Every finding on record at Socal Post-Acute Care

Based on interview and record review, the facility failed to develop and implement a comprehensive, person centered care plan for one of two sampled residents, (Resident 1) who had a change in condition on 8/10/2026, with observed bruising, swelling, and redness to the left lower leg. This deficient practice had the potential to result in inconsistent monitoring, delayed interventions, and care that did not reflect or address the resident's individualized needs and current condition.Findings:During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnosis that included dementia (a condition that affects memory, thinking, and the ability to make decisions), muscle weakness, dysphagia (difficulty swallowing), displaced intertrochanteric fracture of left femur (a broken bone in the upper part of the left thigh, where the broken pieces have moved out of place), type 2 diabetes mellitus (a long-term condition where the body has trouble using insulin, causing high blood sugar), and osteoporosis (a condition that makes bones thin and more likely to break). The AR indicated Resident 1 had fracture of shaft of left tibia on 8/13/2026 during stay. During a review of Resident 1's History and Physical (H&P), dated 6/2/2025, the H&P indicated Resident 1 does not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 12/17/2025, the MDS indicated Resident 1's cognitive skills for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated Resident 1 required substantial or maximal assistance (helper does more than half the effort) in eating, oral and personal hygiene. During a review of Resident 1's Order Summary Report (OSR), the OSR indicated Resident 1 a physician's order on 2/12/2026 for staff to monitor Resident 1's bruising, bleeding and skin discoloration. During a review of Resident 1's physician text messages communication between the physician and the facility, dated 8/10/26 at 12:41 PM, the messages indicated that the physician was informed that Resident 1 had redness on the lower left leg that was beginning to bruise. During a review of Resident 1's physician progress notes, dated 8/19/2026, the note indicated that on 8/10/2026 the physician was notified that Resident 1's left lower leg was swollen and red, and photos of the leg were provided. The note indicated the physician's initial impression was cellulitis (a skin infection that causes redness, swelling, warmth, and pain), and possible deep vein thrombosis (DVT, a blood clot that forms in a deep vein, usually in the leg). The physician ordered a Doppler study (a safe, painless ultrasound test that uses sound waves to check how well blood flows through veins and arteries) and started the resident on Augmentin (an antibiotic used to treat bacterial infections). During a review of Resident 1's care plan, there was no documented evidence that a care plan was developed and implemented on 8/10/2026 for the resident's left lower extremity's redness that was reported to the physician on the same day. During a concurrent interview and record review on 8/21/2026 at 4:15 PM with the Director of Nursing (DON), Resident 1's care plan dated August 2026 was reviewed. The DON stated there was no care plan developed or implemented to address Resident 1's bruises and swollen left lower leg. The DON stated that a care plan is required because it guides staff in monitoring the condition, implementing appropriate interventions, and ensuring consistent care. During a review of the facility's policy and procedures (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 2016, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Area of concerns that are identified during the resident assessment will be evaluated before interventions are added to the care plan. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process.

Based on interview and record review, the facility failed to maintain accurate and complete clinical records for Resident 1 who experienced a change in condition beginning on 8/10/2026, with bruising, swelling, and redness noted on the left lower leg when licensed nursing staff documented no bruising, bleeding, or skin discoloration in the Medication Administration Record (MAR) from 8/10/2026 to 8/12/2026. This deficient practice had the potential to result in incomplete or unreliable medical records, leading to miscommunication among staff, inconsistent care, and delays in providing appropriate interventions.Findings:During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnosis that included dementia (a condition that affects memory, thinking, and the ability to make decisions), muscle weakness, dysphagia (difficulty swallowing), displaced intertrochanteric fracture of left femur (a broken bone in the upper part of the left thigh, where the broken pieces have moved out of place), type 2 diabetes mellitus (a long-term condition where the body has trouble using insulin, causing high blood sugar), and osteoporosis (a condition that makes bones thin and more likely to break). The AR indicated Resident 1 had fracture of shaft of left tibia on 8/13/2026 during stay. During a review of Resident 1's History and Physical (H&P), dated 6/2/2025, the H&P indicated Resident 1 does not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 12/17/2025, the MDS indicated Resident 1's cognitive skills for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated Resident 1 required substantial or maximal assistance (helper does more than half the effort) in eating, oral and personal hygiene. During a review of Resident 1's Order Summary Report (OSR), the OSR indicated Resident 1 had a physician's order dated 2/12/2026 for staff to monitor for the resident's bruising, bleeding and skin discoloration. During a review of Resident 1's physician text messages communication between the physician and the facility, dated 8/10/26 at 12:41 PM, the messages indicated that the physician was informed that Resident 1 had redness on the lower left leg that was beginning to bruise. During a review of Resident 1's physician progress notes, dated 8/19/2026, the note stated that on 8/10/2026 the physician was notified that Resident 1's left lower leg was swollen and red, and photos of the leg were provided. The note indicated the physician's initial impression was cellulitis and possible deep vein thrombosis (DVT, a blood clot that forms in a deep vein, usually in the leg). The physician ordered a Doppler study and started the resident on Augmentin (antibiotic used to treat bacterial infections). During a review of Resident 1's Medication Administration Record (MAR), dated 8/10/2026 to 8/12/2026, the MAR indicated licensed nurses documented that Resident 1 had no bruising, bleeding or skin discoloration. During a concurrent interview and record review on 8/21/2026 at 4:15 PM with the Director of Nursing (DON), Resident 1's MAR and progress notes dated August 2026 were reviewed. The DON stated that the documentation was not accurate and did not reflect the resident's actual condition related to the bruises on the resident's left lower leg. The DON stated that licensed nurses must ensure accurate and timely documentation to reflect the resident's true condition and support appropriate care planning. During a review of the facility's policy and procedures (P&P) titled, Charting and Documentation, dated 2017, the P&P indicated documentation in the medical record will be objective, complete, and accurate.

Based on observation, interview, and record review, the facility failed to ensure the garbage disposal area was free of clutter by leaving the dumpster surrounded by used cardboard boxes and empty plastic containers. This failure had the potential to attract pests such as rats, cockroaches, flies, and ants, which may spread disease to the residents of the facility. Findings: During a concurrent observation and interview on 3/3/2026 at 7:42 AM with the Maintenance Director (MD) at the facility's garbage disposal area, the ground was cluttered with garbage. Next to the main dumpster there were both constructed and deconstructed cardboard boxes stacked on top of each other. Directly adjacent to the dumpster were at least ten empty plastic containers stacked on top of each other. The MD stated the area around the dumpster should be clear of trash and the boxes and containers should not be left around the dumpster. The MD stated it is important not to leave trash around the dumpster as it may attract pests, which may lead to infections. It is a pest control risk. During a review of the facility's policy and procedure (P&P) titled, Garbage and Refuse Disposal, dated October 2017, the P&P indicated all waste should be kept in containers and garbage should be stored in a manner inaccessible to pests. It also indicated garbage storage areas should always be clean and free of surrounding litter.

Based on observation, interview, and record review, the facility failed to implement the facility's infection control policy and procedure by failing to: 1.Ensure the two pillows were not place on the handwashing sink and ensure Family Member (FM) for Resident 64 who was on contact precaution (infection control measures used to prevent the spread of infections transmitted through direct or indirect contact) wore appropriate personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) when in contact with the resident. 2. Ensure Certified Nursing Assistant (CNA 4) performed hand hygiene (the act of cleaning your hands to remove germs, dirt, and viruses) when feeding. 3.Ensure two Certified Nursing Assistants (CNA 1 and 2) performed hand hygiene when entering and exiting the residents' rooms. These failures had the potential to result in cross-contamination and healthcare-associated infections that could lead to a wide spread infection in the facility. Findings: 1.During a review of Resident 64's admission Record dated 3/25/2025, the admission Record indicated Resident 64 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Diagnoses included Enterocolitis (inflammation of both the small and large intestines) due to Clostridium Difficile (C. diff – a highly contagious bacteria that causes severe diarrhea), Encephalopathy (damage or malfunction of the brain that affects the brain function, muscle weakness, and left leg below knee amputation (BKA-surgical removal of the portion of the leg below the knee). During a review of Resident 64's Minimum Data Set ((MDS – a resident assessment tool) dated 1/22/2026, indicated Resident 64's Brief Interview of Mental Status (BIMS – a tool used to screen and identify the cognitive condition) scare of 2 severely impaired (severe problems with thinking and memory). Additionally, Resident 64 is dependent on toileting hygiene, shower/bathe, lower body dressing, putting on/taking off footwear. Substantial maximal assistance in upper body dressing, and personal hygiene. Partial/moderate assistance in eating, and oral hygiene. During an interview on 3/2/2026 at 10:35 AM with the Infection Preventionist (IP) the IP confirmed that two pillows were sitting inside the handwashing sink in Resident 64's room. The IP stated, The sink is for handwashing should be kept clear and the pillows should not be there. During an interview on 3/5/2026 at 12:28 PM with Director of Nurses (DON), DON stated that it is the expectation that any staff member passing a room under precautions should ensure visitor are wearing the required PPE. The pillows in the sink also represent a cross-contamination risk that should have been corrected immediately. During a review of the facility's policy and procedure (P&P) titled, Clostridium Difficile (CD) revised 2018, indicated, that precautions are taken while caring for residents with CD infection to prevent transmission to other residents. Such as increased awareness of symptoms and risk factors among staff, residents and visitors. Wearing gloves when handling feces or articles contaminated with feces. 2. During an observation on 3/4/2026 at 12:28 p.m. in dining room, CNA 4 did not perform hand hygiene between feeding residents. During an interview on 3/4/2026 at 1:49pm with the Infection Preventionist, stated, Staff are required to perform hand hygiene before entering a room, before a task, it's important to follow hand hygiene policy to prevent infection, prevent the spread of germs, and protect the resident's health. During a review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene Policy Statement, dated August 2019, the P&P indicated to use alcohol-based hand rub or water and soap before and after direct contact with the residents. During an observation on 3/3/2026 at 9:26 AM in the hallway, CNA 1 entered and exited Resident 23's room without performing hand hygiene. At 9:27 AM, CNA 1 entered Resident 25's room to retrieve a shower chair. CNA 1 exited Resident 25's room with the shower chair without performing hand hygiene, then proceeded to bring the shower chair into Resident 23's room without performing hand hygiene. At 9:28 AM, CNA 1 entered and exited Resident 24's room without performing hand hygiene. During an observation on 3/3/2026 at 9:34 AM in the hallway, CNA 2 entered Resident 19's room without performing hand hygiene. CNA 2 proceeded to put on a pair of medical gloves and retrieved a shower chair from the bathroom in Resident room [ROOM NUMBER] to prepare the resident for a bath. During an interview on 3/3/2026 at 9:49 AM with CNA 2, CNA 2 stated he forgot to perform hand hygiene before coming into the resident's room, but he was supposed to. CNA 2 also stated staff are supposed to perform hand hygiene every time they come in and out of the rooms to protect the residents from disease. During an interview on 3/3/2026 at 9:55 AM with CNA 1, CNA 1 stated sometimes she forgets to perform hand hygiene, and she forgot this time. She also stated it is important to do hand hygiene before and after every time staff enter the resident rooms for infection prevention. During an interview on 3/4/2026 at 1:49 PM with the Infection Preventionist (IP), IP stated staff are required to perform hand hygiene before entering a room, before a task, when in contact with bodily fluids, upon exiting rooms, etc. Even if the resident's room is empty, they still need to perform hand hygiene. She also stated it is important to follow hand hygiene policy to prevent infection, prevent the spread of germs, and protect the residents' health. During a review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, dated August 2019, the P&P indicated all personnel shall follow hand hygiene procedures to prevent the spread of infection in the facility. It also indicated staff are to perform hand hygiene before and after direct contact with residents and objects nearby residents. 3. During an observation on 3/3/2026 at 9:26 AM in the hallway, CNA 1 entered and exited Resident room [ROOM NUMBER] without performing hand hygiene. At 9:27 AM, CNA 1 entered Resident room [ROOM NUMBER] to retrieve a shower chair. CNA 1 exited Resident room [ROOM NUMBER] with the shower chair without performing hand hygiene, then proceeded to bring the shower chair into Resident room [ROOM NUMBER] without performing hand hygiene. At 9:28 AM, CNA 1 entered and exited Resident room [ROOM NUMBER] without performing hand hygiene. During an observation on 3/3/2026 at 9:34 AM in the hallway, CNA 2 entered Resident room [ROOM NUMBER] without performing hand hygiene. CNA 2 proceeded to put on a pair of medical gloves and retrieved a shower chair from the bathroom in Resident room [ROOM NUMBER] to prepare the resident for a bath. During an interview on 3/3/2026 at 9:49 AM with CNA 2, CNA 2 stated he forgot to perform hand hygiene before coming into the resident's room, but he was supposed to. CNA 2 also stated staff are supposed to perform hand hygiene every time they come in and out of the rooms to protect the residents from disease. During an interview on 3/3/2026 at 9:55 AM with CNA 1, CNA 1 stated sometimes she forgets to perform hand hygiene, and she forgot this time. She also stated it is important to do hand hygiene before and after every time staff enter the resident rooms for infection prevention. During an interview on 3/4/2026 at 1:49 PM with the Infection Preventionist (IP), the IP stated staff are required to perform hand hygiene before entering a room, before a task, when in contact with bodily fluids, upon exiting rooms, etc. Even if the resident's room is empty, they still need to perform hand hygiene. She also stated it is important to follow hand hygiene policy to prevent infection, prevent the spread of germs, and protect the residents' health. During a review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, dated August 2019, the P&P indicated all personnel shall follow hand hygiene procedures to prevent the spread of infection in the facility. It also indicated staff are to perform hand hygiene before and after direct contact with residents and objects nearby residents.

Based on observation, interview, and record review the facility failed to ensure the interdisciplinary team (IDT - a coordinated group of experts from several different fields who work together) assessed one of six sampled residents (Resident 16) to determine the resident's ability to self-administer medication and keep the medications at the bedside. In addition, Resident 16 had no physician's order to self-administer medications and keep artificial tears ophthalmic solution (eye drops) and Tums tablets (chewable antacid tablets containing calcium carbonate for fast relief of heartburn, sour stomach, acid indigestion, and upset stomach) at the bedside. This deficient practice had the potential to result in unsafe medication administration and overdose of medication. Findings: During a review of Resident 16's admission Record the (AR) indicated that Resident 16 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), left and right leg above the knee amputation (AKA-surgical removal of the portion of the leg above the knee joint). During a review of Resident 16's History and Physical (H &P) dated 6/16/2025 indicated that resident have the capacity to understand and make decisions. During a review of Resident 16's Minimum Data Set (MDS - a resident assessment tool), dated 2/18/2026, the MDS indicated that Resident 16 had moderate impaired cognition (the ability to process thoughts and emotions). The MDS indicated that Resident 16 needed substantial/maximal assistance with lower body dressing, partial/moderate assistance with shower/bathe self, supervision or touch assistance with upper body dressing and toileting hygiene. During a review of Resident 16's Order Summary Report dated 2/7/2026 indicated a physician order for artificial tears ophthalmic solution instill one drop in both eyes every 8 hours as needed for dry, itchy eyes. During a concurrent observation and interview on 3/2/2026 at 9:45 AM with Resident16 stated that he has eye allergies and he keeps eye drops at bedside and applies the drops when his eyes get affected by the allergies. Resident 16 also has a container of Tums tablets at the bedside that the resident stated he keeps in the nightstand drawer and takes the tablets when necessary. During an interview on 3/3/2026 at 2:30 PM with License Vocational Nurse (LVN) 1 stated that Resident 16 had no documented evidence the resident was assessed for self-administration of eye drops and Tums. LVN 1 stated Resident 16 was not allowed to have medications at bedside. During an interview on 3/5/2026 at 12:30 PM with the Director of Nurses (DON) stated that there was no assessment indicating Resident 16 was assessed for self-administration medication and that self-administration assessment is done only when needed. During a review of the facility's policy and procedure (P&P) titled Self-Administration of Medication dated 12/2016 indicated that residents have the right to self-administered medications if the IDT determines that it is clinically appropriate for the resident to do so. Additionally, the policy indicated that the staff shall identify and give to the charge nurse any medications found at the bedside that are not authorized for self-administration.

Based on observation, interview, and record review, the facility failed to follow their policy and procedure titled Answering the Call Light for one out of one sampled residents (Resident 8) with call light that was not within reach. This deficient practice placed the residents at risk of not having their needs meet timely, especially during an emergency or accident. Findings: During a review of Resident 8's admission Record (AR), the AR indicated that the resident was admitted on [DATE] with diagnoses that included muscle weakness, down syndrome (a genetic condition leading to intellectual disability and developmental delays), and reduced mobility. During a review of Resident 8's History and Physical (H&P), dated 7/25/2025, the H&P indicated that the resident does not have the capacity to understand and make decisions. During a review of Resident 8's Minimum Data Set (MDS, a resident assessment tool), dated 1/2/2026, the MDS indicated that the resident has severely impaired cognition (the ability to process thoughts). The MDS also indicated that Resident 8 was dependent (helper does all of the effort) in activities such as bed mobility, eating, and personal hygiene. During a review of Resident 8's care plan for falls, initiated on 7/29/2025, the care plan included a goal for the resident's risk of fall and injury will be minimized with interventions, revised on 7/31/2025. The care plan also included an intervention for staff to keep the call light within reach of Resident 8, initiated on 7/29/2025. During an observation on 3/3/2026 at 8:40 AM inside Resident 8's room, Resident 8's call light device was observed behind the resident's headboard, and out of reach from the resident. During a concurrent observation and interview on 3/3/2026 at 8:41 AM inside Resident 8's room with Certified Nursing Assistant (CNA) 3, Resident 8's call light device was observed behind Resident 8's headboard. CNA 3 stated that Resident 8's call light device is not within Resident 8's reach because it's behind the resident's headboard. CNA 3 stated that the call light device should have been placed close to Resident 8's hands. CNA 3 stated that she forgot to place the residents' call light device next to Resident 8's hands before she left the resident's room. CNA 3 stated that the call light device is used by residents to call her for help. During concurrent interview and record review on 3/5/2026 at 10:18 AM with the Director of Nursing (DON), Resident 8's care plan for falls was reviewed. The DON stated that the care plan included a plan for staff to place the call light device within Resident 8's reach. The DON stated that call light devices are used by residents to call for assistance into the room. The DON added that if residents cannot call for help, accidents may happen, such as falls. During a review of the facility's policy and procedure (P&P) titled, Answering the Call Light, revised 9/2022, the P&P indicated that the purpose of the P&P is to ensure timely responses to the resident's requests and needs. The P&P indicated that staff are to ensure that the call light is accessible to the resident when in bed. The P&P also indicated that staff are to answer the resident call system immediately.

Based on observation, interview, and record review, the facility failed to follow their policies and procedures regarding the formulation of an Advance Directive (AD a legal document that specify the person's medical treatment preferences and appoint a surrogate decision-maker if you become unable to communicate their wishes) for two out of four sampled residents (Resident 39 and Resident 47). As a result of this deficient practice, the facility had the potential to not honor the residents' wishes and choices in the event that they become incapable of making decisions regarding their care. Findings: 1.During a review of Resident 47's admission Record (AR), the AR indicated that the resident was admitted on [DATE] with diagnoses that included difficulty in walking, urinary tract infection (infection of the urinary system), and muscle weakness. During a review of Resident 47's History and Physical (H&P), date 1/21/2026, the H&P indicated that the resident has the capacity to make needs known but cannot make decisions. During a review of Resident 47's Minimum Data Set (MDS, a resident assessment tool), dated 1/21/2026, the MDS indicated that the resident has intact cognition (the ability to process thoughts and emotions). During a review of Resident 47's entire physical medical records and electronic medical records, the records did not indicate documented evidence that Resident 47 received information to formulate an advance directive. During a concurrent interview and record review on 3/3/2026 at 9:02 AM with Licensed Vocational Nurse (LVN) 2, Resident 47's entire medical records were reviewed, including the progress notes. LVN 2 stated the records do not indicate that Resident 47 has an advance directive. LVN 2 also stated that the resident's progress notes do not indicate that Resident 47 was offered to formulate an advance directive. During an interview on 3/3/2026 at 9:23 AM with Resident 47, Resident 47 stated she does not recall ever been offered the opportunity to create an advance directive. During an interview on 3/3/2026 at 9:33 AM with SSD, SSD stated that she has not offered Resident 47 the opportunity to formulate an advance directive. SSD stated that she is responsible for offering residents the opportunity to formulate an advance directive. SSD added that advance directives must be offered upon the resident's admission to the facility. 2. During a review of Resident 39's AR, the AR indicated that the resident was admitted on [DATE] with diagnoses that included hyperlipidemia (elevated blood cholesterol level), pneumonia (infection of the lungs), and hypertension (elevated blood pressure) During a review of Resident 39's H&P, dated 2/19/2026, the H&P did not indicate if the resident has the capacity to understand and make decisions. During a review of Resident 39's physician's Progress Note, dated 2/26/2026, the Note indicated that Resident 39 has the capacity to make medical decisions. During a review of Resident 39's MDS, dated [DATE], the MDS indicated that the resident has intact cognition. During a review of Resident 39's entire physical medical records and electronic medical records, the records did not indicate documented evidence that Resident 39 received information to formulate an advance directive. During a review of Resident 39's physical medical records, a form titled, Advance Directive Acknowledgement the form did not have any markings, such as Resident 39's initials or signature, to indicate that Resident 39 received or reviewed the form. During a concurrent interview and record review on 3/3/2026 at 9:02 AM with LVN 2, the form found in Resident 39's physical medical records titled, Advance Directive Acknowledgement, was reviewed. LVN 2 stated that the form is incomplete because there are no markings such as the resident's initials or signatures. During another concurrent interview and record review on 3/3/2026 at 9:02 AM with LVN 2, Resident 39's entire medical records were reviewed, including the progress. LVN 2 stated the records had no documented evidence that Resident 39 was offered to formulate an an advance directive. LVN 2 also stated that the resident's progress notes do not indicate that Resident 47 was offered to formulate an advance directive. During an interview on 3/3/2026 at 9:20 AM with Resident 39, Resident 39 stated that no one from the facility has offered her information to create an advance directive. During an interview on 3/3/2026 at 9:29 AM with the Social Services Director (SSD), SSD stated that she has not offered Resident 39 the opportunity to formulate an advance directive. During an interview on 3/5/2026 at 10:18 AM with the Director of Nursing (DON), the DON stated that the purpose of an advance directive was to determine and honor the residents' wishes when they are no longer able to make decisions for themselves. The DON stated that residents should be offered information on how to formulate an advance directive upon admission or within 48 hours. The DON further stated that if the facility does not offer the residents the opportunity to formulate an advance directive, the facility would not be able to honor the residents' choice or wishes. During a review of the facility's policy and procedures (P&P) titled, Advance Directives, revised 12/2016, the P&P indicated that upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive. The P&P also indicated that if the resident cannot make decisions, the information may be provided to the resident's legal representative. The P&P further indicated that prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. 3.During a review of Resident 20's admission Record (AR), the AR indicated that the resident was admitted on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 20's Minimum Data Set (MDS, a resident assessment tool), dated 1/21/2026, the MDS indicated that the resident has moderately impaired cognition (the ability to process thoughts and emotions). During a review of Resident 20's entire physical medical records and electronic medical records, the records did not indicate documented evidence that Resident 20 received information to formulate an advance directive. During an interview on 3/4/2026 at 9:15 AM with Resident 20, Resident 20 does not understand what an advance directive is. During an interview on 3/4/2026 at 11:27 AM with SSD, SSD verified that the advance directive was incomplete and should have been filled completely with all the statements completed and explained with information given to the resident's responsible party. 4. During a review of Resident 22's admission Record (AR), the AR indicated that the resident was admitted on [DATE], and re-admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (a temporary brain dysfunction caused by a chemical imbalance in the body), dementia (a progressive state of decline in mental abilities), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body). During a review of Resident 22's Minimum Data Set (MDS, a resident assessment tool), dated 2/20/2026, the MDS indicated that the resident has severely impaired cognition (the ability to process thoughts and emotions). During a review of Resident 22's entire physical medical records and electronic medical records, the records did not indicate documented evidence that Resident 22 received information to formulate an advance directive. During an interview on 3/4/2026 at 11:27 AM with SSD, SSD verified that the advance directive was incomplete and should have been filled completely with all the statements completed and explained with information given to the resident's responsible party. During a review of the facility's policy and procedures (P&P) titled, Advance Directives, revised 12/2016, the P&P indicated that upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive. The P&P also indicated that if the resident cannot make decisions, the information may be provided to the resident's legal representative. The P&P further indicated that prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives.

Based on observation, interview and record review the facility failed to reflect the resident's status on the Minimum Data Set (MDS - a resident assessment tool) reflected of the resident's status at the time of the assessment on two of six sampled residents (Resident 22 and Resident 42) by failing to: 1.Ensure Resident 22 fall on 1/3/2026 was documented in the MDS and Activities of daily living (ADL's) were accurately assessed and documented in the MDS. 2. Ensure Resident 42 ADL's were accurately assessed and documented in the MDS. These failures had the potential of not identifying Resident 22 and Resident 42's relevant care needs and developing a plan of care that will meet their needs. Findings: 1. During a review of Resident 22's admission Record (AR), the AR indicated that the resident was admitted on [DATE], and re-admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (a temporary brain dysfunction caused by a chemical imbalance in the body), dementia (a progressive state of decline in mental abilities), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body). During a review of Resident 22's Minimum Data Set (MDS, a resident assessment tool), dated 2/20/2026, the MDS indicated that the resident has severely impaired cognition (the ability to process thoughts and emotions). The MDS indicated that Resident 22 needed partial/moderate assistance in personal hygiene, putting on/taking off footwear, lower body dressing, shower/bathes self, toileting hygiene. Supervision assistance in oral hygiene, and upper body dressing. Setup or clean up assistance in eating. Partial/moderate assistance with walking 10 feet. During a review of Resident 22's Care Plan ADL Functioning with Self-Care Deficit dated 7/1/2025, indicated that Resident 22 needed supervision to extensive assistance with ADL's with the goal to meet daily assistance needed with ADL's. During an observation, on 3/3/2026 in Resident 22's room, Certified Nurse Assistant (CNA 2) was providing total care assistance with ADL's to Resident 22. During a review of Resident 22's Documentation Survey Report documentation from the Certified Nurse Assistants (CNAs) of the type of assistance that was provided to Resident 22 was dependent on bathing/shower, personal hygiene, oral hygiene, putting on/taking off footwear. Resident 22 not ambulating. Not ambulating 10 feet. During an interview on 3/3/2026 at 9:45 AM with CNA 2 stated that Resident 22 has been dependent on ADL's and most of the time he is using the Hoyer lift Hoyer Lift (a mechanical device used to lift and/or transfer a person from place to place) with 2-person assistance to transfer the resident. CNA 2 stated that Resident 22 was not walking any more. During an interview on 3/3/2026 at 1:35 PM, the MDS Coordinator (MDSC) stated that he believed that moderate/maximal assistance already meant the resident was dependent on staff for ADLs, and therefore he mistakenly overlooked the fall that was not captured on the MDS. The MDSC stated that it is important to reflect up to date resident information in order to develop an accurate assessment and care plan, which helps prevent further decline or complications related to the resident's dependence on staff for ADLs. The MDSC further stated that changes in two or more areas of a resident's current condition constitute a change in condition that should be reflected in the MDS and care plan. 2. During a review of Resident 42's admission Record the admission record indicated that Resident 42 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), difficulty in walking, lack of coordination, osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 42's Minimum Data set (MDS - a resident assessment tool), dated 1/16/2026 indicated that Resident 42 has severely impaired cognition (the ability to process thoughts and emotions). The MDS indicated that Resident 42 was not receiving range of motion exercises. During a review of Resident 42's Order Summary Report dated 2/12/2026 indicated an order for Restorative Nurse Assistant to provide bilateral lower extremities passive range of Motion as tolerated once as day five times a week. During an interview on 3/4/2026 at 2:31 with the MDS Coordinator (MDSC) stated that he overlooked the range of motion treatment exercises which was not entered into the current MDS. During an interview conducted on 3/5/2026 at 12:28 PM, the Director of Nurses (DON) emphasized the significance of including all Activities of Daily Living (ADLs) and treatments received by residents in the Minimum Data Set (MDS) assessment. The DON stated all resident ADLs and treatments must be accurately documented in the MDS, as the MDS is intended to reflect each resident's current condition. The DON emphasized that complete and up to date information in the MDS is essential for ensuring continuity of care and keeping all staff informed of the resident's needs. The facility's policy and procedures titled Certifying Accuracy of the Resident Assessment, updated in November 2019, establish clear guidelines regarding the completion of the Minimum Data Set (MDS) assessment. According to this policy, every individual responsible for completing any portion of the MDS assessment must sign to certify the accuracy of the section they have completed. This requirement ensures accountability and maintains the integrity of the resident assessment process, supporting thorough and precise documentation of resident care needs.

Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 10)'s care plan was updated to reflect the discontinuation of Ativan (a medication used to quickly calm the brain and nervous system). This failure had the potential to result in Resident 10 not to receive the necessary care and behavioral monitoring when Ativan was discontinued. Findings: During a review of Resident 10's admission Record (face sheet), dated 3/5/2026, the face sheet indicated the resident was admitted to the facility on [DATE] with diagnoses including but not limited to Alzheimer's disease (an irreversible brain disorder that destroys memory and thinking skills over time), dementia (a general term for loss of memory, language, problem-solving and other thinking abilities), and anxiety disorder (repeated episodes of feelings of intense fear or terror). During a review of Resident 10's History and Physical (H&P), dated 10/5/2025, the H&P indicated Resident 10 does not have the capacity to understand and make decisions. During a review of Resident 10's latest Minimum Data Set (MDS - a standardized clinical tool used in nursing homes to evaluate every resident), dated 1/30/2026, the MDS indicated Resident 10 is rarely/never understood. During a concurrent interview and record review on 3/4/2026 at 2:16 PM with the Minimum Data Set Coordinator (MDSC), Resident 10's care plan (personalized document that outlines a person's specific health needs and goals), last revised 3/2/2026, was reviewed. The care plan indicated Resident 10 was receiving Ativan to manage anxiety and nursing staff are to monitor side effects of the medication such as sedation or drowsiness. MDSC stated that this Ativan section is included in the most current care plan for Resident 10 and the next revision to the care plan is due 5/25/2026. MDSC confirmed if this is on the resident's care plan, it means the resident is currently receiving Ativan either as a scheduled medication or on an as-needed basis. During a concurrent interview and record review on 3/4/2026 at 2:19 PM with MDSC, Resident 10's current Active Order list (record within an electronic health record system that displays all currently valid medical instructions for a resident, including medications) was reviewed. MDSC stated there is no current order listed for Ativan. MDSC also stated the last time Resident 10 had an active order for Ativan was from 5/15/2024 - 5/29/2024. MDSC stated because there is no current order for Ativan in Resident 10's active order list, the Ativan care plan should have been removed. He also stated it is important to remove inactive care plans in a timely manner to ensure the accuracy of the care plan. It is important to have accurate care plans because it tells the healthcare team the latest things that are going on with the residents and how to care for them properly. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated December 2016, the P&P indicated care plans are revised as information about the residents and residents' conditions change. The Interdisciplinary Team must update the care plan when there is a change in the resident's condition and at least quarterly, in conjunction with the quarterly MDS.

Based on observation, interview and record review the facility failed to assess and monitor and evaluate one of six sampled residents (Resident 16) who complained of diarrhea on and off for two months. This deficient practice had the potential to result in weight loss, fluid and electrolytes deficit. Findings: During a review of Resident 16's admission Record the (AR) indicated that Resident 16 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), left and right leg above the knee amputation (AKA-surgical removal of the portion of the leg above the knee joint). During a review of Resident 16's History and Physical (H &P) dated 6/16/2025 indicated that resident does have the capacity to understand and make decisions. During a review of Resident 16's Minimum Data Set (MDS - a resident assessment tool), dated 2/18/2026, the MDS indicated that Resident 16 had moderate impaired cognition (the ability to process thoughts and emotions). The MDS indicated that Resident 16 needed substantial/maximal assistance with lower body dressing, partial/moderate assistance with shower/bathe self, supervision or touch assistance with upper body dressing and toileting hygiene. During an interview on 3/2/2026 at 9:45 AM, Resident 16 stated that he has been experiencing diarrhea on and off for the last 2 months stated that the staff is aware of this issue, but he still does not know why this is happening. Resident 16 stated he was not able to go to activity room due to his diarrhea issues. During an interview on 3/4/2026 with the License Vocational Nurse (LVN 3) stated that she was not aware of Resident 16 having diarrhea and that she will notify Resident 16 physician of the change in condition. During an interview on 3/5/2026 at 12:30 with the Director of Nurses (DON) stated that the licensed nurses were not aware of the episodes of diarrhea stated it is important for the Certified Nurse Assistants to be able to recognize subtle changes in residents condition so that they may report it to the physician because a delayed in treatment care can have a negative impact on the overall residents health. During a review of the facility's policy and procedure (P&P) dated 3/2018 indicated that the Certified Nurse Assistants will be trained in recognizing subtle but significant changes in the resident and encouraged to use the stop and watch early warning tool to communicate subtle changes in the residents to the nurse

Based on observation, record review, and interview, the facility failed to complete Restorative Nursing Assistant (RNA) treatments per physician's orders for one of six sampled residents (Resident 46) by failing to provide range of motion exercises to the affected joints. This deficient practice had the potential to promote the development of contractures (a condition involving shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of the joints) in Resident 46's upper and lower extremities. Findings: During a review of Resident 46's admission Record, Resident 46 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including hemiplegia and hemiparesis (total paralysis of the arm, leg, and trunk on the same side of the body), cerebrovascular accident (stroke), and contracture of the left elbow. During a review of Resident 46's Minimum Data Set (MDS), dated [DATE], the MDS indicated the resident's cognition was intact. The MDS documented that Resident 46 required total dependence for putting on and taking off footwear; substantial/maximal assistance for showering/bathing; partial/moderate assistance for personal hygiene, lower body dressing, upper body dressing, and toileting hygiene; supervision or touching assistance for oral hygiene; and setup assistance for eating. During a review of Resident 46's Care Plan dated 1/16/2026, the plan indicated the goal to minimize the risk of further loss of range of motion daily. The plan directed the RNA to assist with the elbow extension splint, resting hand splint, and passive range of motion exercises to the left upper extremity. During a review of the Order Summary Report dated 2/11/2026, physician orders were noted for the RNA program that included: Application of a left upper extremity elbow extension splint six times a week, up to two hours as tolerated, to decrease decline in function. Application of a left upper extremity resting hand splint six times a week, up to three hours as tolerated, to decrease decline in function. Passive range of motion to the left upper extremity six times a week or as tolerated to maintain functional mobility. During an interview on 3/2/2026 at 11:30 AM, Resident 46 stated he had not received range of motion exercises and, although splints had been applied in the past, he could not remember when this last occurred. He stated the splints were kept in his closet but did not know why staff had not applied them. During concurrent observations and interviews on 3/3/2026 at 3:32 PM and 3/4/2026 at 2:31 PM, Resident 46 again stated he had not received range of motion exercises or had his splints applied to his left upper extremity. During an interview on 3/5/2026 at 10:29 AM, Certified Nurse Assistant (CNA 2) stated he had not seen the splints applied to Resident 46's left arm and had not observed the resident receiving range of motion exercises. During an interview on 3/5/2026 at 3:32 PM, RNA 2 stated Resident 46's left upper extremity was stiff and that the resident had complained that he had not received range of motion exercises or splinting in a while. RNA 2 stated she had provided exercises and applied the splints as ordered by the physician but noted the resident's arm felt stiff. During an interview on 3/5/2026 at 12:28 PM, the Director of Nursing (DON) stated that range of motion exercises are important to prevent a decline in mobility. The DON stated she would follow up to ensure the physician's orders were carried out and acknowledged that the facility was not short-staffed, stating there was no reason the resident should not have been receiving his ordered treatments. During a review of the facility's policy and procedure titled Resident Mobility and Range of Motion dated 7/2017, the policy indicated that residents will not experience avoidable reductions in range of motion and that residents with limited range of motion will receive treatment and services to increase and/or prevent further decrease in range of motion

Based on observation, interview, and record review, the facility failed to follow their policy and procedure for the infusion of intravenous (IV, directly into the vein) medications for one out of one resident (Resident 39) who was receiving IV medications at the facility when Resident 39's IV medication bag did not contain the appropriate labeling. This deficient practice placed Resident 39 at risk of developing IV-related complications such as infections. Findings: During a review of Resident 39's AR, the AR indicated that the resident was admitted on [DATE] with diagnoses that included hyperlipidemia (elevated blood cholesterol level), pneumonia (infection of the lungs), and hypertension (elevated blood pressure) During a review of Resident 39's H&P, dated 2/19/2026, the H&P did not indicate if the resident has the capacity to understand and make decisions. During a review of Resident 39's Physician's Progress Note, dated 2/26/2026, indicated that Resident 39 has the capacity to make medical decisions. During a review of Resident 39's MDS, dated [DATE], the MDS indicated that the resident has intact cognition. The MDS also indicated that the resident requires substantial assistance (helper does more than half the effort) in activities such as changing position from sitting to lying and sitting to standing. The MDS also indicated that the resident requires partial assistance (helper does less than half the effort) in activities such as rolling in bed from left to right and personal hygiene. During a review of Resident 39's physician order indicated an order, dated 2/27/2026, for Dextrose-NaCl (a solution of sugar mixed with salt in sterile water) Solution 5-0.45 % (Dextrose-Sodium Chloride) Use 35 ml/hr (milliliters per hour, a unit of measurement of how much to infuse) intravenously (into the vein) in the afternoon for hydration until 3/2/2026 at 11:59 PM, infuse total 2 liters (a unit of measuring liquid volume). During an observation on 3/2/2026 at 9:18 AM inside Resident 39's room, Resident 39 was observed laying down in bed while an intravenous (IV) tubing was connected to the resident's right left arm. The IV tubing was observed connected to a 1000 mL bag of clear liquid that read 5% Dextrose and 0.45% Sodium Chloride with approximate amount of 200 mL of the clear liquid in the bag that did not have a label of the name and date or time the bag opened and initially administered to the resident. During an interview on 3/2/2026 at 9:18 AM inside Resident 39's room, Resident 39 had IV tubing connected to the resident's -- arm. Resident 39 stated she does not know how long she has had an IV tubing connected to her and who placed it. During a concurrent observation and interview on 3/2/2026 at 9:24 AM inside Resident 39's room with Registered Nurse (RN) 1, Resident 39's IV bag was inspected. RN 1 stated that the IV bag does not have a label and should have had a label must be placed over the IV bag which contains the resident's name, infusion rate, the date and time when the IV bag was started by the nurse who initiated the IV infusion. RN 1 stated that not labeling the IV bag could pose a risk for infection because nurses would not be able to know if the bag is old and needs to be replaced or disposed of. RN 1 added that she does not know when the IV infusion was started. During an interview on 3/5/2026 at 10:18 AM with the Director of Nursing (DON), the DON stated that IV bags must be labeled with the resident's name, date of initiation of the IV infusion, and the name of the nurse that started the infusion. The DON stated that if the bag is not labeled, the resident could be at risk of IV-related complications such as infections and phlebitis (inflammation of the vein). During a review of the facility's policy and procedure (P&P) titled, Infusion Therapy Medication Administration, undated, the P&P indicated that the purpose of the P&P is to provide for the safe, accurate, and effective administration of parenteral medications directly into the vascular system. The P&P indicated that staff are to complete 'Infusion Therapy Solution/Additive' label and place on IV bag

Based on observation, interview, and record review, the facility failed to follow physician ordered parameters for required monitoring prior to medication administration for one of six sampled residents (Resident 63). During a medication pass, Licensed Vocational Nurse (LVN) 1 was observed preparing and about to administer Resident 63's ordered Doxazosin Mesylate (a medication used to lower blood pressure) via the gastrostomy tube (G tube). The surveyor stopped the administration when LVN 1 did not check Resident 63's blood pressure and heart rate as required by the physician's order. The order directed staff to hold the medication if the systolic blood pressure (SBP) was less than 110 or if the heart rate (HR) was below 60. This deficient practice had the potential to result Resident 63's risk for adverse outcomes (undesired effect of medication) such as severe hypotension (dangerously low blood pressure where blood flow to vital organs-like the brain, heart, and kidneys are severely reduced) that could cause harm to Resident 63's health and quality of life. Findings: During review of Resident 63's admission Record indicated Resident 63 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (a blood vessel that carries oxygen and nutrients to the brain is either blocked by a clot or bursts), diabetes (blood sugar, is too high) and hypertension (HTN-the pressure in your blood vessels is too high). During a review of Resident 63's History and Physical Examination (H&P), dated 3/3/2026, indicated Resident 63 does not have the capacity to understand and make decisions. During a review of Resident 63's Minimum Data Set (MDS - a resident assessment tool), dated 3/6/2026, indicated Resident 63's cognitive status (ability to think and understand) was severely impaired, that required partial/moderate assistance (helper does less than half the effort) with personal hygiene, and substantial/maximal assistance (helper does more than half the effort) with toileting, bathing and dressing. During a review of Resident 63's facility document titled Order Summary Report (OSR), dated 3/1/2026, indicated to administer Doxazosin Mesylate 1 mg (unit of weight) via G-tube daily for hypertension, hold if systolic blood pressure (SBP) (the first (top/upper) number) is less than 110 or HR is lower than 60. During a review of Resident 63's care plan (CP) for HTN, dated 3/2/2026, indicated to administer medications as ordered by the physician and monitor blood pressure. During a concurrent observation and interview on 3/3/2026 at 8:45 AM in Resident 63's room, with Licensed Vocational Nurse (LVN) 1, LVN 1 prepared Resident 63's medication Doxazosin Mesylate and was about to administer the medication to Resident 63 via G-tube without checking the resident's BP and HR. LVN 1 explained, she forgot to check Resident 63's blood pressure and heart rate before administering the medication Doxazosin Mesylate. During a concurrent interview and record review on 3/3/2026 at 8:55 AM with LVN 1, Resident 63's medication administration record (MAR) dated 3/3/2026 was reviewed. The document indicated, to administer Doxazosin Mesylate via g-tube, hold if SBP is less than 110 or heart rate is lower than 60. LVN 1 stated, she could have given the Doxazosin Mesylate without checking Resident BP and HR, and if the BP was already low prior to giving the medication it would have caused severe hypotension, that could result into harm to Resident 63's health. During an interview on 3/3/2026 at 1:30 PM with the Director of Nurses (DON), the DON stated, LVN 1 did not follow procedure for administering medication Doxazosin Mesylate. DON stated, LVN 1 should have checked Resident 63's blood pressure and heart rate prior to administering Doxazosin Mesylate to determine if the medication should be held if the parameter if the SBP was less than 110 or heart rate is lower than 60. If the medication was not help according to the parameter, the medication had the potential to result if severe hypotension, which could cause harm Resident 63's health and quality of life. A review of the facility's policy and procedure (P&P) titled, Administering Medications revised 4/2019, indicated: a) medications are administered in a safe and timely manner and as prescribed, b) medications are administered in accordance with prescriber's order and c) information is checked/verified for each resident prior to administering medications Vital Signs (includes BP and HR) if necessary.

Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 10)'s psychotherapeutic drug (medications that affects mood and behavior) Informed Consent Form (a written document ensuring voluntary participation in research or medical procedures, detailing the study's purpose, duration, procedures, risks, and benefits) was completed. This failure had the potential to result in Resident 10 or the responsible party to receive information such as side effects about the medication Rexulti (an antipsychotic medication used to treat agitation). Findings: During a review of Resident 10's admission Record (face sheet), dated 3/5/2026, the face sheet indicated the resident was admitted to the facility on [DATE] with diagnoses including but not limited to Alzheimer's disease (an irreversible brain disorder that destroys memory and thinking skills over time), dementia (a general term for loss of memory, language, problem-solving and other thinking abilities), and anxiety disorder (repeated episodes of feelings of intense fear or terror). It also indicated a family member is the resident's representative and responsible party for Resident 10. During a review of Resident 10's History and Physical (H&P), dated 10/5/2025, the H&P indicated Resident 10 does not have the capacity to understand and make decisions. During a review of Resident 10's Minimum Data Set (MDS - a standardized clinical tool used in nursing homes to evaluate every resident), dated 1/30/2026, the MDS indicated Resident 10 is rarely/never understood. During a review of Resident 10's care plan, last revised 3/2/2026, the care plan indicated Resident 10 has a diagnosis of Alzheimer's dementia and nurses are to administer Rexulti (an antipsychotic medication used to treat agitation associated with Alzheimer's dementia in adults) as ordered. During a review of Resident 10's physician's orders, dated 1/28/2026, the medication order indicated Resident 10 was ordered Rexulti 2 milligrams each morning. During a concurrent interview and record review on 3/4/2026 at 10:17 AM with Minimum Data Set Coordinator (MDSC), Resident 10's Psychotherapeutic Drug Informed Consent Form for Rexulti was reviewed. The form did not indicate the date of the physician's signature. The form also did not indicate the name of the responsible party who confirmed consent to treatment or the date consent was verified. MDSC stated he had called the responsible party and confirmed consent over the phone, but he forgot to write down the name of the responsible party and the date of the phone call. MDSC stated it is important to fill out these consent forms completely to show there is proper consent for the medication, especially because this is a legal form. MDSC further stated it could negatively impact the resident because of the legal aspects of not getting proper consent. During an interview on 3/4/2026 at 11:34 AM with Medical Records Director (MRD), MRD stated the doctor should have filled out the date under their signature on the form. MRD also stated the licensed vocational nurse should have completed the form by putting the name of the resident representative that they confirmed consent from and the date of consent. MRD stated it is ultimately her responsibility to audit paper forms because they are uploaded to the electronic medical record. MRD stated she should have audited this form to ensure it is complete and it is important to have complete forms to ensure the accuracy of records. During a review of the facility's policy and procedure (P&P) titled, Informed Consent - Psychotherapeutic Medications, dated 3/1/2024, the P&P indicated the consent form shall be signed by the licensed nurse if the resident or resident representative's signature cannot be obtained. The licensed nurse shall also list the date and name of the person whom they verified informed consent.

Based on observation, interview and record review, the facility failed to ensure the kitchen freezer was maintained at a temperature of 0 degrees Fahrenheit ( F) and below, per facility's policy and procedure (P&P). This failure had the potential to result in widespread foodborne illnesses with the residents. Findings: During an observation on 3/2/2026 at 8:39 a.m. in the kitchen, the thermometer inside the freezer read 18 F and the digital thermometer on the exterior of the freezer read 22 F. During an observation on 3/3/2026 at 8:13 a.m. in the kitchen, the thermometer inside the freezer read 30 F. During a concurrent interview and record review on 3/3/2026 at 8:21 a.m. with the Director of Food Services (DFS), the Cold Storage Temperature Log, dated 3/3/2026 was reviewed. The log indicated the freezer's readings are to be 0 F or lower. During a concurrent interview and record review on 3/5/2026 at 10:22 a.m. with DFS, the facility's policy and procedure (P&P) titled, Food Receiving and Storage, dated October 2017 was reviewed. The P&P indicated the freezer must keep frozen foods solid. Wrappers of frozen foods must stay intact until thawing. DFS stated the freezer must keep foods frozen solid at 0 F or below.

Based on observation and interview, the facility failed to ensure two of four sampled residents (Resident 17 and Resident 33), had their call light within reach. This failure had the potential to affect the residents' ability to request assistance when needed.Findings: During an observation on 3/2/2026 at 9:32 a.m. in Resident 17's room, Resident 17 was lying in bed with a sling on her right arm. The call light was behind the resident, tied to the bottom right side of the bed, not within reach. During an observation on 3/2/2026 at 9:51a.m. in Resident 33's room, Resident 33 was lying in bed in with their head elevated at a 45degree angle. The call light was behind the resident, on the floor not within reach. During a concurrent interview and record review on 3/5/2026 at 12:38 p.m. with Registered Nurse (RN) 1, the facility's policy and procedure (P&P) title, Answering the Call Light, dated September 2022 was reviewed. The P&P indicated the call light is to be accessible to the resident when in bed, from the toilet, from the shower or bathing and from the floor. RN 1stated it is the entire staff's responsibility to ensure all call lights are within the residents' reach.

Based on interview and record review, the facility failed to post an accurate nurse staffing information of actual hours worked by Registered Nurses (RN), License Vocational Nurse (LVN) and Certified Nurse Aides (CNA) per shift on 2/23/2026 up to 3/3/2026 in accordance with the facility's policy and procedure titled Posting Direct Care Daily Staffing Number. This deficient practice of posting inaccurate nurse staffing information misinforms the residents and responsible parties about sufficient staffing ratio per residents to meet their needs which affects their quality of care.Findings: During a review of the facility documents titled Nursing Personnel on Duty, (posting of staffing information) dated 2/23/2026 up to 3/3/2026, the document did not indicate, the number of actual time worked per shift for each category (licensed or non-licensed) and type of nursing staff (RN, LVN , and CNA), instead it had a combined total hours per shift of all nursing staff. During a concurrent interview and record review of the document Nursing Personnel on Duty, on 3/4/2026, at 8:36 AM, with Director of Nurses (DON), the DON stated the document indicated on 2/23/2026 up to 3/3/2026 the posting reflected the combined total actual hours worked per shift of all nursing staff and not by category or type of nursing staff. DON stated, the nurse posting was inaccurate, the actual hours worked per shift should indicate what type and what category of nursing, because the nursing type and category determines what kind of nursing care are provided to the residents. During an interview on 3/5/2026, at 8:40 AM, the DON stated, the daily nursing postings are intended to inform the residents, resident's responsible parties and the visitors about the type, category, and hours of nursing care provided in the facility per shift. DON stated these nursing posting must be accurate to prevent misinformation and confusion. A review of the facility's policy and procedure (P&P) titled, Posting Direct Care Daily Staffing Number. revised 7/2016, indicated, a) shift staff information shall be recorded for each shift the type (RN, LVN or CNA) and category (licensed or non-licensed) of nursing staff working during that shift, b) the actual time worked during that shift for each category and type of nursing staff, and c) total number of licensed or non-licensed nursing staff working for the posted shift.

Based on interviews and records reviews, the facility failed to ensure certified nursing assistants (CNA) were competent in providing appropriate care and services during resident transfers, to and from the bed, for two of three sampled residents (Resident 1 and Resident 2) who underwent orthopedic surgery (a procedure on the musculoskeletal system [a complex of network of bones, muscles, joints, tendons, and ligaments that work together to provide support, movement, and protection to the body) This deficient practice had the potential to place residents at risk for further injury and delay healing process.A review of Resident 1's general acute care hospital (GACH) records, dated 10/13/24, prior to the admission to the facility, indicated Resident 1 was status post fall with left femur fracture, status post (s/p) surgery on 10/10/24. The record indicated the diagnosis was open femur fracture. A review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 10/23/2024 with diagnoses that included fracture of lower end of left femur (a break in the lower part of the left thigh bone near the knee joint) and Type II diabetes mellitus (a disorder in which the amount of sugar in the blood is elevated). A review of Resident 1's history & Physical (H&P), dated 10/24/24, indicated Resident 1 did not have the capacity to understand or make decisions. A review of Resident 1's Care Plan (CP) for Recent fracture of left femur secondary to s/p fall, dated 10/25/2024, indicated interventions was to immobilize the affected distal (farther away to the point of attachment to the body) and proximal (closer to the point of attachment to the body) joints as indicated. The interventions also indicated to assist with transfers and ambulation as needed. A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 10/28/2024, indicated Resident 1 had intact memory and cognition (ability to think and reason). The MDS also indicated Resident 1 required partial/moderate assistance with personal hygiene, substantial/maximal assistance with eating and oral hygiene, and dependent with shower/bathe self and chair/bed-to-chair transfer. A review of Resident 1's Progress Notes-Situation, Background, Assessment and Recommendation (SBAR, a communication tool) Summary, dated 11/10/2024, indicated Resident 1's oxygen saturation (a measure of how much oxygen in the blood) was 86 percent and pulse was 125. Resident 1 was noted with chronic pain to left leg. The SBAR indicated 911 (emergency services) was called and Resident 1 was sent out for further evaluation. A review of Resident 1's Progress Notes, dated 11/10/2024 at 12:20 PM, indicated Resident 1 complained of pain to left leg prior to transferring Resident 1 to the general acute care hospital (GACH). The Note indicated charge nurse administered pain medication that was ineffective, with minimal relief. A review of Resident 1's GACH 1's Emergency Department Note, dated 11/10/2024, indicated Resident 1 had respiratory distress and complained severe pain to the left leg. A review of Resident 1's GACH 1's Consultation, dated 11/11/2024 at 10:03 AM, indicated left periprosthetic femur fracture (a break of thigh bone). A review of Resident 1's GACH 1's Operative Report, dated 11/14/2024, indicated Resident 1 underwent the surgery of open reduction internal fixation (a surgical procedure to repair a broken bone) to the left femur fracture with a hardware removal. A review of Resident 2's AR, the AR indicated the facility admitted Resident 2 on 10/2/2025 with diagnoses that included aftercare following joint replacement surgery and presence of right artificial knee joint. A review of Resident 2's H&P, dated 10/9/25, indicated Resident 2 was able to make needs known but could not make medical decisions. A review of Resident 2's MDS, dated [DATE], indicated Resident 2 had intact memory and cognition. The MDS also indicated Resident 2 required setup or clean-up assistance with eating and oral hygiene, partial/moderate assistance with personal hygiene and chair/bed-to-chair transfer, and substantial/maximal assistance with toileting hygiene and shower/bathe self. A review of Resident 2's Order Summary Report, dated 11/6/2025, indicated the physician ordered two folded pillows under the heel while in bed. A review of the Facility Assessment, dated from 7/1/2025 to 10/31/2025, indicated the facility admitted and cared for residents with fractures. During an interview on 11/6/2025 at 9:20 AM with Family Member 1 (FM) 1, FM 1 stated Resident 1 had surgery on her left leg and stayed in the facility for rehabilitation. FM 1 stated the physical therapist provided specific instructions on how to transfer Resident 1 to prevent injury to her left leg. FM 1 stated on 11/10/2025, one of the FMs was visiting the resident and observed two nurses transferring Resident 1 from the bed to chair, and Resident 1's left leg was twisted. FM 1 stated the FM heard a crack, then, Resident 1 yelled They broke my leg. FM 1 stated Resident 1 was transferred to the hospital and found out she sustained a fracture on her left leg, then, Resident 1 underwent a second surgery on her left leg. FM 1 stated the nurses in the facility did not have the proper training on how to take care of residents after surgery. During an interview on 11/6/2025 at 1:42 PM with Certified Nursing Assistant (CNA) 1, CNA 1 stated when transferring a resident who had undergone hip or knee surgery, from the chair to the bed or the bed to the chair, the resident's leg must be crossed during the transfer. During an interview on 11/6/2025 at 1:12 PM with family member 2, FM 2 stated Resident 2 had knee surgery and the physician ordered to not place a pillow under Resident 2's knees. FM 2 stated the nurses kept placing a pillow under Resident 2's knee. FM 2 stated the nurses seemed to lack knowledge of taking care of residents with knee surgery. During an interview on 11/6/2025 at 1:22 PM with CNA 2, CNA 2 stated she was assigned to take care of Resident 2 today, 11/6/25, but could not state what type of surgery Resident 2 underwent. CNA 2 could not state what precautions to implement while transferring Resident 2 from the bed to the chair and vice versa. During an interview on 11/6/2025 at 1:58 PM with the Physical Therapist (PT), the PT stated when the staff transferred a resident, who underwent hip or knee surgery, the staff should keep the legs aligned and not cross the legs to prevent compromising the healing process. During an interview and record review on 11/6/2025 at 3:30 PM with the Director of Staff Development (DSD), CNA 1, 2, and 3's Skill Competency File, dated from 2024 to 2025, were reviewed. The DSD stated the facility had not conducted skill competencies to CNA's for resident transfer, The DSD stated transferring residents who underwent hip or knee surgery was not part of CNA skill competency list. During an interview on 11/6/2025 at 5:25 PM with the Director of Nursing (DON), the DON stated the facility admitted and cared for residents with fractures and residents who underwent orthopedic surgeries, so it was important to make sure the CNAs were properly trained and competent in providing care during residents transfer to residents who have fractures and/or orthopedic surgeries, to prevent injuries. During a review of the facility's policy and procedure (P&P) titled, Resident Transfer, dated 5/2019, the P&P indicated all resident transfers are performed safely using appropriate equipment and techniques based on each resident's assessed needs and functional abilities. The P&P indicted staff must follow individualized transfer methods as identified in the resident's care plan. During a review of the facility's P&P titled, Competency of Nursing Staff, dated 5/2019, indicated licensed nurses and nursing assistant will 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. The P&P also indicated the specialized skills or training needed based on the resident population.

Based on observation, interview, and record review the facility failed to account for and administer medications as ordered by the physician for two of two sampled residents (Resident 1 and Resident 2), by failing to: 1. Account for Resident 1 ' s Dilaudid 4 mg tablet bubble pack (also known as a blister pack, a card that packaged doses of medication within small, clear plastic bubbles [or blisters] for easy and safe administration) and the Controlled Medication Count Sheet (CMCS, form used to keep track of how much of a controlled medication was on hand, how much was given to a resident, and how much remained) for the bubble pack. 2. Administer Resident 2 ' s Alprazolam 0.25 mg tablet on 5/4/2025 at 3:30 AM (55 minutes earlier than what was ordered by the physician). 3. Document Resident 2 received Alprazolam 0.25 mg tablet on 5/4/2025 at 3:30 AM in the Medication Administration Record (MAR). 4. Implement Resident 2 ' s Care Plan interventions to administer anti-anxiety medications as ordered by the physician. These deficient practices had the potential for the loss of accountability which affected the controls against drug loss, diversion, or theft for Resident 1 and an inaccurate record and administration of a controlled medication that could have resulted in adverse reactions for Resident 2. Findings: a. During a review of Resident 1 ' s Admission Record (AR), the AR indicated the resident was readmitted to the facility on [DATE], with diagnoses that included orthopedic aftercare (the process of recovering from orthopedic surgery focusing on pain management, wound care, physical therapy, and lifestyle adjustments to promote healing and regain function) following surgical amputation (a surgical procedure where a part of a limb such as a finger, toe, hand, foot, arm, or leg, was removed - absence of left leg below knee, right leg below knee and right finger[s]), and Raynaud ' s syndrome (a condition where blood vessels in the fingers and toes react unusually strongly to cold or stress, causing them to narrow and restrict blood flow) without gangrene (a serious condition where tissue dies due to a lack of blood flow, often resulting in a loss of oxygen and nutrients). During a review of Resident 1 ' s Narcotic Use Care Plan dated 11/19/2024, the Care Plan indicated a goal for the resident to have no complications. The Care Plan interventions indicated to administer medications as ordered, monitor for signs and symptoms of complications, and monitor for pain every shift. During a review of Resident 1 ' s Pain Care Plan dated 11/19/2024, the Care Plan indicated a goal for the resident ' s pain to be r5elieved within 30 to 60 minutes of intervention for 90 days. The Care Plan interventions indicated to administer Dilaudid (a drug used to treat moderate to severe pain) as needed, assess for pain every shift and as needed, and assist in performing non-pharmacological interventions. During a review of Resident 1 ' s History and Physical (H&P) dated 11/27/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1 ' s Peripheral Neuropathy (nerve damage in your body, excluding the brain and spinal cord causing various symptoms like pain) Care Plan dated 11/29/2024, the Care Plan indicated a goal for the resident to have no complications. The Care Plan interventions indicated to administer pain medications as ordered, assist resident to participate with non-pharmacological interventions to relieve pain, and monitor skin status weekly and as needed. During a review of Resident 1 ' s Physician ' s Order dated 12/31/2024 at 3:07 PM, the Physician ' s Order indicated Dilaudid oral tablet 4 milligrams (mg, unit of measurement) (Hydromorphone hydrochloride [also known as Dilaudid]), give one tablet by mouth every four hours PRN for moderate to severe pain, hold if respiratory rate (RR, the number of breaths taken per minute, a normal resting RR for adults was between 12 and 20 breaths per minute) of less than 12. During a review of Resident 1 ' s Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 2/16/2025, the MDS indicated the resident ' s cognition was intact (sufficient judgement and self-control to manage the normal demands of the environment). The MDS indicated Resident 1 received as needed (PRN) pain medication and had experienced occasional pain in the last five days. During a review of Resident 1 ' s Consolidated Delivery Sheets - Controlled Substances dated 5/2/2025 at 1:31 PM, the Delivery Sheets indicated Resident 1 ' s Dilaudid 4 mg tablet, quantity of 120 tablets were delivered from the pharmacy. The Delivery Sheets indicated LVN 1 signed for the delivery of Resident 1 ' s medications. During a review of Resident 1 ' s Delivery Track dated 5/2/2025 at 2:23 PM, The Delivery Track indicated Resident 1 ' s Dilaudid 4 mg tablet, quantity of 120 tablets were delivered from the pharmacy. The Delivery Track indicated LVN 1 signed for the delivery of Resident 1 ' s medications on 5/2/2025 at 2:21 PM. During a review of Resident 1 ' s Narcotic Inventory & Emergency Kit Endorsement Form dated May 2025, the Endorsement Form indicated from 5/1/2025 to 5/7/2025 the one duty and off duty facility staff signed the form with no discrepancies. During a review of Resident 1 ' s MAR dated May 2025, the MAR indicated Resident 1 received Dilaudid oral tablet 4 mg (Hydromorphone HCL), give one tablet by mouth every four hours PRN for moderate to severe pain, hold if RR of less than 12 was given a total of 10 times from 5/1/2025 to 5/7/2025. During a review of Resident 1 ' s CMCS for Dilaudid 4 mg dated 5/2/20205, the CMCS indicated the quantity was 120 tablets. The CMCS only accounted for 60 tablets. During an observation on 5/7/2025 at 7:24 AM, Licensed Vocational Nurse (LVN) 1 and LVN 3 performed a narcotic count for change of shift report (handoff of information when one shift of healthcare workers ends and a new shift begins). LVN 3 was calling out the resident ' s name, medication, and the number of medications left from the CMCS. LVN 1 was repeating the resident ' s name, medication, and the number of medications left from the bubble pack. LVN 1 and LVN 3 after the narcotic count, signed the Narcotic Endorsement Sheet indicating both facility staff agreed on the number of narcotics left for each resident. During an interview on 5/7/2025 at 7:56 AM, LVN 1 stated the outgoing nurse would count the medications used during their shift on paper (CMCS) and the incoming nurse would confirm the amount on the bubble pack for how many there should have been. LVN 1 stated once a bubble pack was all used, the facility staff would shred the name tag and throw away the bubble pack, but the CMCS would be folded and kept inside the binder until medical records filed the CMCS later. During the same interview on 5/7/2025 at 7:56 AM, LVN 1 stated she was training Registered Nurse (RN) 1 and followed RN 1 to administer Resident 1 ' s pain medication. LVN 1 stated when RN 1 was about to take Resident 1 ' s pain medication from the bubble pack, LVN 1 realized there was only one bubble pack instead of two bubble packs. LVN 1 stated the reason she knew there should have been two bubble packs was because she was the one who signed for Resident 1 ' s medications when the pharmacy delivered them. LVN 1 stated the pharmacy delivered a quantity of 120 pills split into two bubble packs with two CMCS and each bubble pack had a sticker indicating the first and second bubble pack. LVN 1 stated one whole bubble pack and one CMCS was missing. LVN 1 stated on the remaining bubble pack, the sticker indicating whether the bubble pack was the first or second one was ripped off. During an observation of Resident 1 ' s Dilaudid 4 mg tablet bubble pack on 5/7/2025 at 8:48 AM, the bubble pack indicated a quantity of 120 pills but only had room to contain 60 pills on the bubble pack. To the left upper corner of the bubble pack there was a sticker indicating PRN and a sticker indicating Caution: opioid, risk of overdoes and addition. Below the caution sticker there was adhesive residue (sticky stuff that was left behind on a surface after a label or sticker was removed) with an area that had a piece of red sticker left over. During a telephone interview on 5/7/2025 at 9:56 AM, RN 1 stated on 5/5/2025 she performed the narcotic count with the outgoing facility staff and everything matched specifically. RN 1 stated during medication pass (the process of nurse distributing medications to patients at scheduled times) for Resident 1, LVN 1 who was training me noticed there was only one bubble pack, when there should have been two. RN 1 stated LVN 1 informed RN 1 not to touch anything. RN 1 stated when there were two bubble packs of the same medication, there would have been two CMCS for them indicating one bubble pack was one of one and the other bubble pack was two of two. RN 1 stated because the sticker on the bubble pack was gone, there was no indication that there would be two bubble packs. RN 1 stated During an interview on 5/7/2025 at 12:21 PM, Resident 1 stated she had a left and right leg amputation (a surgical procedure where a part of a limb, such as leg was removed and had been living at the facility since October 2024. Resident 1 stated she had neuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet) and had bad pain in the mornings. Resident 1 stated she would usually get pain medication twice a day, one in the morning and one in the evening. During an interview on 5/7/2025 at 1:14 PM, LVN 2 stated she worked the 3 PM to 11 PM shift on 5/2/2025 and remembered performing the narcotic count with LVN 1 for Resident 1. LVN 2 stated there were three bubble packs total for Resident 1, two full bubble packs and one bubble pack with a few pills left and three CMCS for each of the bubble packs. LVN 2 stated she did not know the quantity for Resident 1 ' s medication but should have known otherwise the facility staff could lose track of how many narcotics there actually were. LVN 2 stated if the facility did not have Resident 1 ' s narcotics then Resident 1 could be in pain and the facility would not have medication to alleviate the resident ' s pain. During an interview on 5/7/2025 at 1:35 PM, LVN 3 stated she worked the 11 PM to 7 AM shift on 5/2/2025 to 5/3/2025 and remembered performing the narcotic count with the outgoing nurse for Resident 1. LVN 3 stated she could not remember how many bubble packs Resident 1 had. LVN 3 stated the numbers on the resident ' s name tag were so tiny and did not check the quantity but should have to know how much medication should have been there. LVN 3 stated if the facility did not know the quantity of the medication, the medication could go missing and having the resident ' s medications were the resident ' s right and if the facility did not have the medication the resident would be in pain. During an interview on 5/7/2025 at 2:21 PM, LVN 4 stated she worked the 7 AM to 3 PM shift on 5/3/2025 and remembered performing the narcotic count with the outgoing nurse for Resident 1. LVN 4 stated there were two bubble packs, one bubble pack with one pill left and a new bubble pack with all 60 pills accounted for with two CMCS. LVN 4 stated she only checked the quantity of the medication when she received the medication from the pharmacy. LVN 4 stated checking the quantity of the medication would be hard to do for every resident but should have been done to make sure the correct amount was accounted for otherwise the medication could go missing. LVN 4 stated if Resident 1 ' s medication went missing, that would be bad because Resident 1 relied on her pain medication and if she did not receive the pain medication, Resident 1 would continue to be in pain. During an interview on 5/7/2025 at 4:55 PM, the Director of Nursing (DON) stated the facility staff should have been looking at the quantity of the medication, looking at the CMCS, and looking at the actual medication to compare and make sure everything was accounted for. The DON stated otherwise the medication could go missing and the facility would not be aware of the missing medication. b. During a review of Resident 2 ' s AR, the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included dementia (a progressive state of decline in mental abilities), unspecified psychosis (a mental health condition where a person experiences psychotic symptoms [like hallucinations or delusions] but did not meet the specific criteria for a more define disorder like schizophrenia [a serious mental disorder where a person ' s brain interprets reality in an unusual way, often leading to a disconnect from what others perceive as real), and encephalopathy (a disorder of the brain that affects how the brain works). During a review of Resident 2 ' s H&P dated 3/17/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2 ' s MDS dated [DATE], the MDS indicated the resident had severe cognitive impairment (problems with a person ' s ability to think, learn, remember, use judgement, and make decisions). The MDS indicated the resident ' s active diagnoses included dementia, psychotic disorder, and encephalopathy. The MDS indicated the resident was on antipsychotic medication. During a review of Resident 2 ' s Alprazolam Care Plan dated 4/28/2025, the Care Plan indicated a goal for the resident to be free from discomfort or adverse reactions related to anti-anxiety therapy. The Care Plan interventions indicated to administer anti-anxiety medications as ordered by the physician, monitor for side effects and effectiveness every shift, and monitor the resident at least every two hours for safety. During a review of Resident 2 ' s Physician ' s Order dated 5/4/2025 at 10:31 PM, the Physician ' s Order indicated Alprazolam (a drug used to treat anxiety [a feeling of worry, nervousness, or fear, often about something in the future] disorders and panic attacks [a sudden, intense feeling of intense fear or discomfort]) oral tablet 0.25 mg, give one tablet by mouth every eight hours PRN for anxiety manifested by inability to cope with activities of daily living (ADLs, routine tasks/activities such as bathing, dressing, and toileting a person performs daily to care for themselves) causing anger. During a review of Resident 2 ' s MAR dated May 2025, the MAR indicated the resident received Alprazolam 0.25mg, one tablet by mouth every eight hours PRN for anxiety manifested by inability to cope with ADLs causing anger on 5/3/2025 at 8:25 PM and on 5/4/2025 at 5 PM. The MAR indicated Resident 2 only had two doses of Alprazolam documented and no other doses were given to the resident. During a review of Resident 2 ' s Administration Progress Note dated 5/3/2025 at 8:25 PM, the Progress Note indicated Resident 2 received Alprazolam 0.25mg one tablet by mouth every eight hours PRN for anxiety manifested by inability to cope with ADLs causing anger. During a review of Resident 2 ' s Administration Progress Note dated 5/3/2025 at 10:24 PM, the Progress Note indicated the PRN Alprazolam 0.25mg administration was effective. During a review of Resident 2 ' s Nursing Progress Note dated 5/4/2025 at 3:30 AM, the Progress Note indicated Resident 2 was sleeping in bed with no acute distress, the resident ' s bed was low to the floor for safety, and the resident ' s call light was in easy reach. The Progress Note did not indicate the resident received Alprazolam PRN. During a review of Resident 2 ' s Administration Progress Note dated 5/4/2025 at 5 PM, the Progress Note indicated non-pharmacological interventions including distraction and maintaining a calm environment were ineffective and Resident 2 was being monitored by facility staff at the nurse ' s station. The Progress Note did not indicate which medication was given to Resident 2 but a medication was given for outbursts and attempts to flee. During a review of Resident 2 ' s Administration Progress Note dated 5/4/2025 at 6:22 PM,the Progress Note indicated the PRN Alprazolam 0.25mg administration was effective. During a review of Resident 2 ' s Controlled Medication Count Sheet (CMCS) for Alprazolam 0.25 mg tablet dated 5/3/2025, the CMCS indicated Resident 2 received Alprazolam 0.25mg one tablet by mouth every eight hours PRN for anxiety manifested by inability to cope with ADLs causing anger on 5/3/2025 at 8:25 PM, on 5/4/2025 at 3:30 AM, and on 5/4/2025 at 7 PM. The CMCS indicated the second administration of Alprazolam 0.25 mg on 5/4/2025 at 3:30 AM was given to Resident 2, seven hours and five minutes after the first initial dose given on 5/3/2025 at 8:25 AM (55 minutes earlier than what was ordered by the physician). During a concurrent interview and record review of Resident 2 ' s CMCS on 5/7/2025 at 3:48 PM, LVN 2 stated Resident 2 ' s Alprazolam 0.25 mg tablets had a quantity of 42 pills and the resident currently had 39 pills indicating three pills were already dispensed. The CMCS indicated Resident 2 received Alprazolam 0.25 mg tablet on 5/3/2025 at 8:25 PM and then again on 5/4/2025 at 3:30 PM. LVN 2 stated the medication was given sooner than should have been which was not okay because Resident 2 could become lethargic (feeling tired, sluggish, and lacking energy or enthusiasm) if the medication was not given within the time frame and could affect the resident ' s ADLs. During a concurrent interview and record review of Resident 2 ' s MAR on 5/7/2025 at 3:55 PM, the DON stated the MAR did not indicate Resident 2 received Alprazolam 0.25 mg tablet at 3:30 AM on 5/4/2025 as indicated on the resident ' s CMCS. The DON stated the CMCS was accurate and the facility staff failed to document in the MAR the administration of the medication. During an observation of Resident 2 ' s Alprazolam 0.25 mg tablet bubble pack on 5/7/2025 at 4:27 PM, the bubble pack indicated a quantity of 42 pills and the bubble pack had 39 remaining pills. During an interview on 5/7/2025 at 4:47, the DON stated there was a discrepancy between the CMCS and the MAR. The DON stated the CMCS signified the facility staff took the medication from the bubble pack and the MAR indicates the medication was given. The DON stated the facility staff should have signed the MAR indicating the medication was given otherwise the facility staff would not know what happened to the medication and if the resident received the medication or not. The DON stated if the medication was not given the resident ' s behavior could get worse or increase. During a review of the facility ' s policy and procedure (P&P) titled, Documentation of Medication Administration revised April 2007, the P&P indicated The facility shall maintain a medication administration record to document all medications administered. The P&P indicated Administration of medication must be documented immediately after (never before) it is given. Documentation must include, as a minimum name and strength of the drug; dosage; method of administration; date and time of administration; signature and title of the person administering the medication n; and resident response to the medication. During a review of the facility ' s P&P titled, Administering Oral Medications revised October 2010, the P&P indicated, The purpose of this procedure is to provide guidelines for the safe administration of oral medications. Verify that there is a physician ' s medication order for this procedure. The P&P indicated, Check the label on the medication and confirm the medication name and dose with the MAR. During a concurrent interview and record review of the facility ' s P&P titled Controlled Substances revised April 2019 with the DON, the P&P indicated, Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift. The P&P indicated, Upon receipt: the nurse receiving the medication and the individual delivering the medication verify the name, dose, and quantity of each controlled substance. Upon administration: the nurse administering the medication is responsible for recording: name of the resident receiving the medication; name; strength and dose of the medication; time of administration; method of administration; quantity of the medication remaining; and signature of nurse administering medication. The P&P indicated, At the end of each shift: controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together. Any discrepancies in the controlled substance count are documented and reported to the Director of Nursing services immediately. The DON stated the facility staff were not following the policy and instead of focusing on the quantity received, the facility staff were focusing on the number of medications left. The DON stated if the facility did not follow the policy, the facility could be missing narcotics and the resident ' s pain could get worse if no pain medication were available.

Based on observation, interview and record review, the facility failed to provide care and services as ordered by the physician and as indicated in the facility's policy and procedure for one of three sampled residents (Resident 1) after experiencing a fall on 4/4/25 and reported having pain on 4/6/25. Resident 1's x-ray (a medical imaging test that creates images of the inside of the body) that was ordered by the physician 4/6/25 at 7:48 AM due to the resident's complaint of pain on the ankle and x-ray was taken on 4/7/25 at 10:59AM. The facility did not follow up to with the Radiology (company that specialize in x-rays) company of the resident's x-ray to obtain the x-ray result. As a result of this deficient practice the X-ray result was not received until 4/9/25 that showed ankle fracture (broken bone) which delayed Resident 1's care and hospitalization after a fall to receive care which could potentially result in long term functional limitation, persistent pain, and limited of range of motion affecting the resident's quality of life negatively. Findings: During a review of Resident 1's Admission Record (AR), the AR indicated the facility admitted Resident 1 on 3/25/2023 with diagnoses that included dementia (a term for a range of conditions that affect the brain's ability to think, remember, and function normally) and osteoarthritis (a degenerative joint disease, affecting joints over time, leading to pain, stiffness, and swelling). During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 1/17/2025, the MDS indicated Resident 1 had moderately impaired memory and cognition (ability to think and reason). The MDS indicated Resident 1 required setup or clean-up assistance with eating and oral hygiene, and partial/moderate assistance with shower/bathe self, and personal hygiene and chair/bed-to-chair transfer. During a review of Resident 1's SBAR (Situation, Background, Assessment, and Recommendation, a structured communication tool, particularly common in healthcare) Communication Form, dated 4/4/2025, the SBAR indicated Resident 1 had a witnessed fall on 4/4/2025. During a review of Resident 1's Progress Notes, dated 4/6/2025 at 7:48 AM, Resident 1 continued with to experience pain after the fall, the physician ordered an x-ray of left ankle. During a review of Resident 1's X-ray Report of left ankle, dated 4/7/2025 at 7:54 PM, from an x-ray that was taken on 4/7/2025 at 10:59 AM, indicated the resident had nondisplaced complete transverse fracture (a clean and straight break across the bone) of medial malleolus (a bone located on the inner side of the ankle) is noted and complete transverse fracture of distal fibula diaphysis (a lower end of the bone at ankle area) is noted with lateral angulation of distal fractured fragment (in fractures refers to the tilt of the lower end of the fractured fragment of the broken bone away from its normal alignment). During a review of Resident 1's SBAR Communication Form, dated 4/9/2025, the SBAR indicated abnormal x-ray showing fracture to ankle. The SBAR indicated the physician was notified on 4/9/2025 at 5 PM. During a concurrent observation and interview on 4/18/2025 at 1:29 PM, Resident 1 was lying on the bed with her left ankle and foot stabilized with the splints and wrapped in the elastic bandages. Resident 1 stated she was having pain at level 10/10 pain when she tried to move her left foot, and she could not get up of bed or stand anymore. During an interview on 4/18/2025 at 1:25 PM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1's x-ray of left ankle was done by an outside radiology company on 4/7/2025 around 11 AM. LVN 1 stated the nurse who worked in the evening shift and the nurse who worked on the next day did not follow up the X-ray result did not report to the physician within 24 hours after the x-ray of left ankle was done to prevent a delayed treatment to Resident 1. During an interview on 4/18/2025 at 4:02 PM with Registered Nurse (RN) 1, RN 1 stated she worked the evening shift on 4/7/2025 and she did not receive a phone call or a fax of Resident 1's x-ray result on the left ankle. RN 1 stated she did not follow up with the result with the radiology company. During an interview on 4/18/2025 at 4:15 PM with LVN 1, LVN 1 stated she worked the morning shift on 4/8/2025, but she did not get any endorsement to follow up with Resident 1's x-ray report on the left ankle, so she did not follow up with the radiology company for the result. LVN 1 stated, someone notified the physician on 4/9/25, but she did not know when and who received Resident 1's x-ray report and reported to the physician. LVN 1 stated the physician called back and ordered to transfer the resident to the hospital in the afternoon on 4/9/2025. During an interview on 4/18/2025 at 4:38 PM with LVN 2, LVN 2 stated when she started to work the evening shift on 4/8/2025 and she noticed Resident 1's x-ray of left ankle report was blank. LVN 2 stated she asked LVN 1 why the report was blank and LVN 1 said she did not know the reason. LVN 2 stated she called the radiology company, and the representative of the radiology company told her that the radiology company was having issues of sending out the reports for the past two days and the representative did not have the report available to provide a verbal report to the nurse at that time. LVN 2 stated she did not report this issue to the Director of Nursing (DON) immediately. During a concurrent interview and record review on 4/18/2025 at 4:40 PM with the DON, the report of Resident 1's x-ray of left ankle, dated 4/7/2025, and Resident 1's SBAR, dated 4/9/2025, were reviewed. The DON stated the time stamp of the received fax of the x-ray report indicated the report was received on 4/9/2025 at 5 PM. The DON stated the nurse notified the physician on 4/9/2025 at 5 PM. The DON stated he did not know the facility was having issues of obtaining the x-ray report from the radiology company because the staff did not report it to him. The DON stated the nurse should report the issue to him, so he could reach out to the supervisor of the radiology company to escalate the request and make sure they obtained the report and notified the physician within 24 hours once the x-ray was taken to prevent any delayed care for Resident 1. The DON stated any delay treatment could lead to the functional limitation, pain, and the loss of motion of Resident 1' left ankle because of the fractured ankle. The DON stated it was the facility's standard of practice to obtain a x-ray result and report to the physician within 24 hours when the test was done to prevent any delayed care and potential adverse complication for the residents. During a review of the facility's policy and procedure (P&P), dated 5/2017, the P&P indicated Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider and except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received a safe discharge plan from the facility to reduce factors for a readmission to the general acute care hospital (GACH). The facility failed to discharge Resident 1 home without providing the following: 1. Necessary supplies such as medication and gastrostomy tube (G-tube, is a tube inserted through the abdomen that delivers nutrition directly to the stomach) formula feedings. Resident 1 required insulin (medication to control elevated blood sugar levels in the blood) and Nepro [a feeding formula that provides total nutrition for residents receiving [CONDITION(S)] (a process in which a machine helps filter your blood to rid your body of harmful wastes, extra salt, and water)] G-tube feeding. 2. Family education on administration of medication (insulin) and formula feeding (Nepro via G-tube). 3. Arrangement for visits with a Home Health (HH, health care or supportive care provided by a professional caregiver in the individual's home) agency. These deficient practices resulted in Resident 1 requiring emergency services and being hospitalized with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1's blood sugar level was 1,105 milligram per deciliter (mg/dL) (normal blood sugar range between 70 and 99 mg/dL), which required Resident 1 to be put on an insulin drip (medication administered directly through the veins to lower blood sugar levels) and admitted to the GACH's Intensive Care Unit (ICU, a section in the hospital to care for patients who are critically ill) two days after the facility discharged the resident home. Findings: During a telephone interview, on 6/15/21 at 12:47 p.m., Resident 1's Representative 1 (Rep 1) stated the facility discharged Resident 1 on 6/9/21. Rep 1 stated the Social Services Director (SSD) told him the facility arranged Resident 1's HH services. Rep 1 stated the resident's feeding machine (machine used to deliver formula feeding at a specified rate) was delivered to the resident's home on 6/8/21 but the resident's feeding formula (Nepro) and insulin (a medication to help control blood sugar levels in the blood for people with diabetes) were not delivered. Rep 1 stated he had to return to the facility on [DATE] to pick up Resident 1's feeding formula and one vial of insulin. Rep 1 stated the company that delivered the feeding pump showed him how to set it up. Rep 1 stated the facility did not provide any education on how much insulin or G-tube feeding to give Resident 1 prior to discharge. Rep 1 stated the HH nurse never came to the resident's home after the resident was discharged . Rep 1 stated Resident 1 got sick again and, Did not look right. Rep 1 stated the resident was restless and, Not herself. Rep 1 stated that Resident 1 required admission to a GACH on 6/11/21 because the resident's blood sugar was high. Rep 1 stated that the SSD failed to make sure the resident had all the equipment and follow up visit with the HH agency was done. Rep 1 stated the SSD did not do her job in helping Rep 1 with the resident being discharge home. A record review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 5/13/21, indicated the resident had moderate impairment in cognitive skills. Resident 1 required extensive assistance (resident involved in activity, staff provided weight-bearing support) from staff for transferring, dressing, toileting, and personal hygiene. A review of Resident 1's Order Summary Report for the month of June 2021, indicated orders for the following medications for administration routinely: 1. Aspirin (a medication that can also be used to reduce risk of [CONDITION(S)]) 81 milligrams (mg) via G-tube one time a day (Qday) for [CONDITION(S)] ([CONDITION(S)], damage to the brain from interruption of blood supply) prophylaxis (preventative). 2. [MEDICATION(S)] sodium (stool softener) 100 mg via G-tube Q day for bowel management, hold if loose stools. 3. [MEDICATION(S)] [medication used to treat high blood pressure (BP)] 25 mg via G-tube three times a day (TID) for hypertension ([CONDITION(S)], high blood pressure). 4. Insulin NPH (intermediate acting insulin to help control elevated blood sugar levels) 10 units subcutaneously (SQ) two times a day (BID) for DM, hold if blood sugar less than 120, rotate sites. 5. [MEDICATION(S)] (mediation used to treat high cholesterol) 20 mg via G-tube at bedtime for [CONDITION(S)] (high cholesterol). 6. [MEDICATION(S)] (medication used to treat high BP) 25 mg via G-tube BID for [CONDITION(S)], hold for systolic BP (SBP, pressure inside of the artery when the heart is contracting to pump blood) less than 110 or HR less than 60. 7. [MEDICATION(S)] (medication to prevent constipation) 17 grams (gm) via G-tube Qday for bowel management, hold if loose stools, mix with 8 ounces of water. 8. [MEDICATION(S)] (medication used to treat high BP) 5 mg via G-tube Qday for [CONDITION(S)], hold if SBP less than 110. 9. [MEDICATION(S)] (medication to treat increased acid in stomach) 20 mg via G-tube Qday for gastroesophageal reflux disease (GERD, when stomach acid frequently flows back into the tube connecting the mouth and stomach). 10. [MEDICATION(S)] (medication used to treat nausea) 10 mg via G-tube every eight (8) hours for GERD. A review of Resident 1's Multidisciplinary Progress Record, dated 5/28/21, indicated that the SSD would follow up with the HH agency to initiate discharge planning for the resident. A review of Resident 1's Multidisciplinary Progress Record, dated 6/6/21, indicated an anticipated discharge date of [DATE] for Resident 1 with HH services which included: physical therapy (PT, the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's physician order, dated 6/9/21, indicated that the facility discharge the resident home on 6/9/21 with HH to provide the following services: 1. PT, 2. OT, 3. Speech therapy (ST, training to help people with speech and language problem to speak more clearly), 4. Registered Nurse (RN) for G-tube management, and DM/Insulin management, Nepro [a feeding formula that provides total nutrition for residents receiving [CONDITION(S)] (a process in which a machine helps filter your blood to rid your body of harmful wastes, extra salt, and water)] at 55 milliliters (ml, a unit of measurement) per hour (hr.) for 20 hr. or until dose limit was completed, and 5. G-tube supplies. During an interview, on 6/16/21 at 2:12 p.m., Licensed Vocational Nurse 1 (LVN 1) stated the SSD arranged HH for the residents. LVN 1 stated on the day of discharge licensed nurses are supposed to go over the list of discharged medications, give instructions on taking their medications, then document in the computer that they provided teaching instructions upon discharge to the resident and/or family representative. During an interview, on 6/16/21 at 2:31 p.m., the Director of Nursing (DON) stated the SSD coordinated HH services. The DON stated that the resident's family should not have to call the HH agency themselves to set anything up (such as appointment dates for home visits, medications, and/or supply deliveries). During an interview, on 6/17/21 at 3:30 p.m., the SSD stated she was responsible to meet with the resident's family to find out the resident's needs and arrange for HH services as ordered by the physician. The SSD stated she would fax the resident's documents to the HH agency, which included: the resident's face sheet (admission record), history and physical (H&P, provides concise information about a patient's history and exam findings at the time of admission), list of medications, rehabilitation (care that can help get back, keep, or improve abilities that are needed for daily life) notes, and discharge order. The SSD stated that the HH agency should have reached out to the resident's family prior to the resident's discharge. The SSD stated that she would follow up with the resident's family to make sure that the HH agency contacted them. The SSD stated she was not familiar with medications and that the nurses were responsible for providing teaching to the resident/family about the resident's medications. During an interview, on 7/1/21 at 12:20 p.m., the SSD stated that Resident 1's insurance company arranged the HH services and that she did not set up any appointments for the resident. The SSD stated she spoke with a representative from the residents' health insurance carrier to follow up with the HH service arrangements. The SSD stated the resident's health insurance carrier told her that, Everything was arranged. The SSD stated she did not receive any paper confirmation. The SSD stated that she did not know which HH agency or when the HH agency staff would visit Resident 1's home. A review of Resident 1's Nurse's Note, dated 6/9/21 at 2:36 p.m., indicated the resident was discharged home with Rep 1 in a stable condition via private car. The nurse's note did not have documentation indicating that the nurse provided teaching regarding medications (such as insulin) ordered or any supplies for G-tube (such as formula feeding) was sent home with the resident upon discharge. A review of Resident 1's Interdisciplinary Discharge Summary, dated 6/9/21, under the section titled, Nursing Services, indicated that Resident 1 required blood sugar monitoring, insulin therapy, and to send medications with the resident. The summary did not include what medications Resident 1 was to continue at home. During a follow-up telephone interview with SSD, on 8/10/21 at 10 a.m., the SSD stated that Rep 1 called her (could not remember the day, stated maybe a day or two after discharge) and told her that the HH agency did not show up to the home for the scheduled visit. The SSD stated that Rep 1 returned to the facility to pick up medications for Resident 1. During a follow up telephone interview with Rep 1, on 8/10/21 at 10:50 a.m., Rep 1 stated that Resident 1 never received any insulin medication while at home after being discharged from facility (6/9/21). Rep 1 stated that he did not have a machine to check Resident 1's blood sugar level and did not receive any teachings about insulin or G-tube feeding during discharge. Rep 1 stated that he did not receive any paperwork or instructions on how much insulin to administer to the resident or the rate to administer the resident's G-tube feeding. Rep 1 stated upon discharge the SSD told him the HH agency would provide the teaching of medications and administration of insulin and G-tube feeding. During a telephone interview with Representative 2 (Rep 2), on 8/11/21 at 1:08 p.m., Rep 2 stated that Resident 1's family did not get the proper education needed to care for Resident 1. Rep 2 stated that the facility just wanted to get Resident 1 out of the facility and expected the HH agency to do everything. Rep 2 stated that HH staff never came and that the SSD did not follow up to make sure everything was arranged before the facility discharged Resident 1 home. Rep 2 felt, This was an unsafe discharge. A review of Resident 1's GACH admission record, dated 6/11/21, indicated Resident 1 was diagnosed (clinical impression) with DKA, altered mental status, and chronic kidney disease (condition in which the body is unable to get rid of wastes). The record indicated Resident 1's blood sugar level was 1,105 mg/dl and placed on an insulin drip. Resident 1 required admission to the GACH's Intensive Care Unit (ICU-a section in the hospital to care for patients who are critically ill). A review of the facility's policy and procedure (P&P) titled, Discharging the Resident, revised 12/2016, indicated to ensure the resident and/or responsible party received teaching and discharge instructions if the resident was discharged home. The P&P also indicated to assemble the equipment and supplies necessary to discharge the resident.

Based on observation, interview, and record review, the facility failed to follow its policy and adhere to one of two-sampled resident's (Resident 1) plan of care, and ensure assistive devices were in safe and good working condition. The facility's staff transferred Resident 1 from the wheelchair to the bed, using a sling (a material used with loops or straps to support or raise a weight), hooked onto the Hoyer Lift (an assistive medical device used to transfer residents), in which the sling's strap broke, causing the resident to fall to the floor. This deficient practice resulted in Resident 1 sustaining a left forearm skin tear, having severe pain, left hip fracture (a break in the bone), six left rib fractures, which required an eight day hospital stay. These injuries had the potential for the resident to sustain further complications, such as bleeding, infections and/ or death. Findings: A review of Resident 1's Face Sheet indicated the resident was originally admitted to the facility on [DATE] and most recently readmitted on [DATE]. The resident's [DIAGNOSES REDACTED]. A review of Resident 1's Admission Diagnoses/Status, dated 7/21/17, indicated the resident had [DIAGNOSES REDACTED]. A review of Resident 1's Admission Information Sheet, indicated the resident had a [DIAGNOSES REDACTED]. A review of Resident 1's Initial History and Physical, dated 7/21/17, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 10/27/17, indicated Resident 1 was able to recall three of three words repeated to the resident, after cueing. The MDS indicated the resident reported the correct year, but was unable to report the correct month and day of the week. According to the MDS, the resident was completely dependent on one staff for physical assistance with bed mobility, dressing, eating, toilet use, and personal hygiene, and required two or more staff for physical assistance in transferring between surfaces. The MDS indicated Resident 1 had impairment on both sides of the upper extremity and was always incontinent of bowel and bladder (insufficient or involuntary control over urination or defecation (bowel movement)). A review of Resident 1's Care Plan titled, At Risk for Headaches, Injuries, and Falls, due to Seizure Disorder, dated 7/24/17, indicated the staff's plan of approach to ensure the resident's safety. A review of Resident 1's Care Plan titled, At Risk for Fall or Injury, due to Impaired Vision, dated 7/24/17, indicated the staff's approach plan to keep the resident free from environmental hazards. A review of Resident 1's Care Plan titled, At Risk for Bleeding, Skin Discolorations, and Skin Tears, dated 7/24/17, indicated an approach plan to handle the resident gently and carefully at all times. A review of Resident 1's Care Plan titled, Impaired Activities of Daily Living ((ADL) are routine self-care activities such as bathing, dressing, eating) Function: Resident Requires Assist with ADLs, dated 7/24/17, indicated an approach plan for a two-person assist in transferring the resident using a Hoyer Lift. A review of Resident 1's CNA-ADL Tracking Form, for the month of 11/2017, indicated the resident was totally dependent (full staff performance) on two or more persons for physical assist in transfers. A review of Resident 1's Multidisciplinary Progress Record, dated 11/9/17 and timed at 1:30 p.m., indicated while Resident 1 was being transferred from the bed to the wheelchair, using a Hoyer Lift, one of the straps of the sling broke, and suddenly a second strap on the left side of the sling broke as well. The record indicated the resident fell to the floor, landing between the legs of the Hoyer Lift, hitting her left shoulder, and complained of severe pain to her back. The record indicated the resident sustained [REDACTED]. A review of a SBAR (Situation, Background, Assessment, and Recommendation (used to facilitate prompt and appropriate communication)) Communication Form, dated 11/9/17, indicated after Resident 1 had a fall during a transfer from the bed to the wheelchair using the Hoyer Lift, the resident had pain to the left shoulder, chest, and between the shoulders, with grimacing (a facial expression, indicating pain, disgust, or disapproval) behavior and moaning. A review of Resident 1's Discharge Summary, dated 11/9/17, indicated the resident was transferred to general acute care hospital (GACH) for a fall during a Hoyer Lift transfer, after complaining of pain 10/10 (10 indicates the worse pain). A review of the facility's Investigation Form, of an interview with the Maintenance Supervisor (MS), dated 11/9/17, indicated the MS found one sling that looked questionable, which was the one that broke. The investigation indicated that the MS was unsure why the sling had not been discarded before. A review of Resident 1's GACH Record from the Emergency Department (ED), dated 11/9/17, and timed 2:48 p.m., indicated Resident 1 hit the bed and the floor, when the sling broke. The ED record indicated Resident 1 was complaining of severe pain to her head, back, left sided chest, and left hip, and was worse with movement or touch. The record indicated Resident 1 was in distress due to complaining of pain everywhere, and was placed on a C-Collar (a cervical collar, also known a neck brace, a medical device used to support the neck). The record resident received four (4) milligrams (mg) of Morphine Sulfate (pain reliever narcotic), every 10 minutes, intravenously ((IV), administered into the vein), for pain. A review of Resident 1's Admission History and Physical from the GACH Record, dated 11/9/17, indicated the stitching of the Hoyer Lift's sling gave way and the resident fell against the legs of the Hoyer Lift. The record indicated the resident had six fractures of the left ribs posteriorly and a left hip fracture, with severe pain. The record indicated the resident was admitted to the GACH for pain control and possible surgical intervention of the left hip. A review of Resident 1's Radiological (X-ray) Report from the GACH, dated 11/9/17, and timed at 3:13 p.m., indicated the resident had an impacted fracture ( a type of fracture, in which one fragment of the bone goes into the other broken end of the bone) at the left sub capital femur (the neck of the hip bone). The report also indicated Resident 1 had acute fractures at the left lateral third, lateral fourth, posterior fifth, posterior sixth, posterior seventh, and posterior eighth ribs, with various displacement. A review of the facility's Policy and Procedure (P/P) titled, Use of Mechanical (Hoyer) Lift, with a revision date of 11/2017, indicated equipment (mechanical lift and sling) was assessed and prepared for use. The P/P indicated the Certified Nursing Assistants (CNA) would assess the lift slings before each use to ensure slings were in good working condition to protect the safety and well-being of residents. The P/P indicated slings that look suspicious would be replaced immediately by the MS or Director of Nursing Services (DON). The P/P indicated the MS would ensure the slings were in good working condition. A review of the mechanical lift's Owner's Manual, dated 2017, indicated a Warning to visibly inspect the sling prior to each use to ensure the sling was the correct type, size and design to handle lifting. The Manual indicated to ensure the sling was not damaged, torn, worn, discolored, or past its useful life. The Manual indicated to lift the resident one to two inches over the bed or chair, stop and check that all straps, sling fabric and loops are secure. The Manual indicated to ensure not exceeding sling or lift maximum weight, and that the wrong sling size could cause residents to fall out. On 11/14/17 at 12:10 p.m., during an observation and interview, the MS stated that CNAs are required to check the condition of the slings prior to resident use. The Hoyer Lift was observed with a sign on top of its leg, indicating to visually inspect the sling prior to use. The MS presented the sling with the torn strap used by Resident 1 during the time of the fall. The sling was observed with four straps of the sling, with blue, green and purple loops encased within a black strap. The black straps were observed stitched at the base, connected to the sling's material. The black straps on the left top and bottom of the sling was removed, with partial frayed straps remained. The black straps at the right top and bottom of the sling were observed worn out, and partially torn. The blue, right top strap (within the black strap) was observed partially torn. The MS stated the old bag of slings, including the damaged sling shown would be replaced with new slings. On 11/14/17 at 12:40 p.m., during an observation and interview, CNA 1 stated that staff are expected to inspect the straps of the sling prior to use. CNA 1 stated she assisted with the transfer during the resident's fall from the lift. CNA 1 stated she was at the foot of Resident 1, guiding the transfer, while CNA 2 was maneuvering the Hoyer Lift. CNA 1 stated within seconds, two straps of the sling broke while the Hoyer Lift was moving. CNA 1 stated that the resident fell on the floor landing on her left side and sustained a skin tear. CNA 1 stated the sling used for the resident was stored and obtained from the facility's laundry room. On 11/14/17 at 1:33 p.m., during an interview, CNA 2 stated that while Resident 1 was on the sling, the green strap located to the left of the sling, covering the top portion of her body was hooked onto the Hoyer Lift, but suddenly broke, and the purple strap located to the left of the sling, covering the resident's lower part of her body, hooked onto the Hoyer Lift ripped immediately after. CNA 2 stated she was behind the Hoyer Lift and could not prevent Resident 1 from falling. CNA 2 stated the resident fell to the floor, and landed on her left shoulder and left thigh. CNA 2 stated the resident was very fragile, and completely dependent on staff for ADLs care. CNA 2 stated prior to applying the sling on the resident, she and CNA 1 checked the purple and green straps of the sling and they looked ok at the time. CNA 2 stated she could not recall if they inspected the condition of the upper and lower black straps of the sling. CNA 2 stated that all straps, especially the black straps that are connected to the sling, should be inspected prior to putting the sling on the resident. On 11/14/17 at 1:42 p.m., during an observation and interview, the Director of Staff Development (DSD), stated that staff are expected to examine the Hoyer Lift and the slings prior to resident use. The DSD stated if the slings and straps appeared defective or worn out, the sling must be reported and given to the nurse supervisor and the MS for immediate replacement. On 11/14/17 at 1:57 p.m., during an interview and record review, the MS stated that checking the straps of the slings are essential to ensure the resident was safe and securely held by the Hoyer Lift. On 11/14/17 at 3:20 p.m., during and interview, the Director of Nursing (DON), stated there was no record to indicate the sling and the straps of the sling were inspected routinely prior to Resident 1's fall incident on 11/9/17.