled for administration around 6:30 AM so it could be given on an empty stomach before breakfast to ensure it absorbs fully. RN 1 stated she (RN 1) failed to follow up with the prescriber prior to administering the medication to clarify if there was a clinical reason for the deviation from the usual administration instructions for this medication. RN 1 stated if it was given too close to food or other medications, it might cause symptoms of hypothyroidism which could negatively affect her quality of life. During an interview on 4/28/2026 at 9:09 AM with RN 1, RN 1 stated after talking to the prescriber, the order was wrong and should have been written for administration at 6:30 AM. RN 1 stated the order was changed to reflect the standard administration for levothyroxine. During a review of the facility's undated policy Administering Medications indicated Medications are administered in accordance with prescriber orders, including any required time frame. medications are administered within one (1) hour of their prescribed time, unless otherwise specified. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medications, right dosage, right time and right method (route) of administration before giving the medications. During administration of medications, the medication cart is kept closed and locked when out of sight of the medications nurse. no medications are k

Based on observation, interview and record review, the facility failed to ensure residents received meals that met their assessed nutritional needs and prescribed Kosher diet requirements for three of three meal trays reviewed for therapeutic diets. Kosher diet (Kosher foods meet the regulations established by Jewish dietary law and include requirements related to the preparation and serving of foods, including separation of meat and dairy products.) and protein (an essential nutrient necessary for growth, tissue repair, immune function, and maintenance of muscle mass) requirements were not followed when: 1. Two Kosher diet trays were served pureed green beans, pureed potato, and pureed bread without a protein source. 2. One Kosher diet was served pureed lasagna prepared with beef and dairy products in the same meal, which was not consistent with Kosher dietary requirements. These deficient practices had the potential to result in inadequate nutritional intake, failure to meet therapeutic dietary needs, and resident dissatisfaction with meals. Findings: During an observation of the tray line service for lunch (tray line-a system of food preparation, in which trays move along an assembly line) on 4/27/2026 at 12:00PM, the cook (cook1) was observed serving pureed green beans, pureed bread and mashed potatoes on two pureed diet texture and kosher lunch trays. A review of the tray card (a printed sheet that includes resident diet order, preferences and dislikes) on the lunch tray dated 4/27/2026, the tray card indicated the tray was for a resident on a pureed texture and kosher diet. The tray card indicated to serve pureed lasagna, pureed green beans, pureed garlic bread, pureed frosted cupcake and water. A second tray card for lunch in the food cart was observed on 4/27/2026, the tray was for a resident on a pureed texture diet, mildly thick liquids and kosher. The tray card indicated to serve pureed lasagna, pureed green beans, pureed garlic bread, pureed frosted cupcake, mildly thick milk. During a review of the facility menu for lunch on 4/27/2026, the menu indicated the following food items were to be served on the pureed texture diet: pureed lasagna 1 cup; pureed green beans (3 ounces (oz)); pureed garlic bread; pureed frosted cupcake and a beverage. During a concurrent observation in the facility kitchen and interview with cook1 and Dietary Supervisor (DS) on 4/27/2026 at 12:00PM, cook1 stated kitchen staff did not serve meat to residents on kosher diet. [NAME] 1 stated the lasagna was made with ground meat, beef and turkey combined. Cook1 stated for kosher diets, cook 1 only served pureed green beans, pureed bread and mashed potatoes. Cook1 stated kitchen staff did not serve protein on kosher diet trays and only served the side dishes. The DS stated no meat was served on kosher diet trays and disposable plates and utensils covered with plastic wrap were used. During a concurrent interview and test tray (sampling the flavor and texture of the prepared meal) with the DS on 4/27/2026 at 1:00PM, the DS stated for kosher diets I don't know any specifics about the diet, but all I know is that they are not supposed to eat the meat and food should be served with disposable utensils. The DS stated the facility used to provide ready-made frozen kosher meals but stopped that. The DS said after speaking with the residents and explaining the facility did not have a kosher kitchen, the families agreed not to receive the meat and to use disposable utensils. The DS stated the facility did not have any other food alternatives or options for the kosher diet. The DS stated residents who were not on a kosher diet received protein every meal and the two residents on the kosher diet do not receive protein with every meal. During an interview with the registered Dietitian (RD2) on 4/28/2026 at 9:30AM, RD2 stated the kosher diet was a religious diet and was mainly no pork allowed, meats and dairy products were not to be cooked in the same area or served together. RD2 stated residents on a kosher diet could have meat if they were prepared the kosher way and not mixed with dairy products. RD2 reviewed the facility menu and serving guide and stated the facility's menu did not indicate a kosher option and the residents who were on pureed texture and kosher diet did not receive an alternative meal that was nutritionally equivalent to the regular diet. RD2 stated residents who were pureed texture and kosher were missing the protein from the meals which could lead to nutritional deficiency. During a concurrent observation of the lunch trays and interview with cook1 on 4/28/2026 at 12:00PM, cook1 stated the lunch for that day (4/28/2026) was pork, vegetables and mashed potato. Cook1 stated the residents on the pureed diet and kosher did not receive meat or pork and only received pureed Italian blend vegetables (carrots, cauliflower, broccoli), pureed bread and mashed potato with no protein on the tray. During a review of facility's policy and procedures (P & P) titled Dining and Food Preferences (revised 10/2022) the p & p indicated, The Registered Dietitian /Nutritionist RD/RDN or other clinically qualified nutrition professional will review, and after consultation with the resident, adjust the individual meal plan to ensure adequate fluid volume and appropriate nutritional content for residents/patients that do not consume certain foods or food groups. 2. During an observation of lunch service in the kitchen on 4/27/2026 at 12:00 PM one pureed texture diet and kosher tray was observed to have pureed lasagna, pureed green beans and pureed bread. The tray card indicated a pureed texture diet and kosher and was okay with meat. Cook1 stated the meal tray that indicated the kosher diet was okay with meat was served the pureed lasagna. Cook1 stated the lasagna was a mixture of ground beef and ground turkey and three different types of cheese. When asked if it was okay to mix dairy products with meat in a kosher diet, cook 1 replied yes because the resident was ok with meat. During an interview with the DS on 4/27/2026 at 1:00PM, the DS did not know kosher diet guidelines and did not know if it was okay to mix dairy products with meats on a kosher diet. During an interview with RD2 on 4/28/2026 at 9:30AM, RD2 stated a kosher diet was a strict religious diet and it could vary but mainly it was no pork, meats were okay when prepared kosher, dairy products and meats were not to be cooked in the same area or served together. RD2 stated the facility menu did not include kosher diet guidelines for cooks to follow. During a review of facility's policy and procedures (p & p) tilted Menus (revised 10/2022) the p & p indicated, Menus will be planned in advance to meet the nutritional needs of the residents in accordance with established national guidelines. Menu cycles will be developed and tailored to meet the needs and requirements of the facility. Menu cycles will include nutrient analysis to ensure that all client nutritional needs are met. A registered Dietitian or other clinically qualified nutrition professional review and approves the menus. The RD will adjust the individual meal plan to meet the individual requests, including cultural, religious or ethnic preferences as appropriate.

Based on observation, interview and record review the facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen when: 1.Bulk food (sugar, flour, breadcrumbs) were stored in bins lined with trash bags that were not food grade (refers to materials that are safe for direct contact with food, free from harmful substances, and designed to prevent contamination).2.The temperature of bottled juice and a gallon of milk used for lunch service was kept out at room temperature, not at safe temperatures (refrigerated). 3. Food brought to residents from outside of the facility, including leftovers were stored in the resident food refrigerator located in the facility's utility room with no label or received date. These deficient practices had the potential to result in harmful bacteria growth and cross contamination of food (transfer of harmful bacteria and chemicals from one place to another) that could lead to food borne illness in 81 out of 84 residents who received food from the facility.Findings: 1. During a concurrent observation in the kitchen and interview on 4/27/2026 at 10:00AM, bulk food (sugar, flour, breadcrumbs) was observed to be stored in large bins that were lined with plastic bags. The Dietary Supervisor (DS) stated the plastic liners inside the bins were regular trash bags and were not specific for food storage. The DS stated there was no policy regarding food storage liners and trash bags had always been used to store bulk food. The DS stated it would be sanitary and clean if the food was stored directly inside clean bins instead of plastic liners. The DS stated the plastic liners tended to tear and could have chemicals in the plastic touching food. During a concurrent observation and interview with the DS and Dietary District manager (DM) on 4/28/2026 at 11:00AM, the DS stated all the plastic trash bags were removed and food was stored directly inside bins. The DM stated food storage bins should not have been lined with trash bags. During a review of facility's policy and procedures (P&P) titled Food Storage: Dry Goods (revised 2/2023), the P&P indicated All dry goods will be appropriately stored in accordance with FDA Food Code, Toxic materials will not be stored with food. During a review of the 2022 U.S. Food and Drug Administration Food Code titled Characteristics code 4-102.11, the code indicated, The safety and quality of food can be adversely affected through single service and single use articles that are not constructed of acceptable materials. The migration of components of those materials to food they contact could result in chemical contamination and illness to the consumer. In addition, the use of unacceptable materials could adversely affect the quality of the food because of odors, tastes, and colors transferred to the food. 2. During a concurrent observation of the lunch service and interview on 4/27/2026 at 12:00PM, a temperature check of the juices using facility thermometer registered at 54 degrees F and the Milk was at 46.7 degrees F. The DS stated kitchen staff usually stored the beverages in the refrigerator so the beverages could stay cold for lunch service and stated, but I guess we didn't today. The DS stated when beverages were not cold some residents could complain and refuse to eat or drink. The DS stated if the milk sat out long in the warm temperature it could go bad. During an interview with Regional Registered Dietitian (RD1) and Dietary District manager (DM) on 4/28/2026 at 2:00PM, RD1 stated beverages had to be kept on ice during lunch service to maintain temperatures at 41degrees or below for cold items. During a review of facility policy and procedure (p & p) titled Food: Preparation (Revised 2/2023) the p & p indicated, All foods will be held at appropriate temperatures, greater than 135 degrees F (or as state regulation requires) for hot holding, and less than 41 degrees F for cold food holding. During a review of the 2022 U.S. Food and Drug Administration Food Code 3-501.16 titled Time/Temperature control for safety food, hot and cold holding indicated, except during preparation, cooking or cooling, time/temperature control for safety food shall be maintained at 135 degrees F or above, and at 41 degrees F or below. 3. During an observation of the resident refrigerator located in the facility's utility room on 4/27/2026 at 10:30AM, one container of soup was observed with no label sitting on top of the resident refrigerator. Inside the refrigerator one large bag with multiple small containers for leftover soup and stews was observed, with no date. Another large bag with two store bought frozen dinners ([NAME] calendar's frozen turkey pot pie dinners) was observed with no date. One of the turkey pot pie dinner boxes was broken and the contents were out of the box. During a concurrent observation of the resident refrigerator and interview with the Maintenance Director (MTD) and Infection prevention nurse (IPN) on 4/27/2026 at 10:30AM, the MTD stated the soup on top of the refrigerator should not have been on top of the refrigerator and should have been placed inside the refrigerator. The IPN instructed the MTD not to put anything back in the refrigerator that was sitting outside, the IPN then removed the soup to discard. The IPN stated all food that was brought by visitors or ordered from outside for residents was to be checked by nursing staff then labeled and dated with a use by date. The IPN stated the facility stored food for 48 hours and if there were no dates facility staff could not tell how long food had been in the refrigerator. The IPN stated frozen food like the T.V. dinners had to be stored frozen for safe storage. The IPN removed the frozen dinners with no dates and food that was open and contaminated to discard. During a review of facility's policy and procedures (p & p) titled Food Brought in By Visitors (Revised 3/28/2024), the p & p indicated, All food brought in for a resident: a. will be checked by a licensed nurse for appropriate diet texture. When food items are intended for later consumption, the staff responsible will: c. Label foods with the resident's name and the receive date. Items will be thrown out after 48 hours. Refrigerator/freezer for storage of foods brought in by visitors will be properly maintained and d. Daily monitoring for refrigerated storage duration and discard of any food items that have been stored for >2 days.

Based on interview and record review the facility failed to protect residents right to be free from physical and mental abuse (willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish) by three facility employees for one of six sampled residents (Resident 1) on 7/6/2023 at 4:30 a.m., in accordance with facility's policy and procedures titled, Resident Rights Under Federal Law revised 3/1/2023, and Abuse Prohibition revised on 10/24/2022, by failing to: 1. Honor Resident 1's wishes when she stated to stop during the collection of urine sample using the straight catheter (a flexible tube placed in the bladder [body organ that stores urine] to obtain urine) without her consent. 2. Ensure Licensed Vocational Nurse 1 (LVN 1), Certified Nursing Assistants 1 and 2 (CNA 1 and CNA 2), stopped to hold Resident 1's arms and legs, and spread Resident 1's legs against the resident's wishes after Resident 1 screamed at LVN 1, CNA 1 and CNA 2 to stop. 3. Explain straight catheter procedure and obtain Resident 1's consent before collecting a urine sample using a straight catheter As a result, Resident 1 stated she felt scared, experienced pain in her private parts, suffered mental anguish, emotional distress and stated, I felt raped. Resident 1 developed shingles (a highly infectious painful skin rash and fluid -filled blister [raised area on the skin] in the right side of the face and was sent out to the general acute hospital (GACH 1) on 7/19/2023 for evaluation and treatment. On 10/4/2023 at 2:15 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death of a resident) in the presence of the Administrator (ADM) and the Director of Nursing (DON) because of the seriousness related to the facility 's failure to honor Resident 1's wishes, obtain consent for the use of straight catheter to collect urine sample and protect Resident 1 from abuse on 7/6/2023. On 10/6/2023 at 12 p.m., the facility provided acceptable IJ Removal Plan (interventions to correct the deficient practice). While onsite, the survey team confirmed implementation of the IJ corrective actions through interview, and record review, and the SSA removed the IJ in the presence of the ADM, DON, [NAME] President of Operations (VPO), Clinical Consultant and Senior VPO on 10/6/2023 at 1:04 p.m. A review of the IJ removal plan included the following: 1. On 7/19/23, the ADM reported the allegation of abuse to the Ombudsman, SSA and police department. 2. On 7/19/23, licensed nurse initiated a Change in Condition (COC, a major decline or improvement in a resident's status that will not normally resolve itself without intervention from staff) for Resident 1 regarding the abuse allegation. Resident 1's condition was monitored and there was no change of condition since 7/19/2023. The comprehensive care plan was updated to reflect the incident and corrective actions taken to prevent recurrence and to ensure that Resident 1 will continue to feel safe and secure. Resident 1 has continued to perform usual functions, felt safe and secure. 3. On 7/19/23, LVN 1, CNA 1 and CNA 2 were placed on suspension pending further investigation. The facility reinstated LVN 1, CNA 1, and CNA 2 back to work on 7/25/23 after receiving one on one (1:1, when a person receives individualized instruction from an educator) education and training on abuse management. LVN 1 completed 1:1 education and training including skills validation on how to collect urine sample for resident requiring catheterization (procedure used to drain the bladder and collect the urine using a flexible tube called catheter). 4. On 7/19/23, licensed nurse completed COC to address complaint of rash on Resident 1's forehead. Resident 1 was transferred to the GACH 1 for further evaluation. Resident came back the same day with diagnosis of Herpes Zoster Keratitis (shingles). Resident 1 was started on Valacyclovir Hydrochloride (HCL, medication used to treat shingles, helps to relieve pain and discomfort, and helps sores heal faster) one gram (gm, unit of measurement) one tablet by mouth three times a day for 10 days for shingles. The treatment was completed on 7/29/2023. 5. On 7/26/23, Resident 1 was seen by psychologist (professional who is trained and qualified to address emotional and behavioral issues) for supportive visit 6. On 8/9/2023, Resident 1 had follow-up visit with the psychologist. 7. On 10/4/23, Trauma (deeply distressing or disturbing experience) Evaluation was completed for Resident 1 by a licensed nurse. 8. On 10/4/23, DON and the Director of Staff Development (DSD) initiated the following in-services: a. Abuse Management with emphasis on honoring resident's wishes, offering treatment options/alternatives prior to any proposed care and treatment such as offering urine specimen (sample of medical testing) bottle and/or bedpan or urinal (container used to collect urine) and collaborate with the physician for any other alternative options. b. How to collect urine sample for resident requiring straight catheterization and the need for physician order. 9. On 10/4/23 the Activity Director (AD) conducted an emergency Resident Council meeting to identify any concerns about safety and resident rights. All residents who attended the Resident Council Meeting were satisfied with their care and verbalized that they feel safe and secure. 10. On 10/4/23, the ADM informed the Medical Director about the IJ for further recommendations. 11. On 10/4/2023 the Interdisciplinary Team (IDT, group of professionals all working together toward a common goal) will schedule care conference with Resident 1 and Resident 1's representative to discuss care and for further recommendations. This will continue quarterly as scheduled and as necessary. 12. On 10/4/2023, Resident 1 received an order for psychiatrist (medical doctor who diagnose and treat mental, emotional, and behavioral disorders) and psychologist consultation for further evaluation. Findings: During a review of the Admission Record indicated the facility admitted Resident 1 on 2/16/2022 with diagnoses including heart failure (the heart muscle cannot pump enough blood to meet the body's needs for blood and oxygen), generalized muscle weakness and abnormalities of gait and mobility. During a review of Resident 1's untitled Care Plan created on 12/29/2022 indicated Resident 1 had a Physician Orders for Life-Sustaining Treatment (POLST, written medical order that helps give people with serious illness more control over their own care by specifying the types of medical treatment they want to receive during serious illness). The goal of the care plan indicated resident, or healthcare decision maker shall participate in decisions regarding medical care and treatment. The interventions included to inform the resident and/or healthcare decision maker of any change in status or care needs, promote opportunities for resident/healthcare decision maker to participate in decisions regarding care and to provide the resident/healthcare decision maker with sufficient information to make an informed decision (a choice made after learning about the options, potential outcomes, benefits, and risks). During a review of Resident 1's Minimum Data Set (MDS, standardized care and health screening tool) dated 7/4/2023 indicated Resident 1 was cognitively (ability to think and make decisions) intact. Resident 1 needed supervision (oversight, encouragement or cuing) with bed mobility, transfer, eating, toilet use, personal hygiene, and limited assistance (resident highly involved with activity, staff provide guided maneuvering of limbs or other non-weight bearing assistance) with dressing and bathing. The same MDS indicated Resident 1 was occasionally incontinent (inability to control passage of urine) of urine. During a review of Resident 1's Physician Order dated 7/5/2023 at 8:38 p.m., indicated a telephone order to collect urine sample for urinalysis (UA, medical test in which the urine is examined to diagnose and monitor various illness) with culture and sensitivity (a urine test to find the germs that can cause the infection and check what kind of medicine will work best for the infection) for urinary frequency (need to pass urine more often than normal). During a review of Resident 1's Laboratory Results Report indicated the facility collected Resident 1's urine on 7/6/2023 at 4:33 a.m. During a review of Resident 1's Situation, Background, Appearance, Review and Notify (SBAR, tool that allows healthcare team members to provide essential and concise information about the individual's condition) Communication Form and Progress Notes dated 7/19/2023 at 9 a.m., indicated Resident 1 reported abuse allegation to the DSD. Resident 1 reported that on 7/6/2023, she was pinned down while LVN 1 was inserting a catheter. The SBAR indicated Resident 1 was in emotional distress. The SBAR indicated the next of kin 1 (NOK 1), SSA, the ombudsman, the police, and nurse practitioner (NP, a registered nurse who is qualified through advance training to assume some of the duties and responsibilities of the physician) were notified. The same SBAR also indicated Resident 1 had a red rash on the forehead and that the NP gave order to transfer Resident 1 to GACH 1 for evaluation of the rash. During a review of GACH 1 After Visit Summary dated 7/19/2023, indicated Resident 1's rash was diagnosed as Herpes zoster keratitis and was given a physician order to take Valacyclovir one gm one tablet by mouth three times a day for 10 days. The After Visit Summary indicated shingles infection is common in people which included those who are experiencing a lot of stress. During a review of Resident 1's Progress Notes dated 7/20/2023 at 1 a.m., indicated Resident 1 returned to the facility from GACH 1 on 7/20/2023. During a review of the facility's IDT Notes dated 7/20/2023 at 3:33 p.m., indicated the IDT held a conference meeting with Resident 1's NOK. The IDT informed Resident 1's NOK that Resident 1 reported that three employees, LVN 1, CNA 1, and CNA 2, held her down during the collection of the urine sample during early morning between 7/5/2023 and 7/6/2023. Resident 1 reported the incident to the facility on [DATE]. The IDT indicated once the facility learned of the abuse allegation, LVN 1, CNA 1 and CNA 2 were suspended. The Notes also indicated a psychologist consultation was arranged for Resident 1. During a review of the facility's Final Investigation Summary Report dated 7/24/2023, indicated that on 7/5/2023 at about 4:45 a.m., LVN 1 to collect urine using a bedpan ( a device placed underneath a person to pass urine and or stool) sample and to comply with a physician's order for Resident 1. LVN 1 explained to Resident 1 that LVN 1 will have to do catheterization after Resident 1 did not void (pass urine) in the bedpan. LVN sought the help of CNA 1 and CNA 2. CNA 1 held on to Resident 1's knees with her right hand. CNA 2 held Resident 1's folded forearms to immobilize Resident 1 Urine collection took less than five minutes. LVN 1 acted in good faith in trying to obtain a urine sample and proceeded with catheterization . During a review of Resident 1's Psychologist Notes dated 7/26/2023, indicated Resident 1 was cognitively intact and was able to articulate feelings. Resident 1 was anxious and sad, teary at times during the consultation. During an interview and record review with LVN 2 on 9/29/2023 at 8:31 a.m., Resident 1's physician order and the nurses progress notes. LVN 2 stated a physician order was needed to collect a urine sample using the straight catheter for Resident 1. LVN 2 stated she was unable to find a physician's order to collect the urine sample using a straight catheter. LVN 2 also stated she was unable to find any documentation that supported LVN 1 had explained to Resident 1 about an order to obtain a urine sample by straight catheter and that Resident 1 had consented for LVN 1 to insert a straight catheter to collect the urine sample. During an interview with DSD on 9/29/2023 at 10:34 a.m., DSD stated that on 7/19/2023, Resident 1 reported to DSD that LVN 1 came in the middle of the night on 7/6/2023, awakened Resident 1 and informed Resident 1 that LVN 1 needed a urine sample. DSD stated LVN 1 then proceeded to collect the urine sample by using a straight catheter. DSD stated LVN 1 called CNA 1 to help hold Resident 1's legs because LVN 1, may have a hard time inserting the straight catheter in Resident 1. DSD stated LVN 1 also called CNA 2 to help hold Resident 1's arms while LVN 1 inserted a straight catheter in Resident 1. During a telephone interview with LVN 1 on 9/29/2023 at 11:34 a.m., LVN 1 stated on 7/5/2023 she received an order from Resident 1's primary physician to collect urine sample from Resident 1. LVN 1 then stated she did not obtain a physician order to collect the urine sample using a straight catheter. LVN 1 stated before she collected the urine sample on 7/6/2023, she explained to Resident 1 that she will collect a urine sample using straight catheter. LVN 1 stated Resident 1 did not say yes or no to the procedure. LVN 1 stated she inserted a straight catheter in Resident 1 and collected Resident 1's urine with the help of CNA 1 and CNA 2. LVN 1 stated she did not document that she explained the urine collection procedure to Resident 1 and that Resident 1 did not struggle or say no during the procedure. LVN 1 stated the collection of Resident 1's urine by straight catheter was done quickly. During an interview with CNA 1 on 9/29/2023 at 11:58 a.m., CNA 1 stated that on 7/6/2023 between 4 a.m. and 5 a.m., LVN 1 called CNA 1 to help LVN 1 collect urine sample from Resident 1. CNA 1 stated she came to help LVN 1, stood at the end of the bed and held on Resident 1's legs. CNA 1 stated she was just touching Resident 1's legs and did not pin her down. CNA 1 further stated CNA 2 was touching Resident 1's arms during the insertion of the straight catheter. During an interview on 9/29/2023 at 12:17 p.m., ADM stated the incident with Resident 1 happened on 7/6/2023 and that Resident 1 reported the incident to the facility on [DATE]. The ADM stated the procedure of collecting the urine sample was explained to Resident 1, however, the ADM agreed and stated the facility was not able to find any documented evidence that the procedure of collecting urine by straight catheter was explained to Resident 1 and that Resident 1 consented to collecting urine using a straight catheter. During an interview with the DON on 9/29/2023 at 12:29 p.m., the DON stated collection of urine sample by straight catheter required a physician's order because the procedure was invasive, and the physician must be aware of the procedure. During an interview with Resident 1 and NOK 1 in the MDS office on 9/29/23 at 12:45 p.m., Resident 1 stated that, On 7/6/23 at 4:30 a.m., I was restrained (prevent from any action/movement) by three nurses. The nurse told me I must give urine sample for the laboratory test. I was half asleep and I said to myself, what are they doing to my body. The three of them held my arms and legs, they spread my legs and put something sharp in my private parts and I suffered excruciating pain. I can't explain the pain. I was laying there in pain and I was suffering. I was traumatized. I told them to stop, I cried, I screamed, they did not stop. No one came to help me. They should have told me in advance. They just came into my room .and I feel like am not treated as a human being. I am [AGE] years old and 100 pounds. They could have waited later during the day. I kept quiet and did not tell anyone because I feared retaliation, I was always thinking about it, it is in my mind, I was scared. I did not give them permission to do this. I must have told someone, and the administrator came and interviewed me. This is serious, all I want is justice. I want compensation for my pain and suffering, my brain was affected. I got shingles and my doctor told me because of pain (that) was stored in my brain, it must come out. And it came out as shingles. I felt I was raped. NOK 1 stated, It is shocking to me. How can [Resident 1] experience such indignity and violence. It was so shocking to me. During a telephone interview with CNA 2 on 10/4/2023, at 1:56 p.m., CNA 2 stated that LVN 1 asked CNA 2 to help hold Resident's hands. CNA 2 stated she grabbed Resident 1's hands. During a telephone interview with NP on 10/4/2023 at 3:59 p.m., NP stated Resident 1's, memory is intact, and [Resident 1] remembers everything. NP further stated the incident [restraining Resident 1 and performing straight catheterization without Resident 1's consent), was a traumatic experience for [Resident 1] because she is still talking about it until now. During an interview with the DON on 10/5/2023 at 1:49 p.m., the DON stated procedure of collecting the urine sample by straight catheter should have been explained to Resident 1, .make sure the resident will agree first and if she refuse in the middle of the procedure, the nurse should stop and then remove the catheter. The DON further stated, consent is important.We have to honor the resident wishes because resident have the right to refuse, and we have to respect their wishes. During a review of the facility's policy and procedures titled, Abuse Prohibition revised on 10/24/2022, indicated the facility, prohibit abuse, mistreatment (being cruel or thoughtless toward a person), neglect, misappropriation of resident property and exploitation for all residents. Abuse is defined as the willful infliction of injury, unreasonable confinement, . resulting in physical harm, injury, or mental anguish. Willful . means the individual must have acted deliberately, . Mental abuse may occur through either verbal or nonverbal conduct which causes or has potential to cause the patient to experience humiliation, intimidation, fear, shame, agitation, . The purpose of the Policy is to ensure that the facility staff are doing all that is within their control to prevent occurrences of abuse, mistreatment, neglect, . for all residents. 6.1.2 The employee alleged to have committed the act of abuse will be immediately removed from duty, pending investigation. 7.7 Initiate an investigation within 24 hours of an allegation of abuse that focuses om 7.7.1 Whether abuse or neglect occurred and to what extent. 7.7.2. Clinical examination for signs of injuries . 7.7.3 causative factors; and 7.7.4. Interventions to prevent further injury. 7.8. The investigation will be thoroughly documented . During a review of the facility's policy and procedures (P&P) titled, Resident Rights Under Federal Law revised on 3/1/2022, indicated, the purpose of the P&P included to: 1. Treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes or enhance of his/her self-esteem and self-worth. 2. Incorporate the resident's goals, preferences, and choices into care. 3. Protect and promote the rights of the residents. 4. Recognize each resident's individuality as well as honor and value his/her input. The resident has the right to be informed, in advance, by the physician or other practitioner or professional of the risks and benefits of proposed care of treatment and treatment alternatives or treatment options and to choose the alternative or option he/she prefers. Resident has the right to request, refuse and/or discontinue treatment.

Based on interview and record review the facility failed to obtain physician's order to collect urine sample by straight catheter (a flexible tube placed in the bladder [body organ that stores urine] to obtain urine) for three of six sampled residents (Resident 1, Resident 2, and Resident 3) in accordance with the facility's policy and procedure (P&P) titled, Procedure Specimen (sample) Collection: Urine, revised on 2/1/2023, P&P titled, Physician Advanced Practice Provider (APP) Orders revised 3/1/2022, and P&P titled, Catheter: Urinary -Justification for Use, revised on 8/7/2023. 1. Resident 1, who was occasionally incontinent (inability to control passage of urine) of urine, had a physician order dated 7/5/2023 to collect urine sample for urinalysis (UA, medical test in which urine is examined to diagnose and monitor various illness) with culture and sensitivity (C&S, a urine test to find the germs that can cause the infection and check what kind of medicine will work best for the infection), Licensed Vocational Nurse 1 (LVN 1) collected urine sample by straight catheter on 7/6/2023 at 4:33 a.m. As a result, Resident 1 stated she was traumatized (to shock someone so badly that they are affected by it for a very long time) and experienced excruciating (intense) pain in her private parts during straight catheterization (process of draining urine by use of catheter). 2. For Resident 2 who was incontinent of urine and had a physician order dated 9/19/2023 to collect urine sample for UA with C&S, unknown licensed nurse collected the urine sample by straight catheter on 9/21/2023 at 4:50 a.m. As a result, Resident 2 stated he felt pain during the catheterization and did not want to have a straight catheter again. 3. For Resident 3 who was incontinent of urine and had a physician order dated 9/20/2023 to collect a urine sample for UA with C&S, an unknown licensed nurse collected the urine sample by straight catheter on 9/21/2023 at 4:37 a.m. As a result, Resident 3 had the potential to experience excruciating pain in her private parts. Resident 3 was non interviewable. The facility subjected Resident 1, Resident 2, and Resident 3 to invasive (enter a person's body by a needle, tube, device, or scope) procedure without a physician's order/approval. Findings: 1. During a review of Resident 1's Admission Record indicated the facility admitted Resident 1 on 2/16/2022 with diagnoses including heart failure (the heart muscle cannot pump enough blood to meet the body's needs for blood and oxygen), generalized muscle weakness and abnormalities of gait and mobility. During a review of Resident 1's Minimum Data Set (MDS, standardized care and health screening tool) dated 7/4/2023 indicated Resident 1 was cognitively (ability to think and make decisions) intact. Resident 1 needed supervision (oversight, encouragement or cuing) with bed mobility, transfer, eating, toilet use, personal hygiene, and limited assistance (resident highly involved with activity, staff provide guided maneuvering of limbs or other non-weight bearing assistance) with dressing and bathing. The same MDS indicated Resident 1 was occasionally incontinent of urine. During a review of Resident 1's Physician Order dated 7/5/2023 at 8:38 p.m., indicated a telephone order to collect urine sample for UA and C&S for urinary frequency (need to pass urine more often than normal). During a review of Resident 1's Laboratory (Lab) Results Report indicated Resident 1's urine sample was collected on 7/6/2023 at 4:33 a.m. During an interview with Resident 1 and Next of Kin 1 (NOK 1) in the MDS office on 9/29/23 at 12:45 p.m., Resident 1 stated that, On 7/6/23 at 4:30 a.m., three nurses held my arms and legs, they spread my legs and put something sharp in my private parts and I suffered excruciating pain. I can't explain the pain. I was laying there in pain and I was suffering. I was traumatized. I told them to stop, I cried, I screamed. I am [AGE] years old, and I weigh 100 pounds (unit of measurement). They ([LVN 1], certified nursing assistant CNA 1, and CNA 2]) could have waited later during the day. NOK 1 stated, It is shocking to me. How can [Resident 1] experience such indignity and violence. It was so shocking to me. 2. During a review of Resident 2's Admission Record indicated the facility admitted Resident 2 on 8/14/2023 with diagnoses including cerebral infarction (condition caused by interruption or blockage of blood flow to the brain) and abnormal posture. During a review of Resident 2's MDS dated [DATE], indicated Resident 2 had impaired cognition. Resident 2 needed one-person physical assistance with bed mobility, dressing, eating, toilet use, personal hygiene, and bathing. The same MDS indicated Resident 2 was always incontinent of urine. During a review of Resident 2's Physician Order dated 9/19/2023 at 4:10 p.m., indicated to obtain urine for UA and C&S. During a review of Resident 2's Lab Result dated 9/21/2023, indicated a urine sample collection time of 4:50 a.m. During an interview with Resident 2 on 10/5/2023 at 1:09 p.m., Resident 2 stated the facility collected his urine sample .last month [9/2023] using a catheter. Resident 2 stated he felt excruciating pain during the procedure, and 1 do not want it done again because it hurts. 3. During a review of Resident 3's Admission Record indicated the facility admitted Resident 3 on 1/19/2017 with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and muscle weakness. During a review of the MDS dated [DATE] indicated Resident 3 had severely impaired cognitive skills for daily decision making. Resident 3 needed one-person physical assistance with bed mobility, dressing, eating, toilet use, personal hygiene and two and more person physical assistance with transfer and bathing. The same MDS indicated Resident 3 was always incontinent of urine. During a review of the facility's Nursing Staffing Assignment and Sign in Sheet dated 9/20/2023, indicated LVN 1 worked on 9/20/2023 on the 11 p.m. to 7 a.m. shift. During a review of the Situation, Background, Appearance, Review and Notify (SBAR, tool that allows healthcare team members to provide essential and concise information about the individual's condition) Communication Form and Progress Notes dated 10/4/2023, indicated the director of nursing (DON) documented there was a physician's order dated 9/20/2023 to collect Resident 3's urine sample. During a review of Resident 3's lab report dated 9/21/2023, indicated the facility collected Resident 3's urine on 9/21/2023 at 4:37 a.m. During an interview with LVN 2 on 9/29/2023 at 8:31 a.m., LVN 2 stated a physician order was needed to collect a urine sample using the straight catheter for Resident 1. During concurrent review of the Resident 1's Physician Order and Nursing Notes, LVN 2 stated she was unable to find a physician order to collect the urine sample by straight catheter for Resident 1. During an interview with LVN 1 on 9/29/2023 at 11:34 a.m., LVN 1 stated she did not contact Resident 1's physician to obtain Resident 1's urine sample by straight catheter. LVN 1 further stated I did not document the procedure of collecting the urine sample in the nurses' notes. LVN 1 stated It is important to document to ensure good communication among staff. During an interview with the director of nursing (DON) on 9/29/2023 at 12:29 p.m., the DON stated collecting urine sample by straight catheter required a physician's order because the procedure was invasive, and that the physician must be aware of the procedure. During an interview with the DON on 10/5/2023, at 12:48 p.m., the DON stated that Resident 2 and Resident 3 had an order to collect urine sample for UA and C&S and that urine for Resident 2 and Resident 3 were collected using a straight catheter without a physician's order. The DON stated licensed nurses collected urine sample from Resident 2 and Resident 3. However, the DON stated she was unable to identify the licensed nurses that collected the urine sample from Resident 2 and Resident 3 because she was unable to find any documentation that the urine sample was collected. The DON further stated she contacted LVN 1 and LVN 1 denied that she collected the urine sample for Resident 2 and Resident 3. The DON stated, it is important to document in the progress notes to communicate to everyone that the urine sample was collected and the process on how the urine sample was collected. During a review of the facility's policy and procedures titled, Physician Advanced Practice Provider (APP) Orders revised 3/1/2022, indicated, . Telephone orders are received by phone from a practitioner . 1.2.1 Person obtaining the order . can only take the order from a credentialed physician Regarding prescriptive privileges. 1.2.2 Person obtaining the orders must enter the order into the electronic order management system (phone order) plus prescriber's name and title, name and title of the person receiving the order, date, month, year, and time. 1.2.3 Read back to prescriber to clarify the order . order. 1.2.4 Prescriber's signature must be obtained per State regulations. During a review of the facility's policy and procedures titled, Procedure Specimen Collection: Urine, revised on 2/1/2023, indicated to verify the order and to document the following: 1. Date and time of specimen collection 2. Method of collection 3. Indwelling catheter removal and insertion if applicable 4. Type of testing of specimen 5. Amount of urine collected if applicable. 6. Appearance, odor, color, and unusual characteristics of specimen 7. Time specimen transported to laboratory. During a review of the facility's policy and procedures titled, Clinical Record: Charting and Documentation, revised on 2/1/2023, indicated, Process . 2. Document ., reaction to treatment . 3. Documentation will be concise, accurate, complete, factual, and objective. During a review of the facility's policy and procedures titled, Catheter: Urinary -Justification for Use, revised on 8/7/2023, indicated, Intermittent Catheter Criteria: . It is the treatment of choice of physician/advanced practice provider (APP)/patient/representative based on condition. The patient's record must include how and when the patient/representative was involved and informed of care and treatment including the risk and benefits of a catheter. The patient/representative has the right to decline treatment. There must be documented evidence of discussion.

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1), who had a pressure ulcer and was at risk for developing pressure ulcers (also called bedsores or pressure sores, are injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin; usually affect people confined to bed or who sit in a chair or wheelchair for long periods of time), received the necessary care and services to prevent new ulcers from developing. The facility failed to: 1. Implement the Wound Care Specialist's (Physician 1's) treatment ordered on 3/16/2022 to apply [MEDICATION(S)] (a brand name of a honey-based gel used to treat open wounds) to Resident 1's Stage 2 pressure ulcer (the sore has broken through the top layer of the skin and part of the layer below presenting as a shallow, open wound with a red or pink wound bed; may also present as an intact or open/ruptured blister) to the sacral area (the portion of the spine between the lower back and tailbone). 2. Implement Physician's 1 order on 3/16/2022, to provide Resident 1 with a low air loss mattress (LALM - an air mattress covered with tiny holes designed to let out air very slowly which helps keep the skin dry and [NAME] away any moisture as well as to relieve pressure). 3. Implement Physician's 1 order dated 3/23/2022 to apply [MEDICATION(S)] (an ointment used in wound treatment and prevention) to the healed sacral pressure ulcer area. 4. Implement Resident 1's Care Plan interventions for skin breakdown risk to do daily skin check while assisting the resident with activities of daily living (ADLs, such as bathing, personal hygiene, and dressing) and report changes, the licensed nurses to do weekly skin check, and apply a pressure-redistribution surface (mattresses and overlays designed to prevent pressure ulcers by spreading the pressure more evenly across the surface of the mattress). As a result, on 4/18/2022, Resident 1 was identified with four pressure ulcers: 1. A Stage 2 pressure ulcer on the right trochanter area (right hip). 2. A Stage 3 pressure ulcer (full thickness skin loss involving damage or necrosis [dead tissue] of subcutaneous [under the skin] fat may be visible, but bone, tendon, or muscle are not exposed) on the right buttock. 3. A UTD pressure ulcer (unstageable or undetermined stage because the ulcer is covered with slough [type of dead tissue yellow, tan, green or brown in color and may be moist, loose and stringy in appearance] or eschar [type of dead tissue that presents as dry, thick, leathery tissue that is often tan, brown or black]; the ulcer will reveal either a Stage 3 or 4 pressure ulcer [deep wound that may involve muscle, tendons, ligaments, and bone) on left buttock. 4. A Stage 2 pressure ulcer on the left gluteal fold (fold of the buttock). Findings: A review of Resident 1's Admission Record indicated the facility admitted Resident 1 on 3/2/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Skin Assessment form, dated 3/3/2022, indicated Resident 1 had an inner sacral area Stage 2 pressure sore. A review of Resident 1's Physician Order, dated 3/3/2022, indicated to cleanse the Stage 2 sacral pressure sore with NS (normal saline, a salt solution), pat dry, apply [MEDICATION(S)] cream (an antimicrobial [an agent that kills or stops the growth of bacteria] medication to prevent wound infection) and cover with dry dressing for 21 days every day. A review of Resident 1's Care Plan for skin breakdown risk, initiated on 3/3/2022, indicated a goal for the resident's sacral wound to heal. The interventions included observe skin daily for signs / symptoms of skin breakdown and report abnormalities, pressure-redistribution surface to bed, and do weekly skin check by license nurses. A review of Resident 1's Minimum Data Set (MDS - standardized assessment and care planning tool), dated 3/9/2022, indicated the resident had memory problems, needed extensive staff assistance with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. Resident 1 was at risk for developing pressure ulcers and had a Stage 2 pressure sore. A review of Resident 1's Wound Care Evaluation & Treatment by Physician 1, dated 3/16/2022, indicated Resident 1 had a Stage 3 pressure ulcer with a post debridement (removal of dead tissue) size of 12.0 centimeters (cm) long by 5.0 centimeters wide by 0.1 centimeters deep. Physician 1 indicated in the recommendation/plan of treatment to cleanse the wound with NS, apply [MEDICATION(S)] and cover with [MEDICATION(S)] Border a (self-adherent, multilayer foam dressings) daily, turn the resident every two hours, avoid direct pressure on the ulcer site, and to provide the resident with a LALM. A review of Resident 1's Wound Care Evaluation & Treatment by Physician 1, dated 3/23/2022, indicated Resident 1's sacral Stage 3 pressure ulcer had healed. Physicia1's plan of treatment/recommendations were to continue turning the resident every two hours, avoid direct pressure to the healed ulcer site, LALM and apply [MEDICATION(S)] to the healed ulcer and surrounding area daily. A review of Resident 1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's licensed nurses' weekly summary between 3/23/2022 and 4/18/2022, did not indicate the resident had pressure sores. A review of Resident 1's Change of Condition (COC) form Evaluation, dated 4/18/2022, indicated Resident 1 had an oxygen saturation (the amount of oxygen circulating in the blood) between 88 and 92% (normal above 97%) and an elevated body temperature of 102 degrees Fahrenheit (°F, normal range between 97 to 99 °F. The licensed nurse called paramedics (emergency medical services) to transfer the resident to a hospital. The COC Evaluation indicated Resident 1's skin status as having: 1. A Stage 2 pressure sore to the right trochanter area (hip) measuring 11 cm in length by 2.5 cm in width 2. A Stage 3 pressure sore to the right buttock measuring 10.5 cm by 4 cm. 3. A left buttock UTD (unstageable, unable to determine the stage of the pressure sore because the sore is covered with slough [type of dead tissue yellow, tan, green or brown in color and may be moist, loose and stringy in appearance] or eschar [type of dead tissue that presents as dry, thick, leathery tissue that is often tan, brown or black]; the ulcer will reveal either a Stage 3 or 4 pressure ulcer [deep wound that may involve muscle, tendons, ligaments, and bone) 11 cm by 6 cm. 4. A Stage 2 pressure sore to left gluteal fold measuring 1.5 cm by 1.5 cm. On 5/26/2022 at 2:30 p.m., during an interview with the Assistant Director of Nursing (ADON) and concurrent review of Resident 1's documentation prior to hospitalization on [DATE], the ADON confirmed she assessed Resident 1's skin prior to transfer to the hospital and identified four pressure ulcers as documented in the COC form for Resident 1, dated 4/18/2022. On 5/26/2022 at 3:45 p.m., during interview with the Treatment Nurse and concurrent record review, she stated not being aware of Physician 1's recommendations on 3/16/2022 for [MEDICATION(S)] and LALM or the [MEDICATION(S)] ordered on 3/23/2022. Treatment LVN 2 stated she did not do a daily or weekly skin check since the pressure sore to the sacral area healed. On 5/26/2022 at 4:11 p.m., during an interview, the ADON confirmed Resident 1's clinical record did not have Physician 1's orders for a LALM since the visits on 3/16/2022 and 3/23/2022. The ADON confirmed Physician 1's recommendations/treatment plan were orders that should have been transcribed into Resident 1's clinical record. Resident 1 did not have the order to apply [MEDICATION(S)] to Resident 1's healed ulcer on 3/23/2022 because it was not carried out. On 5/26/2022 at 5:10 p.m., during an interview with the Director of Nursing (DON) and a concurrent review of Resident 1's clinical record, the DON confirmed the Wound Care Evaluation & Treatment by Physician 1 dated 3/16/2022 and 3/23/2022 recommendations were orders and were not followed. On 6/2/2022 at 9:30 a.m., during an interview, Resident 1's Responsible Party (RP 1) stated she visited Resident 1 three times a week and did not observe Resident 1 was on a LALM. A record review of Resident 1's GACH record titled Nursing Narrative Note, dated 4/18/2022 at 10:30 a.m., indicated 1030 (10:30 a.m.) pt (patient) received via EMS (Emergency Medical Service) from nursing home for complaints of fever, [CONDITION(S)] (rapid heart rate), and AMS (altered mental status) . pt has large sacral wound, unstageable and raw . pt immobile and has open sacral wound. A review of the facility's policy and procedures (P&P) titled, Skin Integrity Management, dated 5/26/2021, indicated nursing staff will observe for any signs of potential or active pressure injury daily while providing nursing care. The P&P also indicated the facility will implement pressure ulcer prevention for identified risk factors and Implement special wound care treatment/techniques, as indicated and ordered. Furthermore, the policy indicated the facility will notify physician / APP (Advanced Practice Providers) to obtain orders and review care plan and revise as indicated.

Based on interview and record review, the facility failed to immediately notify the physician when one of four sampled residents (Resident 17), who was totally dependent on staff for showering, sustained two episodes of almost falling in the shower room. On 11/10/2021, Resident 17 slid down twice from the shower chair (or bath chair allow resident to have a shower in the seated position; a shower chair is typically a four-legged chair with wheels usually made with a durable plastic seat) but did not fall onto the floor. The facility failed to: 1. Notify the physician of Resident 17's two incidents of sliding down the shower chair, Certified Nursing Assistant 2 (CNA 2) was able to hold the resident and call for help to sit the resident back in the shower chair, and the resident's subsequent complaints of right leg and knee pain, for the physician to determine the course of treatment. 2. Evaluate Resident 17's right leg and knee immediately after the two incidents of sliding down the shower chair and notify the physician of the resident's complain of pain and swelling on the right knee. As result, Resident 17 endured unnecessary pain and there was a delay of five days for the physician to order x-rays (quick, painless test that produces images of the structures inside the body) and identify on 11/15/2021, Resident 17 had sustained a spiral fracture (bone fracture that occurs when a long bone is broken by a twisting force) of the right distal femur (the thigh bone close to the knee). Resident 17 required transfer to General acute care hospital (GACH) on 11/15/2021 to underwent surgery the same day. Findings: A review of the Resident 17's Admission Record indicated the facility admitted the resident on 9/20/2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 17's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 9/20/2021 indicated resident was oriented (aware of surroundings, place, and person), could verbalize needs, and make decisions. Resident 17 needed extensive assistance with one-person physical assist with bed mobility, transfer, dressing, eating, toilet use and personal hygiene. A review of Resident 17's undated Care Plan developed for the resident's risk for alteration in comfort related to immobility and [CONDITION(S)]. The interventions included medicate resident as ordered for pain, monitor for effectiveness and side effects, and report to physician as indicated. A review of Resident 17's undated Care Plan developed for the resident's risk for spontaneous fracture (breakage of bone occurring without any apparent external damage or trauma) related to severe osteopenia (a condition that begins as the person loses bone mass and the bones get weaker) that even just a slight bump she could easily have a fracture even without a fall, included in the interventions observing for changes in medical, pain, and mental status and report to the physician as indicated. A review of Resident 17's nursing Progress Notes, dated 11/10/2021, timed at 2:14 p.m., indicated CNA 2 was giving the resident a shower and CNA 2, while in the shower room, called for help to sit Resident 17 because the resident almost slid down from the shower chair. After sitting her back in the shower chair, Resident 17 slid down once more. Resident complained of pain rated 2/10 (mild pain). The licensed nurse offered pain medication, but Resident 17 refused. The licensed nurse did not explain the reason the resident refused. The note did not include pain assessment such as location, level, intensity, what increased the pain (movement, pressure, touch, etc.) and what relieved the pain. The note did not include Resident 17's physician was notified of the resident's two incidents of almost falling from the shower chair and need of two staff to put her back in a sitting position and the resident's immediate complaints of pain on the right leg and knee. A review of Resident 17's nursing Progress Notes, dated 11/10/2021, timed at 7:00 p.m. (3 p.m. to 11 p.m. shift) Licensed Vocational Nurse 2 (LVN 2) documented the resident complained of right knee pain. LVN 2 did not document the resident's pain level, severity, and quality of the pain. LVN 2 documented Resident 17 had swelling on the right knee, and it was warm to touch. The physician was informed of the swelling and ordered [MEDICATION(S)] (antibiotic, a medication to treat infections) 250 milligram (mg) three times a day for seven days for [CONDITION(S)] (infection of the skin). There was no documentation the physician was informed of the two incidents of almost falling when sliding down the shower chair during the previous shift (7 a.m. to 3 p.m.) for the physician to consider different treatment options such as x-rays and immobilization of the right leg. A review of Resident 17's Change of Condition form dated 11/10/2021 timed at 10:14 p.m., indicated the resident had right knee swelling treated with antibiotic, pain assessment was not clinically applicable, and the pain assessment and location of the pain was left blank. A review of Resident 17's nursing documentation from 11/10/2021 until 11/13/2021, indicated the licensed nurses were monitoring the resident for right knee swelling and antibiotic use. There was no documentation the licensed nurses notified the physician about the continued pain and swelling of the right knee. A review of Resident 17's Radiology result of the right knee on 11/15/2021, indicated Resident 17 had a right femoral (thigh bone) fracture. A review of Resident 17's nursing note on 11/15/2022, indicated the physician when informed of the x-rays result ordered transferring the resident to GACH 1 the same day. A review of Resident 17's discharge summary from GACH 1, dated 11/19/2021, indicated resident was admitted to the hospital on 11/15/2021 with mechanical fall and required on 11/15/2021 to undergo an open reduction, internal fixation (ORIF- a type of surgery used to repair broken bones that need to be put back together; some form of hardware is used to hold the bone together so it can heal) of the right femur. During an interview on 2/25/2022 at 7:33 p.m., Resident 17 stated she did not fall onto the floor but almost fell from the shower chair twice because it was slippery. Resident 17 stated CNA 2 was able to hold her before she fell and with another staff, she was put back in the shower chair in a sitting position. Resident 17 states since then she was in moderate to severe pain for four days and finally the doctor ordered x-rays of the right knee and leg and discovered she had a broken knee. On 2/26/2022 at 4:05 p.m., during an interview with LVN 2 and a review of Resident 17's nursing documentation for 11/2021, LVN 2 stated she was the nurse on 11/10/2021 during the 3 pm to 11 pm shift. LVN 2 stated resident complained of right knee pain and swelling. LVN 2 stated that she was not aware of the incident of Resident 17's almost falling in the morning. LVN 2 stated she notified Registered Nurse 1 (RN 1) about the resident's right knee pain and swelling and RN 1 called the physician. During a telephone interview on 2/26/2022 at 4:35 p.m. with CNA 2, on 11/10/2021, while in the shower chair and as she was pushing the shower chair out of the shower room, Resident 17 slid down twice but she was able to hold her not to fall on the floor On 2/26/2022 at 3:09 p.m. during an interview with Director of Nursing (DON) and concurrent review of Resident 17's Investigation Report dated 11/15/2021, DON stated Resident 17 had an incident on 11/10/2021 during the shower when two staff showered the resident. DON stated there was no need to notify the resident's physician about the incident in the shower because Resident 17 did not fall. DON the physician was notified on 11/14/2021 and ordered x-rays of the right leg and knee because of continued swelling and pain. During a telephone interview on 2/26/2022 at 4:35 p.m., CNA 2 stated that on 11/10/2021, she was showering the resident by herself. Resident 17 almost slid in the shower twice on 11/10/2021 when she was pushing her outside the shower by herself. CNA 2 stated another staff (did not specify who) saw her and started helping her to keep the resident from falling but resident slid again. n 3/1/2/2022 at 11:34 a.m., during a concurrent interview with DON and the Administrator and a review of Resident 1's medical record and the Change of Condition and Accidents policies and procedures, DON stated that during the incident on 11/10/2021, she did not think it was an accident requiring the doctor to be notify and have the incident/accident investigated right away. A review of facility's policy and procedures titled, Accidents/Incidents, with revised date on 1/1/2022, indicated, The facility's staff will use the risk management system to report, review and investigate all accidents/incidents which occurred, or allegedly occurred on property and involved, or allegedly involved a patient who is receiving services .An accident is defined as any unexpected or unintentional incident which may result in injury or illness to a resident an incident is defined any occurrence not consistent with routine operation of the facility or normal care of the patient. an incident can involve a visitor or staff member, malfunctioning equipment, or observation of a situation that poses a threat to safety or security the nurse will notify the physician of the accident/incident, report the physical findings and extent of injuries and obtain orders if indicated. It will also be documented in the patient's chart, documentation will include all pertinent information, date, time, place, notifications, and initial ongoing assessments. It should also be documented in the accident/incident on the 24-hour report.

Based on interview and record review, the facility failed to ensure the residents receive adequate supervision and assistance devices based on the residents' individual needs to prevent injuries for five of five sampled residents (Residents 17, 25, 33, 69 and 174). The facility failed to: 1a. Provide at least two staff assistance on 11/10/2021, when Resident 17, who was quadriplegic (loss of muscle function and strength from the neck down, including the trunk and four extremities) was sat in a shower chair (also called bath chair, allows residents to have a shower in the seated position; a shower chair is typically a four-legged chair with wheels usually made with a durable plastic seat) without a securing device (belt or bar), transported to a communal shower room, was given shower with soap and water, resulting in a slippery chair causing the resident to slide down the chair twice. Certified Nursing Assistant 2 (CNA 2) who was alone giving Resident 17 the shower, held the resident twice before the resident would hit floor, called for assistance and with another staff placed the resident back in a sitting position in the shower chair. Immediately after the two incidents, Resident 17 complained of pain on the right leg and knee. 1b. Evaluate Resident 17's sitting balance (the ability to sit upright and maintain upright posture) to safely use a shower chair and consider safer options for showers including the use of a reclining shower chair or a shower bed (a height adjustable bed makes showering and changing safe and comfortable for disabled and people with mobility disabilities). 2. Provide Resident 25 with assistance when on 12/15/2021 he was calling for assistance to use the toilet, but nobody came to help him. Resident 25 went to the toilet by himself, fell and sustained a fracture of shaft of left tibia (shin bone), was transferred to GACH 2 where he underwent surgery. 3. Provide Residents 33, 69 and 174 with supervision while smoking. 4. Ensure the emergency exit door was always closed and the fire alarm always remained on. 5. Ensure Resident 53's bed was in the low position for safety. These deficient practices resulted in Resident 17's being identified on 11/15/2021 with a right femoral (thigh bone) fracture (broken bone) requiring transfer to General Acute Care Hospital 1 (GACH 1) on 11/15/2021 to have surgery the same day; Resident 25 sustained a leg fracture requiring hospitalization and surgery; Residents 33, 69 and 174 were place at risk for [CONDITION(S)] from smoking, residents and staff were placed a risk in case of fire; and Resident 53, who was at risk for fall was placed at risk for injuries in the bed was not lowered to the lowest position. Findings: 1. A review of the Resident 17's Admission Record indicated the facility admitted the resident on 9/20/2017 with diagnoses including [CONDITION(S)] (loss of muscle function and strength from the neck down, including the trunk and four extremities) and [CONDITION(S)] (disease in which the immune system eats away at the protective covering of nerves in the brain and spinal cord). A review of the Physician's Order for Resident 17, dated 4/6/2020, indicated to administer the resident Tylenol 325 milligram (mg) two tablets by mouth every six hours as needed for mild pain (1-4 out of 10, in pain rating scale from zero to 10, zero indicating no pain and 10 the worst possible pain). A review of Resident 17's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 9/20/2021 indicated resident was oriented (aware of surroundings, place, and person), could verbalize needs, and make decisions. Resident 17 needed extensive assistance with one-person physical assist with bed mobility, transfer, dressing, eating, toilet use and personal hygiene. Resident 17 was dependent on one-person assist for toileting hygiene, shower, and bathing. A review of Resident 17's undated Care Plan developed for the resident's risk for alteration in comfort related to immobility and [CONDITION(S)]. The interventions included medicate resident as ordered for pain, monitor for effectiveness and side effects, and report to physician as indicated. A review of Resident 17's Physical Therapy (PT) evaluation, dated 9/1/2021, indicated the resident was a fall risk related to impaired strength and balance impairment, was dependent with bed mobility, and sitting (balance) was not tested . A review of Resident 17's undated Care Plan developed for the resident's risk for spontaneous fracture (breakage of bone occurring without any apparent external damage or trauma) related to severe osteopenia (a condition that begins as the person loses bone mass and the bones get weaker) that even just a slight bump she could easily have a fracture even without a fall, included in the interventions observing for changes in medical, pain, and mental status and report to the physician as indicated. A review of Resident 17's nursing Progress Notes, dated 11/10/2021, timed at 2:14 p.m., indicated CNA 2 was giving the resident a shower and CNA 2, while in the shower room, called for help to sit Resident 17 because the resident almost slid down from the shower chair. After sitting her back in the shower chair, Resident 17 slid down once more. Resident complained of pain rated 2/10 (mild pain). The licensed nurse offered pain medication, but Resident 17 refused. The licensed nurse did not explain the reason the resident refused. The note did not include pain assessment such as location, level, intensity, what increased the pain (movement, pressure, touch, etc.) and what relieved the pain. The note did not include Resident 17's physician was notified of the resident's two incidents of almost falling from the shower chair and need of two staff to put her back in a sitting position and the resident's immediate complaints of pain on the right leg and knee. A review of Resident 17's nursing Progress Notes, dated 11/10/2021, timed at 7:00 p.m. (3 p.m. to 11 p.m. shift) Licensed Vocational Nurse 2 (LVN 2) documented the resident complained of right knee pain. LVN 2 did not document the resident's pain level, severity, and quality of the pain. LVN 2 documented Resident 17 had swelling on the right knee, and it was warm to touch. The physician was informed of the swelling and ordered [MEDICATION(S)] (antibiotic, a medication to treat infections) 250 milligram (mg) three times a day for seven days for [CONDITION(S)] (infection of the skin). There was no documentation the physician was informed of the two incidents of almost falling when sliding down the shower chair during the previous shift (7 a.m. to 3 p.m.) for the physician to consider different treatment options such as x-rays and immobilization of the right leg. A review of Resident 17's Change of Condition form dated 11/10/2021 timed at 10:14 p.m., indicated the resident had right knee swelling treated with antibiotic, pain assessment was not clinically applicable, and the pain assessment and location of the pain was left blank. A review of Resident 17's nursing documentation from 11/10/2021 until 11/13/2021, indicated the licensed nurses were monitoring the resident for right knee swelling and antibiotic use. There was no documentation the licensed nurses notified the physician about the continued pain and swelling of the right knee. A review of Resident 17's Radiology result of the right knee on 11/15/2021, indicated Resident 17 had a right femoral (thigh bone) fracture. A review of Resident 17's nursing note on 11/15/2022, indicated the physician when informed of the x-rays result ordered transferring the resident to GACH 1 the same day. A review of Resident 17's discharge summary from GACH 1, dated 11/19/2021, indicated resident was admitted to the hospital on 11/15/2021 with mechanical fall and required on 11/15/2021 to undergo an open reduction, internal fixation (ORIF- a type of surgery used to repair broken bones that need to be put back together; some form of hardware is used to hold the bone together so it can heal) of the right femur. During an interview on 2/25/2022 at 7:33 p.m., Resident 17 stated she did not fall onto the floor but almost fell from the shower chair twice because it was slippery. Resident 17 stated CNA 2 was able to hold her before she fell and with another staff, she was put back in the shower chair in a sitting position. Resident 17 states since then she was in moderate to severe pain for four days and finally the doctor ordered x-rays of the right knee and leg and discovered she had a broken knee. On 2/26/2022 at 4:05 p.m., during an interview with LVN 2 and a review of Resident 17's nursing documentation for 11/2021, LVN 2 stated she was the nurse on 11/10/2021 during the 3 pm to 11 pm shift. LVN 2 stated resident complained of right knee pain and swelling. LVN 2 stated that she was not aware of the incident of Resident 17's almost falling in the morning. LVN 2 stated she notified Registered Nurse 1 (RN 1) about the resident's right knee pain and swelling, and RN 1 called the physician. During a telephone interview on 2/26/2022 at 4:35 p.m. with CNA 2, on 11/10/2021, while in the shower chair and as she was pushing the shower chair out of the shower room, Resident 17 slid down twice but she was able to hold her not to fall on the floor On 2/26/2022 at 3:09 p.m. during an interview with Director of Nursing (DON) and concurrent review of Resident 17's Investigation Report dated 11/15/2021, DON stated Resident 17 had an incident on 11/10/2021 during the shower when two staff showered the resident. DON stated that resident needed always two-person assist during shower. DON stated there were two CNAs and a Restorative Nursing Assistant (RNA) showering the resident on 11/10/2021 when resident slid from the shower chair. On 2/26/2022 at 4:35 p.m., during a telephone interview, CNA 2 stated on 11/10/2021, she was showering the resident by herself. CNA 2 stated Resident 2 slid down and almost fall twice on 11/10/2021 when she was pushing her outside the shower room by herself. CNA 2 stated another staff (did not specify who) saw her and started helping her to keep the resident from falling but resident slid again. On 3/1/2/2022 at 11:34 a.m., during a concurrent interview with DON and the Administrator and a review of Resident 1's medical record and the Change of Condition and Accidents policies and procedures, DON stated that during the incident on 11/10/2021, she did not think it was an accident requiring the doctor to be notify and have the incident/accident investigated right away. On 2/27/2022 at 10:19 a.m., during an interview with Director of Rehabilitation (DOR) and a concurrent review of Resident 17's Physical therapy (PT) evaluation and MDS dated [DATE], DOR stated the resident was totally dependent, meaning the resident needed to have two-person assist for most of her activities of daily living (ADLs, such as eating, dressing, transfers, bathing, and showering). DOR stated Resident 17, would require a reclining shower chair, but the facility did not have one. A review of facility's policy and procedures (P &P) titled, Accidents/Incidents, with revised date on 1/1/2022, indicated, The facility's staff will use the risk management system to report, review and investigate all accidents/incidents which occurred, or allegedly occurred on property and involved, or allegedly involved a patient who is receiving services .An accident is defined as any unexpected or unintentional incident which may result in injury or illness to a resident an incident is defined any occurrence not consistent with routine operation of the facility or normal care of the patient. an incident can involve a visitor or staff member, malfunctioning equipment, or observation of a situation that poses a threat to safety or security the nurse will notify the physician of the accident/incident, report the physical findings and extent of injuries and obtain orders if indicated. It will also be documented in the patient's chart, documentation will include all pertinent information, date, time, place, notifications, and initial ongoing assessments. It should also be documented in the accident/incident on the 24-hour report. 2. A review of Resident 25's Admission Record indicated the facility admitted the resident on 8/31/2017, with diagnosis including chronic obstructive pulmonary disease ([CONDITION(S)], a group of diseases that cause airflow blockage and breathing related problems making it difficult to breathe) and major depressive disorder (a mental disorder that have a persistent feeling of loss of pleasure or interest in life). A review of Resident 25's MDS, dated [DATE], indicated the resident was moderately cognitively (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) impaired and required limited assistance from staff with bed mobility, dressing, toilet use, and personal hygiene. On 2/26/2022 at 2:15p.m., during an interview, Resident 25 stated that he had a fall in the facility in 12/2021 which resulted in a left leg surgery. Resident 25 stated he had used the call light for assistance to the bathroom, waited for about 30 minutes, and decided to go to the bathroom on his own since no one came to assist him and could not wait any longer. Resident 25 stated he was in the bathroom, started walking back to his bed and his leg weakened which caused him to fall and break his left leg. On 2/27/2022 at 8:57 a.m., during an interview with Social Services 2 (SS 2), a concurrent review of Resident 25's clinical record was conducted. SS 2 stated Resident 25 fell on [DATE] and LVN 5 found the resident on the bathroom floor. SS 2 stated Resident 25 was immediately transported to the hospital and returned back on 12/18/2021. On 2/27/2022 at 9:20 a.m., during a concurrent observation and interview with Resident 25, observed resident with a yellow risk band (a band to indicate to staff the resident was on fall precautions) on his arm and was laying down on his bed. Resident 25 pointed to his left leg and showed marks which indicated his surgical site which he stated the metal rod was placed in his left lower leg. On 2/27/2022 at 10:32 a.m., during an interview, DON stated prior to Resident 25's fall, resident was alert, oriented, and was placed on fall-risk precautions (any action taken to help reduce the number of accidental falls). DON stated he was a fall risk due to his physical condition, mobility, medication use, and his age. DON stated it is the responsibility of all staff members to answer call lights and need to be answered as soon as possible, no longer than 10-15 minutes. DON stated if call lights are taking longer than 15 minutes, it is considered an issue and needs to be addressed. On 2/28/2022 at 10:55 a.m., during an interview, Resident 28 stated that his roommate, Resident 25, on the day of the fall, he used the call light to request assistance from staff to go to the bathroom. Resident 28 stated he heard a loud breaking sound and Resident 25 screaming in pain. Resident 28 stated LVN 5 came to the room first and many more nurses came afterwards to assist Resident 25. A record review of the facility's P&P titled, Fall Management, dated 5/26/2021, indicated Patients will be assessed for falls risk as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions (action) to reduce risk and minimize injury. Patients experiencing a fall will receive appropriate care and investigation of the cause. A record review of the facility's P & P titled, Accidents/Incident revised on 1/1/2022, indicated an accident is defined as any unexpected or unintentional incident which may result in injury or illness to a resident/patient. The licensed nurse will utilize Risk Management System (RMS) to report accidents/incidents and assist with completion of a timely investigation to determine root cause. The information will: generate notification of appropriate leadership depending on the severity level of the event; trigger specific investigation tools based on the type of event and/or injury of the patient; and flow to individualized state reporting forms to assist with completing the state and federal reporting requirement, as indicated. The nurse will: enter the accident/incident into RMS as a new event within 24 hours of the occurrence; document the accident/incident in the patient's chart; documentation will include all pertinent information, date, time, place, notifications, and initial and ongoing assessments; document the accident/incident on the 24-hour report. The Center Nurse Executive or designee will close the event within five days or per Abuse Prohibition policy for incidents of abuse. A review of the facility's P & P titled, Call Lights dated 06/01/21, indicated Call light or alternative communication device within their reach at all times when unattended. Staff will respond to call lights and communication devices promptly. 3a. A review of Resident 33's Admission Record indicated the facility admitted the resident on 9/20/2021 with diagnoses including [CONDITION(S)] (a disease in which the functioning of the brain is affected by some agent or condition-such as [CONDITION(S)] infection or toxins in the blood) and heart failure (HF-a chronic condition in which the heart does not pump blood as well as it should). A review of Resident 33's MDS dated [DATE], indicated Resident 33's cognition was severely impaired for daily decision-making (unable to understand, comprehend and make decisions) and required extensive assistance from staff for ADLs. 3b.A review of Resident 69's Admission Record indicated the facility admitted the resident on 2/2/2022 with diagnoses including [CONDITION(S)] and type II diabetes (a chronic condition that affects the way the body processes blood sugar [glucose]). A review of Resident 69's MDS dated [DATE], indicated the resident's cognition was moderately impaired for daily decision-making (difficulty comprehending and having poor judgement) and required extensive assistance from staff for ADLs. A review of Resident 69's Care Plan, initiated on 2/4/2022, indicated patient may smoke with supervision per smoking assessment. 3c. A review of Resident 174's Admission Record indicated the facility admitted the resident to the facility on [DATE] with diagnoses including [CONDITION(S)] (a disorder that affects a person's ability to think, feel, and behave clearly) and type II diabetes. A review of Resident 174's MDS dated [DATE], indicated Resident 174's cognition was moderately impaired for daily decision-making and required limited assistance from staff for ADLs. A review of Resident 174's Care Plan, initiated on 2/4/2022, indicated patient may smoke with supervision per smoking assessment. During an observation on 2/26/2022 at 10:30 a.m., Residents 33, 69 and 174 were smoking in the patio without staff supervision. In a concurrent interview, Resident 33 stated they usually smoke in the patio without supervision. Resident 174 had a cigarette in her pocket and stated she keeps her cigarette in her room. During an interview with Activity Director (AD) on 2/26/2022 at 10:46 a.m., AD stated residents should be supervised while smoking to make sure they are safe from [CONDITION(S)] or any accidents. AD further stated and confirmed, there was no staff supervising the residents in the patio while smoking. A review of the facility's P & P titled Smoking revised 11/20/2018, indicated the patient will be allowed to smoke only with direct supervision . supervised smoking is defined as the observer must be in the direct area of the smoker, within eye contact, and able to respond to emergency situations. 4. During a facility tour on 2/25/2022 at 8:06 p.m., it was observed that the emergency exit door by the Station 2 was propped open with an empty box of gloves. During an interview with Maintenance Supervisor (MS) on 2/27/2022 at 10:05 a.m., MS stated emergency doors should be kept always closed. During a concurrent observation of the emergency exit door in Station 2, a key was by the door, and it was to turn off the emergency exit alarm system. MS closed the emergency door and used the key to turn on the alarm system. MS stated they kept the emergency key by the door so that it will be accessible to any staff in the facility. MS further stated he did not know if it the key should be kept by the door. During an interview with the DON on 2/27/2022 at 10:30 a.m., DON stated the key for the alarm system should not be kept by the emergency exit door. DON stated if the key is inserted in the alarm system and turned to off, the alarm will not work, and anyone can access the door and exit the facility. A review of the facility's P & P titled, Fire Protection Systems revised 8/27/2018 indicated the central monitoring services must be continuously stations to electronically supervise the system to ensure site personnel are aware when part of the system fails or needs repair. 5.A review of Resident 53's Admission Record indicated the facility admitted the resident on 1/28/2022, with diagnoses including dysphasia (language disorder, affecting speaking and understanding language), acute respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon [MEDICATION(S)]), heart failure and gastrostomy tube (GT- a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration). A review of Resident 53's MDS, dated [DATE], indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and required extensive assistance from staff for ADLs. A review of Resident 53's fall risk assessment, dated 2/17/2022, indicated Resident 53 was at risk for fall. A review of Resident 53's chart, dated 1/31/2022, indicated Resident 53 had a risk for fall care plan. During an initial tour on 2/25/2022 at 7:17 p.m., Resident 53's bed was observed in a high position level. During a concurrent observation and interview with the Licensed Vocational Nurse 6 (LVN 6) on 2/25/2022 at 7:43 p.m., LVN 6 stated that Resident 53's bed was up too high with risk of possible fall. LVN 6 further stated that the certified nursing assistant might have forgotten to put in the lowest position after basic care. A record review of the facility's P&P titled, Fall Management, dated 5/26/2021, indicated Patients will be assessed for falls risk as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions (action) to reduce risk and minimize injury. Patients experiencing a fall will receive appropriate care and investigation of the cause.

Based on interview and record review, the facility failed to provide pain management for one of four sampled residents (Resident 17), who was unable to move from the neck down and was totally dependent on staff for showering, developed pain immediately after sustaining two episodes of almost falling to the floor. On 11/10/2021, Resident 17 slid down twice from the shower chair (or bath chair allow resident to have a shower in the seated position; a shower chair is typically a four-legged chair with wheels usually made with a durable plastic seat) and Certified Nursing Assistant 2 (CNA 2) was able to hold the resident and call for help to sit the resident back in the shower chair. The facility failed to: 1. Assess Resident 17's extent of injuries from the incidents of almost falling and maneuvering to put her back in a sitting position correlated with the resident's complains of pain on the right leg and right knee immediately after the two incidents. 2. Implement the facility's Pain Management policy by not developing an individualized care plan addressing Resident 17's new onset of pain. 3. Continuously assess Resident 17's pain location, intensity, quality, aggravating factors, what relieved the resident's pain, provide medication as ordered and if ineffective notify the physician for further orders. As result, Resident 17 endured unnecessary pain for five days until 11/5/2021 when x-rays (test that produces images of the structures inside the body) identified Resident 17 had sustained a spiral fracture (bone fracture that occurs when a long bone is broken by a twisting force) of the right distal femur (the thigh bone close to the knee). Resident 17 required transfer to General Acute Care Hospital 1 (GACH 1) on 11/15/2021 to underwent surgery the same day. Findings: A review of the Resident 17's Admission Record indicated the facility admitted the resident on 9/20/2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 17's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 9/20/2021 indicated resident was oriented (aware of surroundings, place, and person), could verbalize needs, and make decisions. Resident 17 needed extensive assistance with one-person physical assist with bed mobility, transfer, dressing, eating, toilet use and personal hygiene. Resident 17 was dependent for toileting hygiene, shower, and bathing. A review of Resident 17's undated Care Plan developed for the resident's risk for alteration in comfort related to immobility and [CONDITION(S)]. The interventions included to medicate resident Tylenol (medication for pain) 325 milligram (mg) two tablets by mouth every six hours as needed for mild pain as ordered for pain and monitor for effectiveness and monitor for side effects, report to physician as indicated. A review of Resident 17's nursing Progress Notes, dated 11/10/2021, timed at 2:14 p.m., indicated CNA 2 took Resident 17 for a shower in a shower room. CNA 2, while in the shower room, called for help to sit Resident 17 because the resident almost slid down from the shower chair onto the floor. After sitting the resident back in the shower chair, Resident 17 slid down once more. Resident 17 complained of pain rated 2/10 (mild pain). The progress notes indicated the licensed nurse offered pain medication, but Resident 17 refused, the reason for the refusal was not documented. The progress notes did not include pain assessment such as location, level, intensity, what increased the pain (movement, pressure, touch, etc.) and what relieved the pain. The progress notes did not include Resident 17's physician was notified of the resident's incidents of sliding down and needing to be put back in the shower chair. A review of Resident 17's nursing Progress Notes, dated 11/10/2021, timed at 7:00 p.m. (3 p.m. to 11 p.m. shift) Licensed Vocational Nurse 2 (LVN 2) documented the resident complained of right knee pain. LVN 2 did not document the resident's pain level, severity, and quality of the pain. LVN 2 documented Resident 17 had swelling on the right knee, and it was warm to touch. The physician was informed of the swelling and ordered [MEDICATION(S)] (antibiotic, a medication to treat infections) 250 milligram (mg) three times a day for seven days for [CONDITION(S)] (infection of the skin). There was no documentation the physician was informed of the accident that occurred in the previous shift (7 a.m. to 3 p.m.) A review of Resident 17's Change of Condition form dated 11/10/2021 timed at 10:14 p.m., indicated the resident had right knee swelling treated with antibiotic, pain assessment was not, clinically applicable, and the pain assessment and location of the pain was left blank. A review of Resident 17's nursing Progress Notes, dated 11/11/2021 timed at 8:03 a.m., indicated the resident asked for pain medication and was given two tablets of Tylenol. There was no documentation of pain level, location, quality, and there was no documentation if the pain medication was effective. A review of Resident 17's Pain Monitoring Sheet for 11/2021, indicated resident had pain (location of the pain was not specified) on: - 11/10/2021, 3 p.m. to 11 p.m. shift, rated 8/10 - 11/11/2021, 7 a.m. to 3 p.m. shift, rated 5/10 - 11/11/2021, 3 p.m. to 11 p.m. shift, rated 5/10 A review of Resident 17's Medication Administration Record (MAR) indicated the only time Tylenol 325 mg two tablets by mouth every six hours as needed for mild pain was administered was on 11/11/2021 at 8:03 a.m. A review of Resident 17's MAR and nursing notes from 11/10/2021 to 11/14/2021 indicated no documentation the resident was provided with non-pharmacological interventions. A review of Resident 17's Radiology result of the right knee on 11/15/2021, indicated Resident 17 had a right femoral (thigh bone) fracture. A review of Resident 17's nursing note on 11/15/2022, indicated the resident's physician ordered to transfer the resident to GACH 1 the same day when informed of the resident's x-rays result. A review of Resident 17's discharge summary from GACH 1, dated 11/19/2021, indicated the resident was admitted to the hospital on 11/15/2021 with mechanical fall and required on 11/15/2021 to undergo an open reduction, internal fixation (ORIF- a type of surgery used to repair broken bones that need to be put back together; some form of hardware is used to hold the bone together so it can heal) of the right femur. During an interview on 2/25/2022 at 7:33 p.m., Resident 17 stated she did not fall onto the floor but almost fell from the shower chair twice because it was slippery. Resident 17 stated CNA 2 was able to hold her before she fell and with another staff, and that she was put back in the shower chair in a sitting position. Resident 17 stated since then she was in moderate to severe pain for four days and finally the doctor ordered x-rays of the right knee and leg and discovered she had a broken knee. Resident 17 stated that she refused the Tylenol because it was not working. On 2/26/2022 at 4:05 p.m., during an interview and a review of Resident 17's nursing documentation with LVN 2 for 11/2021, LVN 2 stated she was the nurse on 11/10/2021 on 3 pm to 11 pm shift. LVN 2 stated resident complained of right knee pain and swelling. LVN 2 stated that she was not aware of the incident in the morning that resident out in the shower chair. LVN 2 stated that she notified Registered Nurse 1 (RN 1), who called the doctor. LVN 2 stated that she was not aware she was supposed to document the pain level in the pain assessment. LVN 2 stated that if resident refused pain medication, she should document nonpharmacological interventions and notify the doctor for unrelieved pain. During a telephone interview with CNA 2 on 2/26/2022 at 4:35 p.m., CNA 2 stated that on 11/10/2021, while in the shower chair and as she was pushing the resident on a shower chair out of the shower room, Resident 17 slid down twice but she was able to hold the resident not to fall on the floor. During an interview on 3/1/2022 at 11:34 a.m., Director of Nursing (DON) stated Resident 17 should have been assessed for pain at least every shift and the licensed nurses should have documented the pain assessment including the pain intensity, quality, and location. The DON stated licensed nurses should notify the doctor if the resident's pain is not getting any better or the pain medication is ineffective. A review of facility's policy and procedures titled, Pain Management revised on 6/1/2021, indicated, Residents will be evaluated as part of the nursing assessment process for the presence of pain upon admission/re-admission, quarterly, with change of condition or change in pain status, and as required by the state thereafter. Pain management that is consistent with professional standards of practice, the comprehensive person-centered care plan, and the patient's goals and preferences is provided to patients who require such services .the nurse will notify the physician as appropriate and obtain treatment orders as indicated. An individualized care plan will be developed and include addressing/treating underlying causes of pain to the extent possible; nonpharmacological and pharmacological approaches and using specific strategies for preventing or minimizing different levels or source of pain or pain related symptoms .if a patient has a change in pain status, complete a pain evaluation .patients who have unstable pain medication will be indicated on the 24-hour summary report.

Based on interview and record review, the facility failed to ensure one of two sample residents (Resident 1), who had history of several surgeries due to vascular (blood vessels) ruptures and abdominal bleeding, was provided with the necessary care and services consistent with professional standards of practice and in accordance with the comprehensive plan of care and clinical needs, including: 1. Failure to implement the facility's policy on Pain Management and Resident 1's plan of care regarding pain risk, by not accurately evaluate Resident 1's pain, by not assessing pain characteristics, possible causes of the pain, effectiveness of intervention, and by not documenting the pain and interventions. 2. Failure to implement Resident 1's plan of care regarding abdominal discoloration and mass, by not monitoring the area for changes suggesting complications from recent surgery and diagnoses. 3. Failure to implement the facility's policy on Notification of Change of Condition by not relaying to the physician or designee, a complete and accurate status of Resident 1's condition and pertinent information to ensure the physician's orders [REDACTED]. 4. Failure to ensure radiological tests were done stat (immediately) as ordered, by not having a policy addressing the timeliness of stat x-rays. These deficient practices resulted in Resident 1's emergent transfer to a General Acute Care Hospital (GACH), underwent emergent surgery, and caused Resident 1 emotional anguish, anger, and sleep problems. The delay in transferring to a GACH, placed Resident 1 at great risk of severe complications including death. Findings: On [DATE] an unannounced visit was made to the facility to investigation a complaint regarding Resident 1's delayed transfer to a General Acute Care Hospital (GACH). A review of the closed clinical record indicated in the Admission Record Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE], after a GACH stay from [DATE] to [DATE] Resident 1's [DIAGNOSES REDACTED].). A review of the Plan of Care initiated [DATE], developed for Resident 1's risk of alteration of comfort due to pain, included in the interventions to evaluate pain characteristics: quality, severity, location, and precipitating/relieving factors, utilize pain scale (rating scale of pain from zero to 10, zero indicating no pain and 10 the worst pain possible), and completing the pain assessment per protocol. A review of the History and Physical (H&P) for Skilled Nursing Facility signed by Physician 1 and dated [DATE], indicated Resident 1 had a history of [REDACTED]. an endovascular aneurysm repair (EVAR)) s/p open AAA repair. The plan was to monitor Resident 1's cardiovascular status closely. Physician 1 documented Resident 1 had the capacity to understand and make decisions. A review of the Minimum Data Set (MDS - standardized assessment and care planning tool) dated [DATE], indicated Resident 1 had no memory or behavioral problems and was able to communicate without difficulties. A review of the Skin Integrity Report dated [DATE], indicated Resident 1 had an eight-centimeters (cm) surgical wound to the left groin, scattered discoloration to the left lower quadrant of the abdomen (LLQ - left of the midline and below the navel), and a hard mass to left lateral abdomen (the dimensions were documented as entire area). A review of the Plan of Care dated [DATE], developed for Resident 1's discoloration of the LLQ, included in the interventions monitoring for any change of condition (C(NAME)) daily for 14 days. A review of the Plan of Care dated [DATE], developed for Resident 1's mass on the left lateral abdomen included in the interventions monitoring any C(NAME) daily for 14 days. A review of the Progress Notes dated [DATE], timed at 1:30 a.m., Registered Nurse 1 (RN 1) documented Resident 1 complained of abdominal pain rated ,[DATE]. Nurse Practitioner 1 (NP 1), was called and ordered to administer Resident 1 [MEDICATION NAME] (narcotic pain medication) one tablet every four hours as needed (PRN), a KUB (kidney, ureter, and bladder x-ray), a blood work stat (immediately). Resident 1 wanted to go to a GACH and RN 1 called NP 1, who stated to wait for the results of KUB. RN 1 documented Resident 1 was, Quiet and RN 1 was waiting for the KUB that would be done at 9 a.m. because of the laboratory backlog. At 6:30 a.m., RN 1 documented family was at the facility and wanted Resident 1 to go to a GACH. RN 1 called NP 1 who ordered to transfer to the GACH. There was no documented evidence RN 1 implemented Resident 1's plan of care related to pain risk and abdominal mass and discoloration. RN 1 did not assess Resident 1's abdomen to determine the specific area Resident 1 had pain, the type of pain, changes in the color of the abdominal skin, swelling, distension, etc., in order to relay to the physician or NP 1 a most accurate and pertinent information of Resident 1's medical condition. According to the Progress Notes dated [DATE] timed at 8:30 a.m., RN 2 documented 911 was called duet to Resident 1's blood pressure of ,[DATE] millimeters of mercury (mmHg - normal blood pressure ranges from ,[DATE] to ,[DATE] mmHg), complaint of severe abdominal pain since this morning, and a new hematoma (collection of blood outside of a blood vessel) on the abdomen. Resident has history of AAA. The heart rate was 122 beats per minute (normal range from 60 to 100 beats per minute). A review of the Progress Notes dated [DATE], timed at 9:11 a.m., Licensed Vocational Nurse 1 (LVN 1) documented that at 7:35 a.m., a message was left to NP 1 regarding Resident 1's relative (Friend 1) asking to transfer Resident 1 to the GACH due to severe abdominal pain. LVN 1 notified Friend 1 the x-ray provider (for the stat KUB) was coming after 9 a.m. NP 1 ordered to transfer Resident 1 to the GACH for evaluation, but Resident 1 was transferred via 911 (paramedics - emergency transfer) due to [MEDICAL CONDITION] (low blood pressure) at 9 a.m. A review of the Medication Administration Record from [DATE] to [DATE], indicated no documentation pain medication ([MEDICATION NAME]) was administered on [DATE] as ordered. There was no documentation of pain assessment thorough the night when Resident 1 was complaining of pain as indicated in the plan of care. This was verified by the Director of Nursing (DON) on [DATE], at 4:49 p.m. According to a review of Resident 1's clinical record at the GACH, the Operative Report indicated Resident 1 underwent surgery on [DATE] (same day of the transfer from the facility), an emergent left groin exploration with control of bleeding and revision of right axillobifemoral bypass graft with replacement of the right femoral artery to left femoral artery limb with an eight millimeter (ml) polytetrafluoroethylene (man-made) graft. On [DATE], at 2:29 p.m., during an interview, LVN 1 stated, Resident 1 was complaining of abdominal pain all night (11 p.m. to 7 a.m., shift) and the pain was not relieved with pain medication. On [DATE], at 2:14 p.m., during a telephone interview, Friend 1 stated Resident 1 called him to the facility because he needed help getting transfer to a GACH as the nursing staff would not transfer Resident 1. On [DATE], at 2:21 p.m., during a telephone interview, Resident 1 stated on [DATE], he was experiencing severe pain (,[DATE]) to his back and to the abdomen. Resident 1 requested to be transferred to a GACH because he has had multiple AAA surgeries and knew the symptoms, There was no question in my mind that it was the aneurysm. The pain was, Absolutely intense. Resident 1 stated, If I did not get out of there I would have died . I was so desperate to get the hell out of there, to go to the hospital. Resident 1 stated he called Friend 1 to help him get transferred. Resident 1 described the anger, anxiety and fear of dying he had that night ([DATE]) and, after four months, he continues to have. Resident 1 stated he developed sleeping problems and is depending on prescribed sleeping pills to help him sleep. A review of the facility's policy and procedure on Pain Management, revised on [DATE], indicated the purpose was to maintain the highest possible level of comfort for patients by providing a system to identify, assess, treat, and evaluate pain. If a patient has a change in pain status, complete a pain evaluation. If PRN medications are given, document on the back of the MAR and on the PRN Pain Management Flowsheet. Patients receiving interventions for pain will be monitored for the effectiveness and side effects in providing pain relief, and document the effectiveness or ineffectiveness. A review of the facility's policy and procedure on Notification of Change of Condition, effective [DATE], indicated, the Center must immediately inform the patient's physician when there is need to alter treatment significantly and a decision to transfer or discharge the patient. When making notification, the Center must ensure that all pertinent information is available and provided upon request to the physician. A review of the facility's policy and procedure on Diagnostic Test, revised on [DATE], indicated diagnostic test including laboratory, radiologic, [MEDICAL CONDITION], and waived testing will be performed as ordered. Laboratory services will be available on-site seven days a week, 24 hours a day. The policy did not include the timeliness of the tests and did not address stat orders. Cross Reference F-510

Based on interview and record review, the facility failed to ensure the resident was treated as an individual with dignity and respect and not subjected to verbal abuse of any kind for one of one sample resident (1). As a result of this deficient practice, Resident 1 felt embarrassed, cried and felt bad about herself. Findings: On September 17, 2014 at 7 a.m., an investigation was conducted to investigate an entity reported allegation of verbal abuse. According to Resident 1's, Admission Face Sheet, the resident was admitted to the facility on [DATE], with cerebral artery occlusion (stroke) and [MEDICAL CONDITION]. The resident's primary language was Spanish. A review of the Minimum Data Set (MDS), a standardized assessment and care screening tool, dated August 27, 2014, indicated the resident was cognitively intact, had clear speech and was understandable. The MDS indicated the resident had no behavioral problems, required extensive physical assistance from one staff person with her activities of daily living and was incontinent of bowel and bladder. The resident was unsteady when standing and required staff assistance for stabilization when standing. During an interview with Resident 1, through a Spanish interpreter, on September 17, 2014, at 8:05 a.m., Resident 1 was asked if there had been any problems with the nursing staff members. Resident 1 replied Yes. Resident 1 was asked to explain the problem. Resident 1 said on September 1, 2014 at 11 a.m., she was sitting in her wheelchair in her room. Resident 1 stated that she requested assistance to use the restroom and to then be placed in bed. Resident 1 also said that a certified nursing assistant 6 (CNA 6) came to the resident's room and told her that she was finishing up in a neighboring room and that she will be back when she finished. When CNA 6 left the room, Resident 1 attempted to transfer herself to the bed and in the process lost control of her bladder and urinated on the floor. Resident 1 then said that when CNA 6 returned to her room to assist the resident to the bathroom CNA 6 was very upset to see urine on the floor, she raised her voice and said, Why did you do that? I told you not to do that an now look what you did. Resident 1 stated that CNA 6 verbalized that now she has to use her lunch time to clean the urine off the floor and that point CNA 6 called the resident a vieja cocina which translates in English to dirty old lady. Resident 1 stated she was embarrassed and felt bad about herself. A review of Resident 1's documented interview with administrator, dated September 2, 2014, confirmed that Resident 1 conveyed the same story to the administrator. Resident 1 reported to the administrator that CNA 6 spoke aggressively toward her, used a loud tone and called her a vieja cocina. According to the documented interview Resident 1 stated when CNA 6 returned to the resident's room CNA 6 began to get upset with Resident 1 as she was cleaning the resident and was not being nice. Resident 1 stated CNA 6 called her a vieja cocina which translated to dirty old lady. Resident 1 was offended by this remark. At the conclusion of a documented interview with the administrator, Resident 1 was asked if there was anyone present that could have heard what occurred. Resident 1 stated Housekeeper 9 was present. During an interview with Housekeeper 9, on September 17, 2014 at 7:50 a.m., Housekeeper 9 was asked what she observed or heard the day of the incident. Housekeeper 9 said she did not observe anything, however she overheard CNA 6 speaking loudly in Resident 1's room. The facility's investigative report, dated September 2, 2014, included a documented interview with Housekeeper 9 conducted by the facility's administrator. According to this interview the administrator asked Housekeeper 9 if on the morning of September 1, 2014, she heard anything occur in Resident 1's room. Housekeeper 9 stated that she heard a dispute between Resident 1 and CNA 6. Housekeeper 9 stated she heard CNA 6 telling Resident 1, Why would you do that, now I have to clean up! Now instead of eating lunch, I need to take care of this. Housekeeper 9 stated CNA 6 was reprimanding Resident 1. The administrator asked Housekeeper 9 if she heard CNA 6 saying words 'vieja cocina to which Housekeeper 9 said no. Housekeeper 9 stated while she was cleaning, CNA 6 came out of Resident 1's room and said Did you see what that vieja cocina did to me? Housekeeper 9 said she went to Resident 1's room afterwards and spoke to the resident about the incident. Housekeeper 9 stated Resident 1 was very upset. During a interview on September 17, 2014 at 9:45 a.m., the administrator stated CNA 7 found Resident 1 crying in her room on September 1, 2014, and because CNA 7 did not speak Spanish she informed the Activity Assistant about her observation. The administrator stated CNA 6 was immediately suspended pending the completion of the investigation. The facility's investigative report dated September 2, 14, also included documentaion of an interview with the Activity Assistant. According to the documented interview, Resident 1 told the Activity Assistant that CNA 6 called her nasty. The CNA Report Of Misconduct form, dated September 2, 2014, indicated CNA 6 was suspended on September 1, 2014, and then terminated on September 9, 2104. A review of the facility's FINAL REPORT on Allegation of Abuse, dated September 2, 2014, indicated the facility was able to substantiate CNA 6's inappropriate tone and behavior toward Resident 1. According to the report the facility investigation did not confirm if CNA 6 called Resident 1 vieja cocina directly, but the facility was able to confirm through an employee that CNA 6 stated Resident 1 was a, vieja cocina. During a telephone interview with CNA 6 on September 17, 2014 at 2:40 p.m., she denied calling Resident 1 nasty and she did not discuss the incident about the resident urinating on the floor with anyone in the facility. The facility's policy and procedure titled, Abuse Prevention dated July 1, 2005, indicated each resident has the right to be free from verbal, sexual, physical, and mental abuse.