Every finding on record at Somerset Post Acute Care

Based on observations, interview, and record review the facility failed to maintain functioning bed railings for one of eight sampled residents (Resident 5).This failure may have resulted in Resident 5 falling when using the railing to pull himself up to a standing position from his wheelchair and had potential for future falls and possible entrapment of a resident. Findings:Record review of Resident 5's Face Sheet indicated he was admitted on [DATE] for diagnoses which included: Metabolic Encephalopathy (brain dysfunction that happens when chemical or metabolic [the total set of life-sustaining chemical reactions that occur within the cells of living organisms] problems in the body disrupt normal brain activity) and a History of Falling.Record review of Resident 5's History and Physical dated 7/6/26 indicated This resident has capacity to understand and makes decisions.Record review of Minimum Data Set (MDS-a standardized, federally mandated clinical assessment tool used to evaluate the health, functional capacity, and needs of every resident in Medicare- or Medicaid-certified facilities) Section C-Cognitive (Thinking) Patterns for Resident 5, dated 8/5/26, indicated a Brief interview for Mental Status (BIMS) of 15, indicating intact cognition (thinking processes).On 8/21/26 at 12:35 P.M, a concurrent interview with Resident 5 and observation of his bed railings was conducted. Resident 5 was observed resting in bed. Resident 5 was alert, oriented, and agreeable to interview. Resident 5 stated his bed rails were wiggly and was asking if someone was going to fix them. Resident 5 stated he fell on 8/17/26 after he tried to get up while he was holding the railing. Resident 5 stated that he was sitting in his wheelchair facing the right side of his bed, grabbed the right railing with his right hand and pulled himself up out of his wheelchair. Resident 5 stated he was holding onto the railing when it was loose and as he turned, he then fell to the floor, but was uninjured. Resident 5 stated I'm not supposed to get up by myself, but luckily I played rugby and was able to roll when I fell. The railing on the right side of the bed was observed to be loosely connected to the bed and could move laterally between 8 inches to a foot without much resistance. Resident 5 stated the left railing on his bed was less wobbly than the right railing . The left railing was observed with less movement (movement of about 4-6 inches with slight pressure applied) than the right railing. On 8/21/26 at 1 P.M., a concurrent interview with the Director of Maintenance (DOM) and observation of Resident 5's bed railings was conducted. The DOM was brought into Resident 5's room to observe his bedrails. The DOM stated he had recently fixed his bedrail with clips. The DOM stated that he fixed the rail after he heard that Resident 5 fell. The DOM was shown the lateral movement of the right railing, and DOM stated, The railing is not safe for the resident and could cause the resident to fall again. The DOM stated he would fix the railing immediately or change the bed if he could not fix the railing. The DOM stated he does monthly inspections of the beds to make sure they are functioning and to prevent falls and entrapment. The DOM stated that he did not log this repair into the maintenance log because it was reported directly to him from resident. The DOM stated since the repair was not logged in the maintenance log there would be no record of the repair. The DOM stated he did not update the nurse of Resident 5's request to fix the railings.Record review of document SOMERSET SUBACUTE AND REHAB MAINTENANCE LOG does not indicated any reported problems with Resident 5's bed railings.Record review of facility document LOGBOOK DOCUMENTATION dated 8/2/26 indicated Steps.1. Inspect Bed for proper operation.Create a repair record of the repairs made .Inspect the seven zones of bed entrapment.3. Zone 3: Between the Rail and the mattress. The are between the bed and the mattress should be less than 4/3/4'.If you don't meet these guidelines you need to make the necessary changes.Proper rails for the bed. Document indicated Resident 5's bed passed inspection by DOM on 8/2/26.On 8/21/26 at 2:15 P.M., a interview with Licensed Nurse 2 (LN 2) was conducted. LN 2 stated he was the LN who was taking care of Resident 5 when he fell. LN 2 stated that housekeeping was doing a deep clean on his room and Resident 5 really wanted to go back into the room. LN 2 stated he offered to sit him in a geri-chair ([short for geriatric chair] is a large, padded medical recliner with wheels designed for older adults and people with limited mobility), but Resident 5 refused. LN 2 stated that he believed Resident 5 fell when he was transitioning between therapy. LN 2 stated that Resident 5 told him he .put himself on the floor, but never mentioned the broken railing to him. LN 2 stated the expectation is that all beds should have functioning railings to provide stability for residents getting up and down, and to prevent falls.Record review of Nursing Note by LN 2, dated 8/17/26 indicated Resident (5) was found on the floor by housekeeping. Pt was on the floor laying at a supine position at the right side of the bed and wheelchair .When pt asked what happened, pt stated My back was hurting and I wanted to get back to bed.On 8/21/26 at 2:30 P.M., a concurrent observation of Resident 5's bed railing and interview with the Administrator (ADM) and the Director of Nursing (DON ) was conducted. ADM and DON were shown the lateral movement of Resident 5's bed railings and both agreed it was not safe and needed to be repaired or replaced. The ADM stated that residents' bed railings should be fully functional to prevent falls or other accidents and should be maintained regularly by maintenance .Record review of facility document titled Physical Environment, Equipment Maintenance dated 7/30/23, indicated It is the policy of this facility to establish procedures for routine and non-routine care of equipment and to ensure that equipment remains in good working order for resident and staff safety.4. The Maintenance Supervisor will carry out routine maintenance on specified program equipment, as per manufacture's recommendations and/or program policy.6. In the event that equipment maintenance or servicing is required between scheduled checks, Maintenance Request Log will be kept at the Nurse's station. All staff filling the request slip will include date, nature of problem, and signature. The log will be checked by Maintenance Supervisor daily,7. If equipment requires repair other than routine maintenance or servicing, the vendor through which the equipment was purchased will be contacted and arrangements made for repair/replacement.

Based on interview and record review, the facility failed to ensure personal and medical documents remained secured and confidential for 2 of 2 (1,3) sampled residents when the facility sent Resident 1 and Resident 3's personal and medical information to the family representatives of other residents (2,4). This failure had the potential to result in misuse of confidential resident information by unauthorized individuals.1. Resident 1 was admitted to the facility on [DATE] with a diagnosis of generalized anxiety disorder per the facility face sheet. Resident 2 was discharged from the facility on 1/17/26 per the facility face sheet. A review of Resident 1's order summary report, active 1/17/26, indicated the document included Resident 1's name, date of birth , admission date, physician, diagnosis, and current prescribed medications and treatment orders. A review of a facility letter, dated 3/17/26, addressed to Resident 1's responsible party (RP), indicated Resident 1's order summary report was sent home with another resident's family representative (Resident 2 FR) upon discharge from the facility on 1/17/26. The letter, signed by the Administrator (ADMIN) indicated the reports included Resident 1's name, date of birth , medications, diagnoses, admission date and physician's name. During an interview and record review on 4/1/26 at 11:45 A.M., the facility's marketer (MKTR) stated she was sent by the administrator on 1/20/26 to pick up Resident 1's order summary report from Resident 2's home. The MKTR stated she retrieved 6-7 pages of Resident 1's order summary report from Resident 2's FR and returned to the facility to dispose of the paperwork. During an interview on 4/2/26 at 9:38 A.M., licensed nurse (LN) 1 stated she prepared and provided Resident 2's discharge papers on 1/17/26. LN 1 stated she mistakenly included Resident 1's order summary report paperwork in Resident 2's discharge packet and handed it to Resident 2's family member. LN 1 stated it is important to double check all resident information on paperwork to protect resident privacy. 2. Resident 3 was admitted to the facility on [DATE] with a diagnosis of cognitive (thinking) communication deficit per the facility face sheet. Resident 4 was discharged from the facility on 9/26/25, per the facility face sheet. A review of an email and accompanying attachments sent by the Medical Records Assistant (MRA), dated 3/9/26, indicated a digital copy an ambulance transportation bill for Resident 3, signed 3/27/25, was sent to Resident 4's family representative (FR) and included Resident 3's name and date of birth . A review of a facility letter, dated 3/18/26, addressed to Resident 3, indicated an ambulance bill with Resident 3's personal information was emailed to another resident's family representative (Resident 4 FR) at the facility on 3/9/26. The letter signed by the Administrator (ADMIN) indicated the bill included Resident 3's name and date of birth . During an interview on 4/1/26 at 11:26 A.M., Medical Records Assistant (MRA) stated on 3/9/26 that she scanned a stack of medical records handed to her by ADMIN and emailed them to Resident 4's family representative (FR) upon request. MRA stated the documents sent via email to Resident 4's family representative on 3/9/26 included a digital copy of an ambulance bill for Resident 3 which listed the resident's name and date of birth . MRA stated it was facility policy to ensure right person was receiving any transfer of confidential medical documents. MRA stated it was important to protect resident privacy and avoid documentation transfer mistakes because it puts residents at risk for fraud. During an interview on 4/9/26 at 10:15 A.M., the Administrator (Admin) stated the facility's expectation was to provide all residents with adequate privacy protections, including maintaining the confidentiality of residents' personal and medical information. The Admin acknowledged the facility failed to maintain those protections when Resident 1's personal information and Resident 3's personal and medical information were disclosed to the family representatives of other residents. A review of the undated facility policy titled, HIPPA Compliance Policy and Procedure: Notice of Privacy Practice, indicated, . The purpose of this Policy and procedure is to describe and outline how covered entities will provide individuals adequate notice of the uses and disclosures of their protected health information. ensuring individual privacy rights, and outlining the covered entity's duty with respect to protect health information in accordance with Health Insurance Portability and Accountability Act of 1996. (HIPPA). Policy: Covered entity will:. 6) Adhere to Federal HIPPA rule. A review of the undated facility document titled, Attachment F, indicated, . FEDERAL RESIDENT RIGHTS. Privacy and Confidentiality. You have the right to personal privacy and confidentiality of your personal and medical records. You have the right to. secure and confidential personal and medical records.

Based on observation, interview and record review the facility failed to ensure the physical environment was maintained in a safe and well-kept condition by not addressing a ceiling leak during rainy weather.These deficient practices placed 4 out of 8 sampled residents (Resident 1, 2, 5, and 6) and eleven residents who used the physical therapy room at risk for exposure to safety hazards and potential health risks related to unresolved ceiling leaks.Findings:On 1/6/26 at 1:19 P.M., an interview was conducted with the Maintenance Director (MNTD). The MNTD stated roofing contractors visited the facility on Friday (1/2/26) due to the heavy rain which had occurred on 12/26/25. The MNTD stated the roofing contractors did a walk-through but not all areas and rooms at the facility had been checked.On 1/6/26 at 1:21 P.M., an interview was conducted with the Roof Contractor (RC). The RC stated they found some fissures (also known as cracks that are openings in your roof or ceiling from age/weather, water damage, or structural shift) on the membrane (a continuous, watertight layer installed on flat or low-slope roofs to create a waterproof barrier, preventing leaks and protecting the building's structure) of the facility roof as well as roof penetrations (any hole that is made through the roof). The RC stated they did not do a thorough walk-through and only inspected two rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) of the building. RC stated that the roof fissures could lead to leaks.On 1/6/25 at 1:30 P.M., a joint observation of room [ROOM NUMBER] and interviews with Resident 1 and Resident 2 was conducted with the MNTD: Resident 1 was observed sitting on his bed watching TV and stated, I noticed leaks on my blankets.Resident 2 was observed lying in bed covered in blankets and stated There was some leaking happening overnight, it was really coming down hard from the last rain (1/5/26) we had. They (staff) placed a bucket on the ground. Resident 2 stated he did inform the staff about the water leak coming through the ceiling and stated staff had brought in buckets to catch the rain and stated it was an unpleasant sight. Resident 2 pointed to the area in the ceiling on the right side of room by the curtain dividers which showed a rippling droop (half-golf ball sized) in the ceiling. The MNTD was then observed testing the ceiling strength of room [ROOM NUMBER] with the end of a broomstick toward the rippling ceiling droop that Resident 2 had identified. The area surrounding the ceiling droop (fist sized) appeared soggy and soft which was easily penetrated by the broomstick end and white debris crumbled off and made a hole the same size as the broomstick end (approximately 1-1.5 inches). The MNTD stated that the droop in the ceiling in room [ROOM NUMBER] indicated rain damage that could result in ceiling collapse on residents and potential health problems from mold. A record review of Resident 1's admission Record indicated Resident 1 was re-admitted to the facility on [DATE] with diagnoses which included history of Chronic Obstructive Pulmonary Disease (COPD-a chronic lung disease causing difficulty in breathing). A record review of Resident 2's admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses which included history of COPD. On 1/6/26 at 2:11 P.M., a joint observation of room [ROOM NUMBER] and interviews with Resident 5 and Resident 6 was conducted with the MNTD: Resident 6 stated there was a leak dripping down from the ceiling at the end of his roommates (Resident 5) foot of the bed by the curtain dividers on the left end of the bed. Resident 6 stated he was concerned for his roommate and was uncomfortable seeing the rain coming down through the ceiling and this could be unsafe if the ceiling collapsed and or we (Resident 5 and Resident 6) could get sick. Resident 6 stated staff had put a bucket under the ceiling leak and staff had stated, they should fix it. Resident 6 stated it was leaking from the heavy rain that happened a few weeks ago.The MNTD was then observed testing the ceiling strength in room [ROOM NUMBER] in the same area where Resident 6 had identified a water leak. The area had a brownish linear discoloration (17.5 inches) with a ripple like drooping ceiling. When MNTD poked the ceiling with the tip of the broomstick a part of the ceiling appeared soggy and soft (approximately 7 inches round).A record review of Resident 5's admission Record indicated Resident 5 was re-admitted to the facility on [DATE] with diagnoses which included a history of Chronic Respiratory Failure with Hypoxia (a decrease in oxygen).A record review of Resident 6's admission Record indicated Resident 6 was re-admitted to the facility on [DATE] with diagnoses which included a history of Chronic Obstructive Pulmonary Disease (COPD-a chronic lung disease causing difficulty in breathing).On 1/6/26 at 2:24 P.M., the Certified Nursing Assistant (CNA) 1 was interviewed. CNA 1 stated the facility had water leaks in residents' rooms that included room [ROOM NUMBER] (Resident 5 and Resident 6's room) and there were also water leaks in the Physical Therapy (PT) room. CNA 1 stated they (staff) had buckets or trashcans to catch the water that leaked from the ceilings during the rain that happened within the last 1-2 weeks ago. CNA 1 stated staff had told MNTD about it.On 1/7/26 at 3:08 P.M., a joint observation (of the PT room) and interview with the Physical Therapy Assistant (PTA), and Speech Therapist (ST) was conducted with the MNTD. The PTA and ST stated there were water leaks in the physical therapy room which came from the air vent by the charting area and the air filter vent had a black linear line on the bottom right corner. On 1/6/26 at 3:16 P.M., an interview was conducted with MNDT. The MNDT stated the facility had received past complaints from the residents about the water leaks starting around 12/1/25. The MNTD stated he thought he was being proactive but had not contacted the roof contractors until after the rainy days had occurred, within the last 1-2 weeks. The MNTD stated if the roof continued to not be fixed this could cause safety risks and mold concerns. The MNTD stated the roof can cave in and collapse.On 1/6/26 at 4:51 P.M., an interview was conducted with Licensed Nurse (LN) 1. LN 1 stated there were leaks in rooms 21, 23, 6 or 8 and the Physical therapy room. LN 1 stated the leaks started within 2 weeks of the rainy days. LN 1 stated if the leaks were not fixed it was possible that the ceiling could collapse and hurt residents. LN 1 stated there could be health risks with mold build up and this was not a homelike environment. LN 1 stated we defiantly need to get the roof fixed.A record review of a list of residents who received rehabilitation services was conducted. The Rehab therapy list dated from 12/14/25 to 1/5/26 listed eleven Residents who received rehabilitation services and utilized the physical therapy room. On 1/7/26 at 3:15 P.M., an interview was conducted with the DON. The DON stated, enough is enough we need to fix the roof. The DON stated if left unresolved (leaky ceiling) could lead to safety (falling debris from ceiling and accidents) risks and health concerns with mold that affects all residents. A review of the facility's policy and procedure titled, Physical Environment (undated), indicated .Equipment and environmental conditions needing repair will be logged and acted upon at a reasonable timeframe, as appropriate

Based on interview and record review, the facility failed to ensure the confidentiality of residents' personal and medical information was protected when binders containing sensitive resident data was left unsecured at the nursing station, resulting in the unauthorized removal of the binders by unauthorized personnel.As a result, all residents at the facility were at risk for unauthorized access to their personal and medical information, in violation of their right to privacy and confidentiality. Findings: A review of the facility census on 6/25/25 indicated the total in house occupancy was 42 residents. Resident 1 was admitted to the facility on [DATE] with a diagnosis of cardiac arrest per the admission record. The record identified a resident family member as the resident representative (RR). The record indicated Resident 1 left the faciity on 6/16/25 against medical advice. During an observation and record review on 6/25/25 at 10:35 A.M., the facility nursing station was unattended, with no staff present near or at the desk. Multiple binders were observed sitting unsecured on an open cart located behind the nursing desk, against the wall. The nursing desk was unobstructed on either side and the binders were accessible within a few steps. The binders were clearly labeled, and included binders titled, Vital Signs, Treatment Audit, Controlled Drug Record, and Monthly Appointments. A review of the records inside the Monthly Appointment binder indicated the binder contained resident face sheets with identifying information such as name, date of birth , insurance identification number, diagnosis and social security number, along with other personal information. The nursing station remained unattended for five minutes. During an interview on 6/25/25 at 11:01 A.M., certified nursing assistant (CNA) 1 stated she was working on 6/15/25 when she witnessed a woman at the nursing station flipping through a binder on the top of the nursing desk. CNA 1 identified the woman as resident 1's resident representative (RR). CNA 1 stated RR said the phrase this is illegal, each time she flipped a page in the binder. CNA 1 stated after a few seconds RR walked away from the nursing desk with two binders and out of the facility. CNA 1 stated she heard licensed nurse (LN) 1 call out for RR to return to the nursing desk with the binders but RR did not comply. CNA 1 stated she did not know what was in the two binders. During an observation and interview on 6/25/25 at 11:17 A.M., LN 1 stated on 6/15/25 he witnessed Resident 1's RR remove two facility binders containing resident information from the top counter of the nursing station and leave the facility. LN 1 pointed to the area of the nursing countertop where the binders had been located and stated that they should have been stored behind the nursing station but had been left out for the phlebotomist (contracted staff who drew blood samples for testing). LN 1 reported that he attempted to stop RR and asked her to return the binders, but she refused. LN1 stated the binders contained resident face sheets, physician orders and requisitions for laboratory and radiology services for multiple residents. During an interview and record review with the Director of Nursing (DON) on 5/25/25 at 11:42 A.M., video footage of the incident on 6/15/25 showed a woman walked down the hallway towards the nursing station, stopped at the nursing desk and flipped through one of the two binders on the top of the desk. The footage indicated two staff members, identified by DON as CNA 1 and LN 1, were standing at the nursing station at the time of the incident. The footage indicated the woman, identified by DON as Resident 1's RR, removed the binder from the desk and walked towards the main exit of the facility. The DON stated RR refused to return the binders upon request. The DON stated RR returned to the facility the following day, 6/16/25, and discharged Resident 1 from the facility's care against medical advice. The DON stated the RR reported she was going to use the information in the binder to bring a malpractice lawsuit against the facility. The DON stated the RR was asked again to return the binders because they contained confidential resident information and RR refused to comply with the second request. DON stated approximately 50 residents were affected by the breach of information. The DON acknowledged that binders containing resident identifiers and personal health information should not be accessible to the public or facility visitors and should be stored in a secure location. The [NAME] stated that the information in the binders included resident names, dates of birth, and Social Security numbers which could be used for identity theft or financial fraud. The DON confirmed, as of the interview, the binders and resident information had not been recovered. A review of a blank facility form the facility stored in the laboratory and x-ray binders that were stolen, titled, Mobile X-ray and EKG Request Form Dispatch, indicated, fields for the resident full name, date of birth , Social Security number, imaging requested, physician name, and billing information, including Medicare or Medicaid number, other insurance details, and the reason for the exam. A review of another blank facility form, provided by the DON and confirmed to be stored in the stolen binders, titled, Comprehensive Test Requisition, indicated fields for the resident's full name, date of birth , social security number, email address, billing address, race, ethnicity, insurance policy number, and laboratory tests requested. A review of the undated facility document titled, NOTICE OF PRIVACY PRACTICES, indicated, . 4. Our legal duty. We are required by law to protect the privacy of your health information, provide this Notice about our privacy practices, follow the privacy practices that are described in this Notice. II. WE HAVE A LEGAL DUTY TO SAFEGUARD YOUR PROTECTED HEALTH INFORMATION (PHI). We are legally required to protect the privacy of your health information. We call this information Protected Health Information, or PHI for short, and it includes information that can be used to identify you that we have created or received about your past, present, or future health or condition; the provision of health care to you; or the payment for this health care. Statement of Resident Rights and Responsibilities: Under federal and state laws, you have the following rights and responsibilities. 11.The resident has the right to personal privacy and confidentiality of his or her personal and clinical records. Rights and Responsibilities under State Law. H. The right to have privacy in treatment and in caring for personal needs, confidentiality in the treatment of personal and medical records, and security in storing and using personal possessions.

Based on observation, interview and record review, the facility failed to ensure food safety and sanitation practices were maintained in the kitchen according to standards of practice and policy when: 1. Expired food items were stored in the kitchen storage and used in the kitchen areas. 2. The Kitchen Supervisor (KS) did not remove gloves and perform hand washing after disposing the kitchen garbage. These failures exposed residents to contaminated food and unsanitary practices, which had the potential to place them at risk of developing a foodborne illness. Findings: 1. A kitchen observation and interview was conducted on [DATE] at 8:05 A.M., with the Kitchen Supervisor (KS). The following food items were observed: [brand name] classic yellow mustard - best by date (BB) [DATE]; Mango Cakes - use by date (UB) [DATE]; [brand name] Thousand Island salad dressing - BB [DATE]; [brand name] Blue Cheese Dressing - BB [DATE]; [brand name] Puree French Toast - BB ,d+[DATE]-25; [brand name] California Wine - opened date (OD) [DATE]; [brand name] Vanilla Almond milk - BB [DATE]; [brand name] Chocolate Milk - BB [DATE]; [brand name] Hamburger Buns - BB [DATE]; [brand name] Sliced Bread - BB [DATE]; [brand name] milk - BB [DATE]; Sandwich prepared on [DATE]. The KS acknowledged that these food items with best by and use by dates on or after [DATE] were expired food items and included the wine and the prepared sandwiches. An interview was conducted on [DATE] at 10 A.M. and [DATE] at 9:35 A.M. with Registered Dietician Specialist (RDS). The RDS stated that the stored expired food items should have been disposed after the expiration date. The RDS acknowledged that expired food items can potentially affect resident's health. A review of facility's undated policy and procedure titled Dry Goods Storage Guideline indicated, .This storage length is to be followed unless you have manufacturer's recommendation indicating otherwise. A review of facility's undated policy and procedure titled Storage of Food and Supplies indicated, .Procedures for Dry Storage: 8.All food products will be used per the times specified in the Dry Food Storage Guidelines .No food will be kept longer than the expiration date on the product. 13. Bread will be delivered frequently and used in the order that it is delivered to assure freshness . Check manufacturer's recommendations . According to the Food and Drug Administration (FDA) Food Code 2022, section ,d+[DATE].17 (A) (B) (C) (D) indicates the day the original container is opened in the food establishment shall be counted as Day 1 .The date marked shall not exceed a manufacturer's use-by date .mark the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises. 2. An observation and interview were conducted on [DATE] at 4:02 P.M. with the KS. The KS took trash and the trash bin out to the dumpsters and pushed the trash bin back to the kitchen. The KS reentered the kitchen, did not remove his soiled gloves or perform hand hygiene by washing his hands. The KS walked through the kitchen, passed the food preparation areas, and touched the faucets and sink area. Per the KS, he should have removed his soiled gloves and washed his hands when he reentered the kitchen. The Registered Dietician Specialist (RDS) acknowledged that the KS should have removed his gloves, performed hand washing, and put on the new gloves when he reentered the kitchen after he took the trash out to the dumpster. According to the 2022 US FDA Food Code. Annex 3 titled Garbage disposal: . The failure of food-handlers to wash hands in certain situations (such as after using the toilet, handling raw meat, cleaning spills, or carrying garbage), wear clean disposable gloves .is responsible for the foodborne transmission of these pathogens. Non-foodborne routes of transmission, such as from one person to another, are also major contributors in the spread of these pathogens . According to the 2022 US FDA Food Code, Section ,d+[DATE].11 titled Clean Condition .The hands are particularly important in transmitting foodborne pathogens. Food employees with dirty hands and/or fingernails may contaminate the food being prepared. Therefore, any activity which may contaminate the hands must be followed by thorough handwashing in accordance with the procedures outlined in the Code . According to the 2022 US FDA Food Code, Section ,d+[DATE].14 titled When to Wash .The hands may become contaminated when the food employee engages in specific activities. The increased risk of contamination requires handwashing immediately before, during, or after .activities . Employees must wash their hands after any activity which may result in contamination of the hands . A review of facility's undated policy and procedure titled Hand Hygiene, indicated .Purpose: .All personnel shall follow the handwashing/hand hygiene procedure to help prevent the spread of infections . Procedure: .1. Wash hands with soap and water for the following situations: a. When hands are visibly soiled .

Based on observation, interview, and record review, the facility failed to ensure infection control procedures were followed when: 1. A Licensed Nurse (LN) 2 and two Certified Nursing Assistants (CNA) did not wear a gown when providing care for one resident (Resident 26) on enhanced barrier precautions (EBP - gown and gloves must be worn during high-contact resident care activities [example: residents with medical devices]). 2. Urinary catheter (tube inserted into the bladder to aid in urine flow) bag for two residents (37 and 40) was touching the floor. 3. A resident's (34) nasal cannula (tubing connected to the oxygen and to the resident for supplement) was not properly stored. These failures had the potential for cross contamination, spread of infection, and residents' decline of health. Findings: 1. Resident 26 was readmitted to the facility on [DATE], with diagnoses which included respiratory failure, epilepsy (condition that affects the brain and causes frequent seizures) and with a gastrostomy tube (g-tube, a tube inserted through the stomach that brings nutrition or medications directly to the stomach) per the facility's Admission Record. Resident 26's attending physician completed Resident 26's history and physical (H & P) dated 2/13/24. The H & P indicated Resident 26 was not able to make his own decisions. On 3/10/25 at 9:09 A.M., an observation and interview was conducted in Resident 26's room. An EBP sign was posted on Resident 26's door and there were personal protective equipment (PPE; safety gear includes the use of gown, gloves, mask, goggles) supplies in the cart. Resident 26 was lying in bed, with TF formula ongoing connected to Resident 26's g-tube. Resident 26 gestured a thumbs up when asked how he was doing. On 3/11/25 at 3:04 P.M., an observation was conducted in Resident 26's room. Three staff members (Licensed Nurse [LN] 2, Certified Nursing Assistants 2 and 3) were transferring Resident 26 from the geri-chair (padded chair for residents with limited mobility) to the bed. The three staff members were not wearing a gown. During the transfer, CNA 1 was holding Resident 26's feet and touched the CNA's scrub suit. LN 2 was helping Resident 26 position himself in the bed, while CNA 2 was controlling the remote of the lift (equipment used to help transfer a patient). On 3/11/25 at 3:24 P.M., an interview with LN 2 was conducted. LN 2 stated that they did not wear PPE while transferring Resident 26 from the chair to his bed. LN 2 stated that they had forgotten to wear PPE. LN 2 stated the staff were required to wear PPE when touching or providing care to residents with medical devices such as g-tube. LN 2 stated it was important (to wear PPE) to prevent transmission of infection to the resident and for infection control prevention. On 3/11/25 at 8:58 A.M., an interview with CNA 2 was conducted. CNA 2 stated that she helped CNA 3 the day before (on 3/10/25) to transfer Resident 26 from the chair to his bed. CNA 2 stated she did not know what the use of PPE was for, when transferring a resident from the chair to the bed. CNA 2 stated she did not know the purpose of that. On 3/11/25 at 4:18 P.M., an interview with the Infection Preventionist (IP) was conducted. The IP stated that when transferring a resident on EBP from a chair to the bed, as long as there was high contact activity, the expectation was for the staff to wear PPE to prevent cross contamination and infection. On 3/12/25 at 10:28 A.M., an interview with CNA 1 was conducted. CNA 1 stated that when transferring a resident on EBP, .they were told not to do so, but if we have to gown up, then we have to gown up. On 3/13/25 at 9:43 A.M., an interview with the Director of Nursing (DON) was conducted. The DON stated the staff were expected to wear PPE when transferring a resident on EBP, to prevent spread of infection. A review of the EBP sign dated 8/2/24, utilized by the facility was conducted. The EBP sign indicated that use of gown and gloves were required when transferring a resident on EBP. A review of the facility's policy titled, IPCP Standard and Transmission Based Precautions, revised 9/2023, indicated, It is the policy of this facility to implement infection control measures to prevent the spread of communicable diseases and conditions .c. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precaution include: iii. Transferring . 43674 2a. Resident 37 was admitted to the facility on [DATE] with diagnoses which included metastatic prostate cancer (prostate cancer that has spread from the prostate gland to other parts of the body) per undated Admission Records. Observations were conducted on 3/10/25 at 10:25 A.M. and 2:24 P.M., and on 3/11/25 at 8:49 A.M. and 10:36 A.M., in Resident 37's room. During each observation, Resident 37's urinary catheter bag was hanging from the bed and touching the floor/mat. A concurrent observation and interview was conducted on 3/12/25 at 8:20 A.M., with Certified Nurse Assistant (CNA) 21. Resident 37's urinary catheter bag was hanging from the bed and touching the floor. CNA 21 stated that Resident 37's urinary catheter bag was touching the floor/mat and acknowledged that the urinary catheter bag should not touch the floor/mat, to prevent contamination and spread of infection. In a concurrent observation and interview on 3/12/24 at 8:24 A.M., with Licensed Nurse (LN) 21, LN 21 verified that Resident 37's urinary catheter bag was touching the floor/mat and acknowledged that the urinary catheter bag should not touch the floor/mat to prevent contamination and to protect the resident from infection. An interview was conducted on 3/12/25 at 8:42 A.M., with the Director of Nursing (DON). The DON acknowledged that the urinary catheter bag should not touch the floor, to prevent infection and for the safety of the resident. The facility's policy and procedure titled Catheter Care, Indwelling, last reviewed 12/2019 indicated .Policy: It is the policy of this facility that each resident with an indwelling catheter will receive catheter care daily and PRN (as needed) for soiling. Purpose: To promote hygiene, comfort and decrease risk of infection for catheterized residents. Procedures: .13. Keep foley drainage bag from touching the floor or landing mat . 2b. Resident 40 was admitted to the facility on [DATE] with diagnoses which included anemia (the body does not produce enough red blood cells) and atrial fibrillation (irregular heart rhythm that begins in your heart's upper chambers - atria) per undated Admission Records. Observations were conducted on 3/10/25 at 12:28 P.M. and 3/12/25 at 8:33 A.M., in Resident 40's room. Resident 40's urinary catheter was hanging from the bed and touching the floor/mat. A concurrent observation and interview was conducted on 3/12/25 at 8:35 A.M., with Certified Nurse Assistant (CNA) 21. Resident 40's urinary catheter bag was hanging from the bed and touching the floor/mat. CNA 21 acknowledged that the urinary catheter bag should not touch the floor/mat to prevent contamination and spread of infection. A concurrent observation and interview was conducted on 3/12/25 at 8:37 A.M. with Licensed Nurse (LN) 21. LN 21 verified that Resident 40's urinary catheter bag was touching the floor/mat and acknowledged that the urinary catheter bag should not touch the floor/mat to prevent contamination and to protect the resident from infection. An interview was conducted on 3/12/25 at 8:42 A.M., with the Director of Nursing (DON). The DON acknowledged that the urinary catheter bag should not touch the floor to prevent infection and for the safety of the resident. The facility's policy and procedure titled Catheter Care, Indwelling last reviewed 12/2019 indicated .Policy: It is the policy of this facility that each resident with an indwelling catheter will receive catheter care daily and PRN (as needed) for soiling. Purpose: To promote hygiene, comfort and decrease risk of infection for catheterized residents. Procedures: .13. Keep foley drainage bag from touching the floor or landing mat . 45909 3. A review of Resident 34's Admission Record indicated, Resident 34 was in the facility on 4/2/24 with medical diagnoses which included asthma (condition with difficulty of breathing) and muscle weakness. Resident 34's physician order dated 4/2/24 indicated, May use oxygen supplement via nasal cannula (NC- device applied in the nose to deliver oxygen). During an observation conducted on 3/10/25 at 11:57 A.M. inside Resident 34's room, a NC was observed directly placed on top of slippers on Resident 34's personal storage rack. During a concurrent observation and interview with the respiratory therapist (RT) on 3/10/25 at 12:40 P.M., the RT stated Resident 34's NC should had been stored in a clean, plastic bag to prevent cross contamination (transfer of germs). During an interview with the Infection Preventionist (IP) on 3/11/25 at 4 P.M., the IP acknowledged that NCs should be kept in a storage bag when not being used, to protect the residents from infection. The facility's undated policy titled, Infection Control Policy/Procedure indicated, Procedures .2. The oxygen tubing will be stored appropriately if not in use

Based on observation, interview and record review, the facility had a medication error rate of 6.45% when two medication errors occurred out of 31 opportunities during medication administration, for two out of four residents (Resident 65 and Resident 27). These failures resulted in medications not given in accordance with the physician's orders which resulted in residents not receiving the therapeutic effects of the medication. Findings: 1. During the medication pass observation on 3/12/25 at 8:15 A.M. with Licensed Nurse (LN) 11, LN 11 did not administer Lexapro (a medication to treat depression; feeling sad) to Resident 65. Resident 65's Physician Order dated, 2/27/25 indicated to give Lexapro 20 milligrams (mg -unit of measurement) 1 tablet by mouth one time a day for verbalization of feeling depressed. During an interview with the Director of Nursing (DON) on 3/13/25 at 10:40 A.M., the DON stated that Resident 65's Lexapro medication card (container card that stores medication) was inside the afternoon (labeled to store medications that were supposed to be administered in the afternoon) drawer and resulted in the LN missing to administer the morning dose. In addition, the DON stated that physician ordered medications should be given to residents. 2. During the medication pass observation and interview on 3/12/25 at 8:36 A.M. with LN 11, LN 11 administered 20 milliliters (ml-unit of measurement) of Potassium Chloride (KCL-medication supplement) liquid to Resident 27. Resident 27's physician order dated 5/7/24 indicated Give KCL liquid 20 milliequivalent (mEq-unit of measurement) per 15 ml. Give 20 mEq . one time a day for hypokalemia (low potassium). During a concurrent interview and record review with LN 11 on 3/12/25 at 3:30 P.M., LN 11 stated that she should have reviewed the physician order and should have administered KCL 15 ml to Resident 27. LN 11 acknowledged that Resident 27 received more than the medication prescribed, which may have caused harm to Resident 27. During an interview with the DON on 3/13/25 at 10:42 A.M., the DON stated that LNs should verify physician's orders before administering medications. The DON acknowledged that the LN should have checked the physician's order and administered the appropriate dose to the patient, to prevent overmedication. The facility's undated policy and procedures titled, Medication Administration indicated, .Procedures .2. Review and verify MD orders and follow 6 Rights of Medication Administration .

Based on observation, interview and record review, the facility failed to follow physician's order for one of seven sampled residents, when Resident 2's compression stocking (CS- worn to decrease swelling) was not worn. This failure had the potential to affect Resident 2's well-being. Findings: A review of Resident 2's admission record indicated Resident 2 was admitted to the facility on [DATE] with medical diagnoses which included heart failure, hypertension (elevated blood pressure), and edema (swelling). A review of Resident 2's physician order dated, 4/16/24, indicated, Apply ted hose (compression stocking) above the knee to Right Lower Extremity every day shift (morning shift work hours that begin at 7 am) for swelling for 12 hours. A concurrent observation and interview with Resident 2 was conducted on 3/10/25 at 9:20 A.M. inside Resident 2's room. A signage was posted on Resident 2's side of the wall, that indicated Leg compressors at 9 am, off in the evening at 2100 (9 pm). Resident 2 stated he did not know that he needed to wear a compression sock. During a follow-up observation and interview with Licensed Nurse (LN) 13 on 3/10/25 at 3:30 P.M., Resident 2 was observed not wearing a compression stocking on his right leg. LN 13 stated that the nursing staff should have applied the compression stocking on Resident 2's right leg as ordered, to decrease swelling. During an interview with the Director of Nursing (DON) on 3/13/25 at 9:11 A.M., the DON stated that physician's orders should be implemented by nursing staff. The DON further stated that the day shift staff should have applied Resident 2's CS as ordered to prevent Resident 2's leg from swelling. The facility's undated policy and procedure titled, Physician Orders, indicated, Policy .It is the policy of this facility to accurately transcribe and implement orders in addition to medication orders (treatment, procedures .)

Based on observation, interview, and record review, the facility staff failed to consistently monitor and document urine output (UO) per the facility's policy, for three of three sampled residents (8, 37, and 40) with a urinary catheter (a tube inserted into the bladder to aid in urine flow). In addition, there was no urinary catheter order for Resident 40. This failure had the potential for Resident 8, Resident 37 and Resident 40 to have urinary retention and develop urinary tract infection (UTI). Findings: 1. Resident 8 was readmitted to the facility on [DATE], with diagnoses which included encephalopathy (a change in how the brain functions; may cause confusion, agitation) and UTI, per the facility's Admission Record. Resident 8's attending physician completed Resident 8's history and physical (H & P) dated 2/10/25. The H & P indicated Resident 8 did not have the capacity to understand and make decisions. On 3/10/25 at 11:45 A.M., an observation of Resident 8 was conducted in the dining room. A urinary catheter was attached to Resident 8's wheelchair. On 3/12/25 at 10:09 A.M., an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that Resident 8 was confused and did not know what was going on. CNA 1 stated Resident 8 had a urinary catheter. CNA 1 stated CNAs should be monitoring and documenting Resident 8's output in Resident 8's clinical record. On 3/12/25 at 10:50 A.M., a joint review of Resident 8's clinical record and an interview with Licensed Nurse (LN) 1 was conducted. LN 1 stated that the clinical record of Resident 8 indicated the CNAs did not consistently measure his urine output. LN 1 stated the record indicated CNAs documented Resident 8's urine output as how many times he was changed, compared to measuring the urine output in milliliters (ml, unit of measurement), to ensure Resident 8 was not retaining urine in his bladder and to prevent Resident 8 from developing UTI. On 3/13/25 at 9:43 A.M., an interview with the Director of Nursing (DON) was conducted. The DON stated that staff should have consistently monitored and documented the urine output in mls, to ensure the residents have enough urine output and address if the residents did not have urine retention. A review of the facility's undated policy titled, Intake and Output, indicated, It is the policy of this facility to maintain an intake and output record when needed to monitor residents for adequate fluid balance .Weekly Assessment .2. I & O assessments will be documented in the resident's medical record . 43674 2. Resident 37 was admitted to the facility on [DATE] with diagnoses which included metastatic prostate cancer (prostate cancer that has spread from the prostate gland to other parts of the body) per undated Admission Records. An observation was conducted on 3/10/25 10:25 A.M., in Resident 37's room. A urinary catheter bag was hanging from the side of Resident 37's the bed. A review of Resident 37's physician's order dated 3/3/25 indicated Monitor intake and output every shift for 30 days . A concurrent interview and record review was conducted on 3/13/25 at 2 P.M., with the Minimum Data Set (MDS) Coordinator. The MDS Coordinator stated that Resident 37 had a urinary catheter and that there was a physician's order to monitor Resident 37's intake and output per volume in milliliter (mL). Resident 37's Medication Administration Record dated 3/3/25 through 3/11/25 was reviewed. There was no documentation that Resident 37's urinary output was consistently monitored on 3/4, 3/5, and 3/8 through 3/11/25. The record did not include Resident 37's urinary output per volume in mL. Instead, there was documentation that indicated the number of times Resident 37's urinary catheter was emptied. The MDS coordinator acknowledged that Resident 37's urinary output record should have been documented per volume in mL and not the urinary catheter's frequency of when it was emptied. An interview was conducted on 3/13/25 at 2:35 P.M., with the Director of Nursing (DON). The DON stated that Resident 37's urinary catheter's output monitoring should have been measured accurately. The DON acknowledged that documentation of urinary output should be per volume to ensure that the resident did not have urinary retention. A review of the facility's undated policy titled, Intake and Output, indicated, It is the policy of this facility to maintain an intake and output record when needed to monitor residents for adequate fluid balance .Weekly Assessment .2. I & O assessments will be documented in the resident's medical record . 3. Resident 40 was admitted to the facility on [DATE] with diagnoses which included anemia (the body does not produce enough red blood cells) and atrial fibrillation (irregular heart rhythm that begins in your heart's upper chambers - atria) per undated Admission Records. An observation was conducted on 3/10/25 12:28 P.M., in Resident 40's room. A urinary catheter bag was hanging from the side of Resident 40's bed. A review of Resident 40's physician's order dated 3/3/25 indicated, Monitor intake and output every shift for 30 days . A concurrent interview and record review were conducted on 3/13/25 at 2 P.M., with the Minimum Data Set (MDS) Coordinator. The MDS Coordinator stated that Resident 40 had a urinary catheter and that there was had a physician's order to monitor intake and output per volume in mL (milliliter). Resident 40's Medication Administration Record dated 2/7 through 3/11/25 was reviewed. There was no documentation that Resident 40's urinary output was consistently monitored on 2/15, 2/17, 2/18, 2/23, 2/25, 3/2 through 3/8, 3/10 and 3/11/25. The record did not include Resident 40's urinary output per volume in mL. Instead, there was documentation that indicated the number of times Resident 40's urinary catheter was emptied. The MDS coordinator acknowledged that Resident 40's urinary output record should have been documented per volume in mL and not the urinary catheter's frequency of when it was emptied. An interview was conducted on 3/13/25 at 2:35 P.M., with the Director of Nursing (DON). The DON stated that Resident 40's urinary catheter's output monitoring should have been measured accurately. The DON acknowledged that documentation of urinary output should be per volume to ensure that the resident did not have urinary retention. A review of the facility's undated policy titled, Intake and Output, indicated, It is the policy of this facility to maintain an intake and output record when needed to monitor residents for adequate fluid balance .Weekly Assessment .2. I & O assessments will be documented in the resident's medical record . 4. Resident 40 was admitted to the facility on [DATE] with diagnoses which included anemia (the body does not produce enough red blood cells) and atrial fibrillation (irregular heart rhythm that begins in your heart's upper chambers - atria) per undated admission records. A review of Resident 40's progress notes dated 2/1/25 indicated, .Received new order . to place FC (foley catheter) 16 F (16 French - size of FC). Orders were noted and carried out. A review of Resident 40's progress notes dated 2/7/25 indicated, .Resident arrived in facility .admitted from [name of hospital] .foley cath (catheter) patent and draining yellow urine output . A concurrent interview and record review were conducted on 3/13/25 at 2 P.M., with the Minimum Data Set (MDS) Coordinator. Resident 40's physician orders dated 1/23 to 2/11/25 were reviewed. Resident 40's health records did not include physician's orders for a urinary catheter. The MDS Coordinator acknowledged that a physician's order for a urinary catheter should had been obtained and entered in Resident 40's medical records. An interview was conducted on 3/13/25 at 2:35 P.M., with the Director of Nursing (DON). The DON stated the expectation was for staff to obtain a physician's order for a urinary catheter and enter the order in the resident's health record. The DON acknowledged that Resident 40 should have had a physician's order for a urinary catheter, to ensure appropriateness of treatment. A review of the facility's undated policy and procedure titled Physician Orders, Telephone Orders and Recapitulation Process Documentation in a Long Term Care Record indicated, .Policy: .1. Physician's orders shall be obtained prior to the initiation of any medication or treatment . Verbal and Telephone Orders .3. The facility personnel receiving the verbal or telephone order shall transcribe the order into the PCC system . A review of the facility's undated policy and procedure titled Physician Orders indicated, Policy: .It is the policy of this facility to accurately transcribe and implement orders . (treatment, procedures .) only upon the written order of a person duly licensed . 5. Verbal orders must be recorded immediately in the resident's chart .A review of facility's undated policy and procedure titled Physician Orders indicated, Policy: .It is the policy of this facility to accurately transcribe and implement orders . (treatment, procedures .) only upon the written order of a person duly licensed . 5. Verbal orders must be recorded immediately in the resident's chart .

Based on observation, interview, and record review, the facility failed to ensure dialysis (the process of cleaning the blood through a machine) access site was properly cared for one of two residents investigated for dialysis (246). This failure had a potential for Resident 246's dialysis access to clot. Findings: Resident 246 was admitted to the facility on [DATE], with diagnoses that included End Stage Renal Disease (kidney failure), per the Admission Record. On 3/10/25 at 9:29 A.M., Resident 246 was observed sleeping in her room, and did not respond to her name. There was a note by the wall indicating Resident 246 had a left arm dialysis access site. On 3/11/25 at 3:19 P.M., an observation of Resident 246 was conducted. Resident 246 arrived via stretcher to the facility, accompanied by transportation staff. Resident 246's left upper arm had a bandage wrapped around her dialysis access site. On 3/12/25 8 A.M, an observation of Resident 246 was conducted in her room. Resident 246 was lying in bed, with her eyes closed and did not respond when her name was called. Resident 246 had a bandage wrapped around her dialysis access site. On 3/12/25 8:42 A.M., an observation and interview with Resident 246 was conducted in her room. Resident was awake, with the bandage on her dialysis access site. Resident 246 stated that she did not know why she still had the bandage on her arm, and that she did not know if the access site bled. Resident 246 stated she had dialysis yesterday (3/11/25). A review of Resident 246 dialysis communication record (communication record between the dialysis center and the facility) was conducted. The dialysis communication record indicated the following special instructions from the dialysis center to the staff at the facility as follows: 3/6/25 - Remove bandage after 4 hours after dialysis. 3/8/25 - Remove bandage after 4 hours after dialysis. 3/11/25 - Remove bandage after 3 hours after dialysis . A review of Resident 246's physician order dated 3/4/25, indicated to remove the dialysis access dressings after 2 hours (after) the resident's dialysis. On 3/12/25 at 11:36 A.M, a joint observation of Resident 246's dialysis access site, an interview and joint record review with Licensed Nurse (LN) 1 was conducted. LN 1 stated that the bandage was still wrapped around Resident 246's dialysis access site. LN 1 stated that Resident 246's dialysis schedule were Tuesdays, Thursdays, and Saturdays. LN 1 stated that the LNs responsibility was to check the resident's access site for signs of bleeding, and infection. LN 1 stated the resident's dialysis access site dressing was removed at the dialysis center. LN 1 stated, I don't take it out. LN 1 stated she did not know about the special instructions from the dialysis center that Resident 246's dressings should have been removed after 4 hours. LN 1 stated, I didn't know about the communication. LN 1 stated it was important to remove the dressing from the access site, since it was a pressure dressing and could cause clotting of the access (site). On 3/13/25 at 9:43 A.M., an interview with the Director of Nursing (DON) was conducted. The DON stated Resident 246's dialysis dressing should have been removed, and that the LNs should have verified the physician order, to monitor the dialysis access site and prevent clotting of Resident 246's dialysis access site. A review of the facility's undated policy titled, Renal Dialysis, Care of Resident, Hemodialysis Access Site, indicated, It is the policy of this facility to provide standards in the care of the residents on renal dialysis and the care of the vascular access site for hemodialysis, 1. Vascular access site care will be provided by Licensed nurse, with physician's orders .

Based on observation, interview and record review, the facility failed to ensure controlled medications (CM -medications with high potential for abuse and addiction) were accurately accounted for when four out of 10 CMs were not documented on the Electronic Medication Administration Records (EMAR) and controlled drugs accountability sheet (CS-count sheet that monitors the storage and usage of controlled medications) to indicate the CMs were given to the resident. This failure had the potential for misuse or diversion of CMs. An observation of CM handoff (report that typically occurs at the end of the shift; includes necessary information to ensure safe transition of care) between Licensed Nurse (LN) 14 and LN 15 was conducted on 3/11/25 at 3:12 P.M. LN 14 counted 27 tablets of Lacosamide (medication used to treat seizures- abnormal electrical activity in the brain) 200 milligrams (mg-unit of measurement) documented as remaining on the CS. LN 15 counted 26 tablets of Lacosamide in the medication card (container card that packages medication). LN 14 counted 10 tablets of Briviact (medication used to treat seizures) 100 mg tablets documented as remaining on the CS. LN 15 counted nine tablets of Briviact in the medication card. LN 14 counted 16 tablets of Lorazepam (medication used to treat anxiety) 0.5 mg tablets documented as remaining on the CS. LN 15 counted 15 tablets of Lorazepam in the medication card. LN 14 counted 25 Oxycodone (pain medication) 5 mg tablets documented as remaining on the CS. LN 15 counted 24 tablets of Oxycodone in the medication card. During a concurrent interview and record review with LN 14 on 3/11/25 at 3:30 P.M., LN 14 stated that CMs taken out of the medication card should be immediately documented on the CS. Further, LN 14 stated that after CM administration, the time the CM was given should be documented on the EMAR. LN 14 acknowledged that she should have documented the CMs to provide accuracy on the CS, and she should have documented the exact time that residents took the CMs, on the EMAR. During an interview with the Director of Nursing (DON) on 3/13/25 at 10:05 A.M., the DON stated she expected all LNs to document on the CS, all CMs that were taken out of the medication cards. In addition, the DON stated she expected the LN to document the CM administered to the resident, on the EMAR. The DON acknowledged that the quantity of CM that were documented on the CS did not accurately match the quantity of CM tablets that were inside the medication cards. The facility's policy titled, Controlled Medications - Storage and Reconciliation dated 5/2007, indicated, Policy .6. When a controlled medication is administered, the licensed nurse administering the mediation immediately enters all the following information on the accountability record: Date and time of administration, amount administered and signature of the administering the dose, competed after the medication is actually administered.

Based on observation, interview, and record review, the facility failed to indicate the appropriate and measurable target behavior of antidepressant (medication used to treat depression, sad mood and lack of interest) for one of two sampled residents (Resident 8) reviewed for unnecessary psychotropic (mind-altering medications) medication use. This failure had the potential for unnecessary psychotropic medication use, side effects, and a decline for resident's psychological and mental well-being. Findings: Resident 8 was readmitted to the facility on [DATE], with diagnoses which included encephalopathy (a change in how the brain functions; may cause confusion, agitation) and UTI, per the facility's Admission Record. Resident 8's attending physician completed Resident 8's history and physical (H & P) dated 2/10/25. The H & P indicated Resident 8 did not have the capacity to understand and make decisions. A review of Resident 8's physician order dated 3/6/25 indicated the following order: - Escitalopram Oxalate Oral Tablet at bedtime for as evidenced by (AEB): Self isolation related to MAJOR DEPRESSIVE DISORDER (MDD, a mood disorder that causes a persistent feeling of sadness and loss of interest), . - ANTI-DEPRESSANT TARGET BEHAVIOR: Depression aeb verbalization of feeling sad, MONITOR EPISODES OF TARGETED BEHAVIOR, every shift . On 3/10/25 at 11:45 A.M., an observation of Resident 8 was conducted in the dining room. Resident 8 was yelling at the staff and requested to return to his room. On 3/12/25 at 10:09 A.M., an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that Resident 8 was confused and did not know what was going on. CNA 1 stated there was no behavioral monitoring for Resident 8. CNA 1 stated, We were not informed to monitor, the information was not passed down to us. On 3/12/25 at 10:50 A.M., a joint review of Resident 8's clinical record and an interview with Licensed Nurse (LN) 1 was conducted. LN 1 stated that Resident 8 was confused and was unable to express that he was sad. LN 1 stated, I am not sure if the target behavior is appropriate for the medication. It is really hard for him because he is confused. On 3/13/25 at 9:43 A.M., an interview with the Director of Nursing (DON) was conducted. The DON stated that the LNs should have checked the appropriate target behavior being monitored for Resident 8's anti-depressant medication. The DON stated it should have been corrected in the physician's order to prevent the use of unnecessary psychotropic medication. A review of the facility's policy titled, Psychotropic Medications, revised 12/2023, indicated, It is the policy of this facility to ensure that residents who have not use psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed .Procedure .3. The LN shall review the classification of the drug, the appropriateness of the diagnosis, its indication, behavior monitors .

Based on observation, interview and record review the facility failed to ensure safe and appropriate storage of medications when: 1. One out of one intravenous medication cart (IV cart - medications used through the vein) was left unlocked and unattended by a licensed nurse (LN). 2. A medication room key was left in the doorknob and left unattended by a LN. 3. Multiple medications were left unattended by a LN in the nursing station. These failures had the potential for unauthorized access of residents, visitors, and/or unlicensed staff to medications. Findings: 1. During a concurrent observation and interview with LN 1 in the facility hallway on 3/10/25 at 7:40 A.M., an IV cart was observed unlocked and unattended by a licensed staff. The drawers of the cart were able to be pulled open. The drawers contained IV medications, needles and tubing. LN 1 stated that the IV cart should have been kept locked to prevent unauthorized access to medication and supplies. During an interview with the Director of Nursing (DON) on 3/13/25 at 10:15 A.M., the DON stated that all treatment and medication carts should be kept locked to prevent residents, visitors and unlicensed staff from gaining access. The facility's undated policy and procedure titled, Medication Administration and Storage, indicated, .Procedures .7. Medication and treatment carts will be kept locked when unattended. 2. During a concurrent observation and interview with LN 1 on 3/10/25 at 11:10 A.M., a medication room key was observed inserted in the medication room doorknob. LN 1 stated that the medication room key should not have been left in the doorknob, to prevent unauthorized people gaining access to medications and supplies stored inside the medication room. During an interview with the DON on 3/13/25 at 10:17 A.M., the DON stated that the medication room key should be with the LN's all the time. The DON further stated that the medication room key should not have been left in the doorknob, to prevent unauthorized people from entering the medication room. The facility's undated policy and procedure titled, Medication Administration and Storage, indicated, .Procedures .4. The door to the medication room should be locked at all times when an authorized staff member is not present. 3. During an observation on 3/10/25 at 11:25 A.M., multiple medications were observed stacked unattended, on top of the nursing station counter. During an interview with LN 1 on 3/10/25 at 2:45 P.M., LN 1 stated that the multiple medications were delivered by the pharmacy, and that the medications should have been brought inside the medication room for safekeeping. During an interview with the DON on 3/13/25 at 10:20 A.M., the DON stated that all medications should be immediately stored in the medication cart or medication room to ensure safety. The facility's undated policy and procedure titled, Medication Administration and Storage, indicated, .Procedures .5. Drugs and/or biologicals should not be left unsecured/unattended. Drug deliveries should be stored immediately after delivery and should not be unattended/unsecured.

Based on observation, interview and record review, the facility failed to protect residents' rights to confidentiality of protected health information (PHI - includes name, diagnoses, treatment of patients) for multiple residents when a vital signs sheet (VSS - form/record that included residents medical information) was found in the medical cart's trash bin. This failure had the potential to unnecessarily expose residents' PHI to individuals such as visitors and/or other residents. Findings: During a concurrent medication observation and interview on 3/12/25 at 8:24 A.M. with Licensed Nurse (LN) 11, a VSS was observed upward to view, inside LN 11's medication cart's open trash bin. LN 11 stated that the VSS contained residents' names, diagnoses and treatment. LN 11 further stated that the VSS should have been shredded to protect residents' PHI from unauthorized individuals. During an interview with the Director of Nursing (DON) on 3/13/25 at 9:08 A.M., the DON stated that resident PHI should be kept confidential. The DON further stated that the VSS should had been thrown away in the facility's confidential bin for proper shredding, to protect residents' PHI. The facility's policy titled, Access to Electronic Health Record Policy dated 8/2016, indicated Policy .1. The facility is responsible for safeguarding all resident data, ensuring it is protected from accidental or malicious destruction, or modification

Based on observation, interview, and record review, the facility failed to provide treatment in accordance with the facility's policy and procedure when a Licensed Nurse (LN) 2 did not auscultate (listening to the stomach with a stethoscope when administration of air to check the placement of the gastrostomy tube [g-tube, a tube inserted through the stomach that brings nutrition or medications directly to the stomach]) before giving a resident (26) his tube feeding (TF) formula. This failure had the potential for Resident 26 to have respiratory aspiration of gastric contents, that may cause a life-threatening aspiration pneumonia (bacterial infection in your lungs, it can happen when you aspirate, or inhale, something other than air into your respiratory tract). Findings: Resident 26 was readmitted to the facility on [DATE], with diagnoses which included respiratory failure, epilepsy (condition that affects the brain and causes frequent seizures) and with a g-tube, per the facility's Admission Record. Resident 26's attending physician completed Resident 26's history and physical (H & P) dated 2/13/24. The H & P indicated Resident 26 was not able to make his own decisions. A review of Resident 26's physician order dated, 3/7/24, indicated, Enteral feed: check placement/ patency via air, auscultation (listening to the stomach via stethoscope while injecting 30 cc [cubic centimeter, unit of measurement] of air into the g-tube with a syringe before giving medication and starting TF). On 3/10/25 at 9:09 A.M., an observation and an interview of Resident 26 was conducted in his room. Resident 26 was lying in bed, with TF formula ongoing, connected to Resident 26's g-tube. Resident 26 gestured a thumbs up when asked how he was doing. On 3/11/25 at 3:20 P.M., an observation of LN 2 preparing Resident 26's TF formula was conducted. LN 2 primed (the process of filling the tubing with solution/formula prior to attaching it to the resident) the tubing of the administration set. LN 2 primed the tubing with approximately 6 inches of air at the end of the tubing. LN 2 waited for Resident 26 to be transferred from the geri-chair (padded chair that is designed to help residents with limited mobility) to his bed. After Resident 2 was transferred back to his bed, LN 2 took the 60 ml syringe, connected the syringe to the g-tube, and administered some air to the resident's g-tube. LN 2 did not have a stethoscope and did not auscultate Resident 26's stomach upon administering air. After LN 2 checked the residuals from the g-tube, LN 2 connected the primed tubing with air, to Resident 26, then started the TF. On 3/11/25 at 3:24 P.M., an interview with LN 2 was conducted. LN 2 stated she did not auscultate Resident 26's stomach when she administered air to Resident 26's g-tube because she gave Resident 26 his medications via g-tube 30 minutes prior, in the nurses' station while Resident 26 was in his geri-chair. LN 2 stated she assumed it is still good. LN 2 stated she should have checked and auscultated Resident 26's g-tube to ensure the placement of g-tube and prevent aspiration. On 3/13/25 at 9:43 A.M., an interview with the Director of Nursing (DON) was conducted. The DON stated LN 2 should have listened to the resident's stomach to ensure proper placement of the g-tube and for resident's safety. A review of the facility's undated policy titled, Enteral Feeding Administration, indicated, .7. Check enteral feeding tube placement before initiating feeding .

Based on interview and record review, the facility failed to implement a care plan (detailed plan with information about a patient's treatment, goal, and interventions) related to having a call light within reach for two of two sampled residents (10 and 26). In addition, the facility failed to implement a physician's order related to the administration of wound treatment and measurement of wound for one resident (37). These failures had the potential to not meet the goals of treatment and needs for Resident 10, Resident 26, and Resident 37. Cross reference to F-558 Findings: 1. Resident 10 was readmitted to the facility on [DATE], with diagnoses which included epilepsy (condition that affects the brain and causes frequent seizures) and the need for assistance with personal care, per the facility's Admission Record. Resident 10's attending physician completed Resident 10's history and physical (H & P) dated 2/19/25. The H & P indicated that Resident 10 did not have the capacity to understand and make decisions. On 3/10/25 at 12:41 P.M., an observation was conducted in Resident 10's room. Resident 10 was lying in bed. Resident 10 appeared to be mouthing words but no sound was coming from his mouth. Resident 10's call light was dangling from the bed side rails. A review of Resident 10's care plan related to falls, dated 2/13/25, indicated, Be sure the call light is within reach . On 3/13/25 at 9:43 A.M., an interview with the Director of Nursing (DON) was conducted. The DON stated that the care plan related to ensuring the resident's call light was within reach, should had been implemented to ensure safety of the residents. Per the facility's undated policy tiled, Care Planning/ Care Conference, It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive care plan for each resident .5. The resident's plan of care will be implemented as appropriate . 2. Resident 26 was readmitted to the facility on [DATE], with diagnoses which included respiratory failure, epilepsy (condition that affects the brain and causes frequent seizures) and the need for assistance with personal care, per the facility's Admission Record. Resident 26's attending physician completed Resident 26's history and physical (H & P) dated 2/13/24. The H & P indicated that Resident 26 was not able to make his own decisions. On 3/10/25 at 9:09 A.M., an observation was conducted in Resident 26's room. Resident 26 was lying in bed. A soft pad (call device) was hanging from the bed frame. The soft pad was out of reach for Resident 26. A review of Resident 26's care plan related to falls, dated 2/13/24, indicated, Be sure the call light is within reach . On 3/10/25 at 10:15 A.M., a joint observation of Resident 26's call device and an interview with Licensed Nurse (LN) 1 was conducted. LN 1 stated that the call device was not in Resident 26's reach. LN 1 stated it was important to place the call device within resident's reach for the resident to access and call for help. On 3/13/25 at 9:43 A.M., an interview with the Director of Nursing (DON) was conducted. The DON stated that the care plan related to ensuring the resident's call light was within reach, should had been implemented to ensure safety of the residents. Per the facility's undated policy tiled, Care Planning/ Care Conference, It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive care plan for each resident .5. The resident's plan of care will be implemented as appropriate . 43674 3. Resident 37 was admitted to the facility on [DATE] with diagnoses which included metastatic prostate cancer (prostate cancer that has spread from the prostate gland to other parts of the body) per undated Admission Records. A joint record review was conducted on 3/13/25 at 10:48 A.M., with the Minimum Date Set (MDS) Coordinator. Resident 37's pressure ulcer care plan, initiated on 1/1/25 was reviewed. This care plan included interventions: Administer treatments as ordered and monitor for effectiveness . Assess/Record/monitor wound healing. Measure length, width and depth . Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD (medical doctor; physician) . A concurrent interview and record review was conducted on 3/13/25 at 2 P.M., with the MDS Coordinator. Resident 37's initial admission assessment on 12/31/24 indicated that Resident 37 had an open wound however, there was no documented measurement until 1/7/25. Resident 37's treatment order for the left buttocks dated 1/9/25 indicated Cleanse with NS (Normal Saline), pat dry. Apply Medihoney and Xeroform, and cover with dry dressing . There was no documented evidence that treatments were completed on 1/15/25 through 1/18/25 and on 1/21/25. Resident 37's treatment order for the left buttocks dated 1/21/25 indicated Cleanse with Dakins, pat dry. Apply Medihoney and Xeroform, and cover with dry dressing . There was no documented evidence that treatments were completed on 2/24/25 and 2/27/25. The MDS Coordinator stated that a measurement of the wound should have had been completed on the initial assessment and treatment of the left buttock should have been completed as ordered. The MDS Coordinator acknowledged that Resident 37's care plan interventions related to administration of treatments, measurement of wound during admission, and reporting changes in skin/wound status to the physician were not consistently implemented and should have been. A review of facility's undated policy and procedure, titled Comprehensive Resident Centered Care Plan indicated .The IDT team will also develop and implement a baseline care plan . that meet professional standards of quality care .

Based on observation, interview and record review, the facility failed to ensure call lights (device used to communicate a need for help) were within residents' reach for two of two sampled residents (10 and 26). The concerns for the call light within reach had been an ongoing issue during the Resident Council (RC) Meetings from August 2024 through November 2024. In addition, the facility failed to provide the appropriate call bell for one resident (17) with contractures (stiffening/shortening at any joint, that reduces the joint's range of motion). These failures had the potential to not meet the needs of the residents when needing help. Cross reference to F-656. Findings: 1a. Resident 10 was readmitted to the facility on [DATE], with diagnoses which included epilepsy (condition that affects the brain and causes frequent seizures) and the need for assistance with personal care, per the facility's Admission Record. Resident 10's attending physician completed Resident 10's history and physical (H & P) dated 2/19/25. The H & P indicated that Resident 10 did not have the capacity to understand and make decisions. On 3/10/25 at 12:41 P.M., an observation was conducted in Resident 10's room. Resident 10 was lying in bed. Resident 10 appeared to be mouthing words, but no sound was coming from his mouth. Resident 10's call light was dangling on the bed's side rails. On 3/13/25 at 9:43 A.M., an interview with the Director of Nursing (DON) was conducted. The DON stated that resident's call light should be within reach to ensure resident safety when they needed help. Per the facility's undated policy tiled, Call light/ Bell, It is the policy of this facility to provide the resident a means of communication with nursing staff .5 .Place the call device within resident's reach before leaving room . 1b. Resident 26 was readmitted to the facility on [DATE], with diagnoses which included respiratory failure, epilepsy (condition that affects the brain and causes frequent seizures) and the need for assistance with personal care, per the facility's Admission Record. Resident 26's attending physician completed Resident 26's history and physical (H & P) dated 2/13/24. The H & P indicated that Resident 26 was not able to make his own decisions. On 3/10/25 at 9:09 A.M., an observation was conducted in Resident 26's room. Resident 26 was lying in bed, with a soft pad (call device) hanging from the bed frame. The soft pad was out of reach for Resident 26. On 3/10/25 at 10:15 A.M., a joint observation of Resident 26's call device and an interview with Licensed Nurse (LN) 1 was conducted. LN 1 stated that the call device was not in Resident 26's reach. LN 1 stated it was important to place the call device within resident's reach for the resident to access, and call for help. On 3/13/25 at 9:43 A.M., an interview with the Director of Nursing (DON) was conducted. The DON stated that resident's call light should be within reach to ensure resident safety when they needed help. Per the facility's undated policy tiled, Call light/ Bell, It is the policy of this facility to provide the resident a means of communication with nursing staff .5 .Place the call device within resident's reach before leaving room . 2. A review of the Resident Council (RC) Meeting minutes from August 2024 through November 2024 was conducted. The meeting minutes were as follows: 8/16/24 - Unsampled resident (247) requested call light button within reach before leaving the room. 11/15/24 - Unsampled resident (247) indicated the call light button issue was unresolved. - Unsampled resident (248), call light was left on the floor. - Unsampled resident (249), call light was out of reach. On 3/13/25 at 9:43 A.M., an interview with the Director of Nursing (DON) was conducted. The DON stated that resident's call light should be within reach to ensure resident safety when they needed help. Per the facility's undated policy tiled, Call light/ Bell, It is the policy of this facility to provide the resident a means of communication with nursing staff .5 .Place the call device within resident's reach before leaving room . 45909 3. A review of Resident 17's Admission Record indicated Resident 17 was admitted to the facility on [DATE] with diagnoses which included a history of communication deficit and brain damage. A review of Resident 17's Minimum Data Set (MDS- nursing facility assessment tool) dated 1/8/25 indicated that Resident 17 had an impairment of both upper and lower extremities. During a concurrent observation and interview conducted with Licensed Nurse (LN) 12 on 3/10/25 at 11:16 A.M. inside Resident 17's room, Resident 17's hands were contracted (tightened muscles that cause the joints to shorten and become stiff, preventing normal movement). LN 12 stated that Resident 17 had a push button call light that she was not able to press. In addition, LN 12 stated that Resident 17 should have been provided a soft pad call light to accommodate Resident 17's needs. During an interview with the Director of Nursing (DON) on 3/13/25 at 9:09 A.M., the DON stated that all residents, regardless of their mental orientation, should be provided with the appropriate call light to provide dignity and access when residents or family members called for assistance. The DON acknowledged that Resident 17 should have been provided with the soft pad call light that was more appropriate for Resident 17's condition. The facility's undated policy titled Accommodation of Needs indicated, It is the policy of this facility to provide accommodation of reasonable needs to the residents while in the facility.

Based on interview and record review, the facility did not ensure wound treatment for one of one resident (Resident 37) was completed as ordered by the physician. This failure had the potential to affect Resident 37's care and well-being. Findings: Resident 37 was admitted to the facility on [DATE] with diagnoses which included metastatic prostate cancer (prostate cancer that has spread from the prostate gland to other parts of the body) per undated Admission Records. A review of Resident 37's treatment order for the left buttocks dated 1/9/25 indicated, Cleanse with NS (Normal Saline), pat dry. Apply Medihoney and Xeroform, and cover with dry dressing . A review of Resident 37's treatment order for the left buttocks dated 1/21/25 indicated, Cleanse with Dakins, pat dry. Apply Medihoney and Xeroform, and cover with dry dressing . A concurrent interview and record review of Resident 37's electronic treatment administration record (eTAR) was conducted on 3/13/25 at 2 P.M., with the Minimum Data Set (MDS) Coordinator. The MDS Coordinator stated that the treatment administration record for the left buttocks did not include documentation that the wound treatments were completed for Resident 37 on 1/15/25 through 1/18/25, 1/21/25, 2/24/25, and 2/27/25. The MDS coordinator acknowledged that the wound treatments should have been consistently completed and documented. A review of facility's undated policy and procedure titled Physician Orders indicated, Policy: .It is the policy of this facility to accurately transcribe and implement orders . 6. Medication, treatment or related orders are transcribed in the eMAR (electronic medication administration record), eTAR accurately and verified via the double check system process.

Based on interview and record review, the facility failed to provide adequate assistance to a resident (Resident 2) who required total dependence with activities of daily living (ADL-bathing or showering, dressing, getting in and out of bed or a chair, walking, toileting and eating) reviewed for accidents. This failure resulted in Resident 2 falling from bed. Findings: Resident 2 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with hypoxia (a condition where the lungs fail to adequately exchange oxygen, leading to low oxygen in the blood) and dependence on ventilator (breathing machine) according to the facility's Admission Record. A complaint investigation was conducted on 2/5/25 at the facility. At 8:57 A.M during an interview with Licensed Nurse (LN) 1, LN 1 stated Resident 2 was still at the hospital due to a fall incident. An interview was conducted with Certified Nurse Assistant (CNA) 1 on 2/5/25 at 9:45 A.M. CNA 1 stated she was assigned to the subacute (a place where residents require higher level of care including ventilator [breathing machine] dependent residents) side of the facility. CNA 1 stated she had been assigned to Resident 2. CNA 1 stated Resident 2 had a tracheostomy (an opening on the neck with a tube to help with breathing) connected to a ventilator. CNA 1 stated Resident 2 was dependent on staff for all ADLs. CNA 1 stated Resident 2 required two-person assist with brief change because Resident 2 was heavy, had a tracheostomy and had episodes of being combative. An interview was conducted with CNA 2 on 2/5/25 at 9:55 A.M. CNA 2 stated she had been assigned to Resident 2. CNA 2 stated Resident 2 was dependent with ADLs. CNA 2 stated Resident 2 was, A big guy and moved a lot. CNA 2 stated she had to ask for another staff to assist with changing Resident 2's brief for safety. CNA 2 further stated Resident 2 had episodes of refusing care and had struck out at staff. During an interview on 2/5/25 at 10:15 A.M. with Licensed Nurse (LN) 2, LN 2 stated she was the assigned nurse on the day Resident 2 fell out of bed. LN 2 stated she was at another room when she heard a CNA calling for the Respiratory Therapist (RT). LN 2 stated she followed the RT to Resident 2's room and saw Resident 2 lying on the floor, perpendicular to the bed. LN 2 stated she assessed Resident 2 and found skin tears on the left great toe, a red mark on the left eyebrow and reddened knees. LN 2 stated upon interview of CNA 3, CNA 3 told LN 2 that Resident 2 rolled off the bed during brief change. An interview was conducted with CNA 3 on 2/5/25 at 10:27 A.M. CNA 3 stated she was assigned to Resident 2 the day of the fall incident. CNA 3 stated Resident 2 had a bowel movement with smears on Resident 2's face and arms. CNA 3 stated she stood on the left side of Resident 2's bed as she cleaned Resident 2' s face and arm. CNA 3 stated she pulled the flat sheet under Resident 2 towards her then turned Resident 2 to his right side. CNA 3 stated as she cleaned Resident 2's back, Resident 2, Moved his arms, wiggled his body and started rolling off the bed. CNA 3 stated she was not able to stop Resident 2 from rolling off the bed and Resident 2 landed on the floor. CNA 3 stated she usually had a second person to assist with caring for Resident 2, but at that time CNA 3 stated, It was a lapse in my judgment. During a review of Resident 2's weights in the electronic medical record, the weight record indicated Resident 2 weighed 175.1 pounds as of 1/3/25. A review of a fall assessment for Resident 2 dated 12/2/24 indicated a score of 13 . High Risk. A review of Resident 2's care plans were conducted. A care plan for Resident 2 titled, ADL Self Care Performance Deficit r/t Chronic respiratory failure, dated 12/3/24 indicated Resident 2 required total assistance with personal hygiene, toilet use, bathing, dressing. The care plan did not address the number of staff assistance Resident 2 required for ADLs. During a review of Resident 2's fall risk care plan dated 12/3/24, the care plan indicated, At risk for falls r/t: Epilepsy [a brain disorder causing seizures], CVA [Cerebrovascular Accident-stroke] .Goal .Will be free of falls . A review of Resident 2's Minimum Data Set (MDS-a clinical assessment tool), dated 12/6/24 was conducted. The MDS section GG0170A indicated, 01 .Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed . The MDS indicated coding of 01 indicated, Dependent-Helper does ALL of the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity . An interview was conducted on 2/14/25 with the Director of Nursing (DON). The DON stated Resident 2's CNA should have called for someone to assist her during resident's care. The DON stated it was best practice to have two people to care for Resident 2 for safety. A review of the facility's undated policy and procedure (P&P) titled, Fall Prevention was conducted. The P&P indicated, .When a resident is admitted to this facility, a Fall assessment will be completed for the resident .A care plan is formulated based on that assessment. If a potential for a fall is triggered, a care plan will be formulated pertaining to fall prevention . The policy did not indicate fall preventive measures.

Based on interview and record review, the facility failed to readmit one of three sampled residents (Resident 1), who was transferred to a General Acute Care Hospital (GACH) for medical care, when the facility did not document a reason for refusal to readmit Resident 1 after GACH 2 had deemed Resident 1 medically and psychologically safe for discharge back to the facility according to facility policy. This deficient practice placed the resident at risk for confusion and psychosocial harm related to the inability to return to the facility and an unnecessary, extended stay at the GACH 2. Findings: Resident 1 was admitted to the facility on [DATE] with a diagnosis of suicidal ideations (thoughts about or a plan to commit suicide) and chronic respiratory failure (a condition that makes it difficult to breathe on one's own) requiring a tracheostomy (a surgical procedure that creates an opening in the neck to provide an alternative airway for breathing) and ventilator (a machine that helps patients breathe) per the facility's admission record. A review of Resident 1's Post-Event IDT Review, dated 9/2/24, indicated Resident 1 was transferred and admitted to GACH 1 on 8/31/24 for attempted self-harm after he was discovered in his room with a charger cord wrapped around his neck and he verbalized a plan to kill himself. The Post-Event IDT Review indicated Resident 1's room was prepared for return to the facility by removal of potential self-harm items and that staff were in-serviced regarding care and monitoring on resident safety. A review of Resident 1's Post-Event IDT Review, dated 9/12/24, indicated Resident 1 was readmitted to the facility on [DATE] following an acute care admission at GACH 1 for a suicide attempt on 8/31/24. The IDT Review recommended Resident 1 be assessed for suicidal intent every shift. A review of Resident 1's History and Physical Examination (H&P), dated 9/13/24, indicated, . transferred back to the hospital . after reportedly wrapping a cord around his neck at his post-acute facility . deemed psychiatrically stable for discharge back to post-acute facility . The H&P indicated Resident 1 had a documented history of chronic passive thoughts of self-harm on a daily basis. On 11/21/24 at 11:04 AM, an interview was conducted with certified nursing assistant (CNA) 1 at the facility. CNA 1 stated the facility accepted residents with psychiatric conditions. CNA 1 stated the facility provides in-services that review interventions for psychiatric residents that have a history of harming themselves. CNA 1 stated staff were trained to periodically take inventory of resident drawers for items that were used to self-harm and frequent visual checks. CNA 1 stated she was familiar with Resident 1. CNA 1 stated Resident 1 had history of trying to hurt himself and stated he had previously attempted to wrap a cord around his neck at the facility. CNA 1 stated the facility accepted him back from the hospital after this incident and safety interventions were put in place. CNA 1 stated Resident 1 was recently sent out for attempting to hurt himself by drinking hydrogen peroxide rinse (a diluted solution of hydrogen peroxide used to clean the mouth of bacteria). On 11/21/24 at 11:36 AM, an interview was conducted with facility licensed nurse (FLN) 1 at the facility. FLN 1 stated she was the nurse for Resident 1 the day he swallowed the hydrogen peroxide oral rinse. FLN 1 stated Resident 1 was transferred out to GACH 2 per the NP's order. FLN 1 stated Resident 1 had suicidal ideations in the past. FLN 1 stated Resident 1 had previously gone to the hospital for putting a cord around his neck. FLN 1 stated safety interventions were put in place after the hospital stay which included placing cords out of reach, removing sharp items and liquids from the room, and making sure no medications were left on the counter. FLN 1 stated the facility conducted in-services on suicidal ideations which included not leaving any type of liquids at the bedside. FLN 1 stated Resident 1 had not stated or verbalized an intention to hurt anyone else and was not physically aggressive towards others. FLN 1 stated Resident 1 had signed a seven-day bed hold. FLN 1 stated care plan for suicidal ideation was created for Resident 1 following the ingestion of hydrogen peroxide oral rinse. A review of Resident 1's nursing progress note, dated 11/11/24 at 6:02 P.M., indicated Resident 1 was ordered to be transferred to GACH 2 by the nurse practitioner (NP) after he reported he drank something he found in his drawer and verbalized that he wanted to die. The note indicated registered nurse (RN) 1 found an empty 2-ounce bottle of hydrogen peroxide oral rinse near the resident. A review of Resident 1's physician's orders (PO) indicated an order to transfer to GACH 2 was placed on 11/11/24. A review of the facility document, completed for Resident 1, titled, eINTERACT Transfer Form V4.1 (ETF), dated 11/11/24 at 7:20 P.M, indicated, B. Transfer Details . Reason(s) for: Other: suicidal attempt/ideation . 2. Primary Goals of Care at Time of Transfer; 1. Rehabilitation and/or Medical Therapy with intent of returning home . 3. Conditions of Return . Nursing Home Would be able to Accept Resident Back Under the Following Conditions . 1. ED determines diagnoses, and treatment can be done in NH (nursing home); 2. VS (vital signs) stabilized and follow up plan can be done in NH . On 11/21/24 at 2:18 P.M., an interview with the facility case manager/social services director (CM/SSD) was conducted at the facility. The CM/SSD stated Resident 1 was transferred out to GACH 2 after an attempted suicide by trying to drink a solution. CM/SSD stated Resident 1 had a seven-day bed hold. CM/SSD stated GACHs notified the facility when a resident was ready to discharge from the hospital and return to the facility. CM/SSD stated the director of nursing (DON), and the care team reviewed the hospital discharge paperwork and would readmit the resident for transfer if there was a bed available. The CM/SSD stated she had spoken with GACH 2 who stated Resident 1 had been cleared for discharge. The CM/SSD stated she had spoken with Resident 1 over the phone, and he reported not feeling stable. The CM/SSD stated she told the hospital the facility did not feel they could accept the resident back. The CM/SSD stated the facility had not gone to the hospital to assess Resident 1. The CM/SSD stated she had not reported to anyone at GACH 2 regarding Resident 1's reports of feeling unstable. A review of Resident 1's social services progress note, dated 11/18/24, at 3:08 P.M., authored by the CM/SSD, indicated, .Spoke with CM (case manager) from [name of hospital] to explain why [name of facility] is not the appropriate setting for this resident . The facility is not a psych facility . The facility has concerns the resident would attempt suicide again . it is of the utmost importance that the resident gets the care that he needs and not get put back into a LTC (long term care) without regular psych visits and meetings. The facility would rather the resident be safe in a psych related facility . On 11/25/24 at 11:46 A.M., a follow-up telephone interview and record review of Resident 1's clinical record was conducted with CM/SSD. The CM/SSD stated she had spoken to Resident 1 on the phone multiple times and was concerned about readmitting him. CM/SSD stated she did not document any of the phone calls she had with Resident 1. CM/SSD stated the interdisciplinary care team (IDT) discussed reasons for not wanting to readmit Resident 1 to the facility at their clinical meeting. CM/SSD acknowledged the clinical record did not contain documentation that indicated the reasons why the facility determined they were no longer able to care for Resident 1. The CM/SSD stated the full discussion of why the facility did not want to accept Resident 1 back from the hospital was not reflected in the clinical documentation. A review facility social services progress notes, dated 9/16/24 through 11/10/24 were conducted. The social service progress notes did not indicate Resident 1 was exhibiting suicidal ideation, mood, and behavioral issues the facility was unable to accommodate during this time period. On 11/25/24 at 1:52 P.M., an interview with the facility nurse practitioner (NP) was conducted. NP stated she was readmitted to the hospital following a recent suicide attempt. The NP stated Resident 1 was in the hospital two months ago following a previous suicide attempt. The NP stated she had read the facility progress notes indicating the resident was not returning to the facility because the facility was unable to meet Resident 1's needs. The NP stated she was not involved in the decision to not accept the resident back from the facility. A review of the facility document, dated 11/11/24, titled, Physician Discharge Summary, indicated Resident 1 was discharged to the hospital on 11/11/24. The section of the document, titled, DISCHARGE DIAGNOSIS, was left blank. The section of the document, titled, A FINAL SUMMARY OF RESIDENT'S STATUS AT TIME OF DISCHARGE, was left blank. The document included a physician signature, dated 11/11/24. The document did not indicate the reason for the hospital transfer or that the facility was unable to provide ongoing care for Resident 1's psychological need. A review of Resident 1's Post-Event IDT Review, dated 11/11/24, indicated Resident 1 was transferred and admitted to GACH 2 for verbalizing wanting to die and consuming a bottle of hydrogen peroxide oral rinse found in his drawer. The Post-Event IDT Review recommendations included emergency room evaluation for self-harm intent, a psychiatric evaluation, follow-up with the acute care facility regarding resident discharge planning, staff training, and a re-evaluation of Resident 1's preferred activities by the activity department. An inability to care for the resident's psychosocial needs upon discharge from the hospital was not documented. The NP and medical doctor were not listed as IDT members involved in the IDT review. A review of GACH 2 case manager note, dated 11/13/24, indicated, .Called and spoke with [Marketer name] @ [facility name] and is able to return if he's doing better . A review of GACH 2 case manager note, dated 11/18/24, indicated, .Called [Marketer name] back . agreed to accept patient back tomorrow at 10am . transportation set up for tomorrow @ 10am . A review of GACH 2 document titled, Discharge Summary, dated 11/19/24, indicated, .Patient is now cleared by psychiatrist for discharge back to skilled nursing care facility . A review of GACH 2 nurse note, dated 11/19/24, indicated, .Patient is discharge back to [facility name] today and scheduled for pick up at 10 am. A review of GACH 2 case manager note, dated 11/19/24, indicated, .Unable to transport patient d/t - facility not accepting per [CM/SSD name] . On 11/21/2024 at 4:00 P.M., a telephone interview was conducted with the director of case management at GACH 2 (GACH 2 DCM). GACH 2 DCM stated Resident 1 was still at the GACH 2 and had been medically and psychologically cleared for discharge back to the facility. GACH 2 DCM stated, on 11/19/24, the facility notified GACH 2 they were unable accept Resident 1 back to the facility. On 12/13/24 at 4:06 P.M., an interview with the director of nursing (DON) was conducted. The DON stated the facility accepted Resident 1 back to the facility after the first suicide attempt involving the cord around his neck because they felt they could provide a safe environment for Resident 1 and manage his psychological needs. The DON acknowledged the facility did not document why the facility was unable to care for Resident 1's needs following the second suicide attempt. The DON acknowledged the facility did not follow their policy on transfer and discharge requirements. A review of the facility census, dated 11/20/24, indicated 8 of 42 total beds were empty and unoccupied. The census indicated there were no new pending admissions. A review of the facility policy, titled, Criteria for Transfer and Discharge, revised 12/2023, indicated, .Policy: It is the policy of this facility that each resident will remain in the Facility, and not be transferred or discharged unless the discharge or transfer is appropriate as per the existing criteria. When the Facility transfers or discharges a resident, the Facility shall ensure that the transfer or discharge is documented in the resident's medical record . Procedure: The Facility shall permit each resident to remain in the Facility, and not transfer or discharge the resident from the Facility unless: a. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the Facility . 5. If the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the Facility, the resident's physician shall document the following in the resident's medical record: a. The specific resident need(s) that cannot be met; b. Facility attempts to meet the resident needs; and c. The service available at the receiving Facility to meet the need(s) . 10. If the Facility determines that a resident, who was transferred with an expectation of returning to the Facility cannot return to the Facility, this constitutes a discharge and this policy shall apply. Therefore, a refusal to readmit the resident to the Facility is considered a discharge, and the requirements of 42 CFR Section 483.15 in terms of documentation, notice before transfer, and orientation for transfer/discharge apply .

Based on observation, interview and record review, the facility failed to provide interventions to prevent the development of pressure injuries (skin damaged by lack of movement for staying in a position for too long) for two of six residents reviewed for pressure injuries (Resident 17, Resident 26.) As a result, Resident 17 developed a new pressure injury on the right trochanter (hip) and Resident 26 developed a new pressure injury on the right trochanter area. Findings: 1. Resident 17 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure; subdural hemorrhage (bleeding in the brain); anoxic brain damage (lack of oxygen to the brain); tracheostomy (a surgical opening in the neck to help air and oxygen reach the lungs, and sepsis (a serious infection that leads to organ failure) per the facility's Admission Record. A record review of Resident 17's document titled, Braden Scale for Predicting Pressure Sore Risk, dated 3/6/24 indicated Resident 17 was at high risk for developing pressure injuries due to very limited mobility . cannot always communicate discomfort ., and chairfast .cannot bear own weight . A review of Resident 17's care plan dated 1/2022 related to potential for pressure ulcer development due to weakness indicated, .skin checks as needed, use lift sheet to reduce friction, requires LAL (pressure relieving) bed mattress . A review of Resident 17's undated care plan related to pressure injury indicated, .Resident 17 has actual skin impairment r/t (right) trochanter Stage 4 pressure injury identified 11/24/23, follow facility protocols for treatment of injury . and turn and reposition every shift . The turning and repositioning began in January 2024. Observations of Resident 17 were conducted on the following dates and times: 3/18/24 8:20 A.M., Resident was turned on his left side and a soft pillow was placed under his back. A large sign was posted on the wall behind the bed labeled, Turning Schedule, indicating every 2-hour schedule of turning from back-door-window. On 3/18/24 at 10:20 A.M., Resident was turned on his left side and a soft pillow was placed under his back. On 3/18/24 at 12 P.M., Resident was turned on his left side and a soft pillow was placed under his back. On 3/20/24 at 8:41 A.M. a concurrent observation and interview was conducted with the Wound Care Nurse (WCN) 31 during a dressing change. Resident 17 was positioned on his back. The right trochanter pressure injury measured approximately 1.6 centimeters (cm) and had a hole in the center. WCN 31 stated the depth of the wound was not known. There was approximately 4 cm of scar tissue around the wound. WCN 31 stated, It is a facility acquired (developed while the resident was in the facility) pressure injury. We just implemented the turning and repositioning protocol 2 months ago. It was not consistently done prior to that and that contributed to the pressure injury development. He also has multiple co-morbidities. An interview was conducted on 3/20/24 at 10:42 A.M. with WCN 31.WCN 31 stated, The resident developed the right trochanter pressure ulcer on 11/19/23 and was seen by the nurse practitioner one week later and the wound was now a stage 4 pressure ulcer. A review of the Interdisciplinary Team (IDT) Skin Review-Weekly Update dated 11/29/23 was conducted on 3/20/24 at 8:45 A.M. Section II: Wound Management/Pressure Ulcer Review indicated: .Wound location/etiology: right trochanteric/Stage 4 pressure injury Tissue Bed 5x5x0 cm (centimeters), slough 30% with biofilm (70%) Inflammation/Infection: without periwound cellulitis, purulent or pain out of proportion. Moisture: mild serous exudate Edge of Wound normal defined edge Preoperative Indications: Slough, biofilm poor healing. Procedure: debridement (muscle) Operative Note: pain control was achieved by topical 20% benzocaine spray. A curettage debridement technique was employed using a 3mm (millimeter) surgical steel curette. Devitalized muscle tissue was identified and excised until healthy, bleeding tissue was encountered. Hemostasis was achieved with direct pressure. Estimated blood loss was less than 5cc (cubic centimeters) Wound was dressed as described below. Post-op dimension 5x5x1. Dressing used Dakin's solution, gauze apply island dressing . A review of the Turning and Positioning documentation for March 2024 for Resident 17 was reviewed. March turning schedule (1st through 21st, 2024): AM (day) shift - positioned x1 PM (evening) shift - positioned x 1 NOC (night) shift - positioned x 1 From March 1 through March 21, Resident 17 was only turned once per shift. A concurrent interview and record review of the above turning and positioning documentation was conducted on 3/20/24 at 10:20 A.M. with the Director of Nursing (DON). The DON stated, Documentation was not done for night shift. If it is not documented, it is not done. Four things we need for pressure injury prevention are nutrition, treatment, equipment (LAL-low air loss mattress) and doing turning and repositioning. Not turning residents according to the protocol can contribute to the slowing/decline in healing of the pressure injury. An interview was conducted with certified nursing assistant (CNA) 32 on 3/20/24 8:59 A.M. CNA 32 stated he had worked for the facility for 2 months and, Our protocol is to turn residents every 2 hours. An interview was conducted on 3/20/24 at 2:07 P.M. with CNA 33. CNA 33 stated she worked for the facility for two months and We have a turn protocol, it is posted near the bed, and we stick to it. An interview was conducted on 3/20/24 at 2:54 P.M. with CNA 34. CNA 34 stated, Turn protocol only started two months ago. I have been here three months; before that, there was no schedule, it was if we noticed the resident was in the same position, we would turn them. An interview was conducted on 3/20/24 at 3:32 P.M. with CNA 35. CNA 35 had worked for the facility for six months. CNA 35 stated, We have a turning protocol posted above the patient's bed that tells us what to do and when. It has been in place about one month. Prior to that, it was based on the CNA's knowledge to just do it. Residents (including Resident 17) did not get turned and repositioned every two hours regularly before and that can lead to bed sores. An interview was conducted on 3/21/24 at 1:33 P.M. with the DON. The DON stated, The turning protocol should have always been in place, it is taught in school, but it was started probably around November 2023. January 2024 was when I started pushing it because wounds (facility residents with doucumented pressure injuries including Resident 17 ) were not improving. Staff said they were turning residents, but based on my observations, it wasn't happening, and wounds were not improving. I couldn't tell if they were really turning. As DON, I expected residents to be turned every two hours at least; especially for non-verbal residents. The progression of this ulcer (Resident 17) should have been identified and reported. It is documented that the pressure ulcer was avoidable; if a resident is high risk and not turned, a pressure ulcer would erupt. The turning change implemented two months ago did not help prevent this resident's (Resident 17) injury in November. Also, care plans (all) that say q (every) shift are wrong! That is 8 hours in the same position. 46980 2. Resident 26 was admitted to the facility on [DATE] with diagnoses which included moderate protein calorie malnutrition (a nutritional deficiency that can impact healing), and quadriplegia (inability to move arms and legs independently), and cognitive communication deficit (impairment in the ability to communicate). An observation of the turning schedule posted on the wall at the head of Resident 26's bed indicated 12 AM back. 2 AM door. 4 AM window. 6 AM back. 8 AM door. 10 AM window. noon back. 2 PM door. 4 PM window. 6 PM back. 8 PM door. 10 PM window. Observations of Resident 26 were conducted on the following dates and times: 3/18/24 at 4:35 P.M., Resident 26 was observed in bed on her back with the head of the bed raised to fifteen degrees (a slight incline). According to the turning schedule, Resident 26 should have been positioned on her left side facing the window. 3/19/24 at 11:37 A.M., Resident 26 was observed in bed on her back. According to the turning schedule, Resident 26 should have been positioned on her left side facing the window. 3/20/24 at 5:15 P.M., Resident 26 was observed in bed on her back. According to the turning schedule, Resident 26 should have been positioned on her left side facing the window. 3/21/24 at 8:10 A.M., Resident 26 was observed in bed on her back. According to the turning schedule, Resident 26 should have been positioned on her right side. An observation and interview were conducted on 3/20/24 at 11:08 A.M., with the wound care nurse (WCN) during wound care for Resident 26. The WCN stated Resident 26 had a facility acquired pressure injury on her right hip that started as a skin tear from a brief. An interview was conducted on 3/21/24 at 8:13 A.M., with CNA 22. CNA 22 stated all residents should be repositioned every two hours at a minimum. CNA 22 stated, The importance of turning is for the comfort of the residents and to prevent bed sores. An interview was conducted on 3/21/24 at 8:37 A.M., with CNA 23 who stated, In the past couple of months the turning became strict. The importance of the resident of being turned regularly is for good circulation and to make them comfortable and out of pain. If a resident is left in one position too long, they might have skin breakdown and get open wounds. An interview was conducted on 3/21/24 at 10:34 A.M., with the WCN who stated, The sign on the headboard was implemented two months ago. Prior to 2 months ago the turning was hit or miss. (Resident 26's) right hip wound developed in the facility because the brief was too tight and caused a scratch. It happens like this every time because the urine is acidic. Her skin was macerated (a breakdown of skin resulting from prolonged exposure to moisture). Lack of turning was part of the cause. In addition, the WCN stated, Intervention of turn and reposition as tolerated is vague. An interview with the Director of Nursing was conducted on 3/21/24 at 1:36 P.M. regarding Resident 26's position during the above observation times. The DON stated, They always seem to be on their back. A review of the risk for skin breakdown care plan initiated on 10/17/23 for Resident 26 indicated, Turn and reposition as tolerated. Encourage to turn and reposition, provide assistance as necessary. Follow facility policies/ protocols for the prevention/ treatment of skin breakdown. Educate resident, family/ caregivers as to causes of skin breakdown; including: .frequent repositioning. Needs monitoring/ reminding/ assistance to turn/ reposition. Resident 26 could not reposition herself due to her diagnosis of quadriplegia. A review of physician orders dated 2/18/24 for Resident 26 indicated Santyl external ointment 250 unit/ gram (Collagenase) apply to right trochanter topically each day shift for stage 4 pressure injury for 21 days. This was the first physician order related to treatment of the pressure injury. An interview was conducted with the WCN on 3/21/24 at 10:24 A.M. The WCN stated, The right trochanter wound developed in the facility. A review of the facility Interdisciplinary Team (IDT) Care Plan Review dated 3/11/24 was conducted. Resident 26's right hip wound was not mentioned in the IDT document although the existence of the wound was known to the facility and physician who wrote an order for wound care on 2/18/24. A review of the Physician Progress Note dated 3/14/24 indicated Resident 26 had decreased movement of both right and left upper and lower extremities. A review of the Change of Condition (COC) note dated 3/17/24 indicated wound on left groin area. This wound was not present on admission to the facility. A review of the Wound Physician Note dated 3/13/24 indicated Change in Health: Noted sacral wound increased in size.Wound 7: right trochanter stage 3 (a wound in which fatty tissue may be visible) pressure injury. Tissue bed: 11.5 x 10.5 x 0.4 cm (centimeters, a metric unit of measurement). A review of an undated facility policy titled, System: Skin/ Wound Prevention Management Best Practice indicated, frequent turning and repositioning as tolerated. A review of a staff training titled Proper Positioning dated 1/26/24 indicated, Importance of turning every 2 hours and as tolerated. 26 staff members signatures were on the Attendance Record, seven of which were CNAs and one of which was a Restorative Nursing Aid (RNA). An interview was conducted on 3/21/24 at 1:36 P.M., with the Director of Nursing (DON), who stated Turning patients is a typical nursing responsibility, we are taught that in school. My expectation is the staff should turn the residents every 2 hours at least. They always seemed to be on their back. Turning should be automatic. There was no turning protocol prior to January 2024. I said to myself, they say that they're turning their patients so why does it look like they're still in the same positions? If a resident who is high risk for pressure ulcer development is not turned their skin would erupt, it would not stay intact. A review of the facility's undated policy titled Pressure Ulcer Management indicated, .Procedures: 6. Turn and Reposition as tolerated . 48263

Based on interview and record review, the facility failed to prevent an avoidable accident for one of three residents (Resident 1), when: - 1:1 supervision (one staff assigned to provide continuous supervision to a resident) was not provided when Resident 1 was agitated and pulling on her trach (tracheostomy tube/breathing tube) collar (device that secured a trach in position). - Resident 1 ' s cognitive impairment and behavior was identified, but was not evaluated, analyzed, or care planned with resident-specific interventions to meet the resident ' s behavioral, and supervision needs. - Resident 1 ' s quetiapine (a psychotropic medication used to control mood and behavior) indicated for use when resident pulled at life sustaining tubes (trach) was not administered when the resident ' s behavior was observed. As a result, Resident 1 removed her trach collar and decannulated herself (tracheostomy tube was removed from the trachea/windpipe) while unsupervised. Resident 1 had to be reintubated (reinsertion of the tracheostomy tube) at the facility, transferred to the hospital, and experienced an anoxic brain injury (brain death occurring from lack of oxygen) per the hospital record. Findings: A review of Resident 1 ' s Admission Record, dated [DATE], indicated the resident was admitted to the facility on [DATE] with diagnoses to include acute and chronic respiratory failure, attention to tracheostomy (opening in the trachea to insert a breathing tube/trach), attention to gastrostomy (opening in the abdomen to insert a feeding tube/g-tube), unspecified dementia (condition characterized impaired judgement and memory loss), severe, with behavioral disturbance, and Alzheimer ' s disease (affects memory and other important mental functions). On [DATE] at 8:46 A.M., a telephone interview was conducted with Resident 1 ' s family member (FM) 1. FM 1 stated she or another family member spent most of the day at the facility supervising Resident 1. FM 1 stated Resident 1 would touch and manipulate her trach and g-tube. FM 1 stated she would have to move the resident ' s hands away from those areas. FM 1 stated Resident 1 pulled out her intravenous line (IV, used to put medication or fluids into the bloodstream) and had pulled out her g-tube three times. FM 1 stated she had asked nursing staff to place mittens (a restraint device used to prevent fingers from grasping) or to tie the resident ' s hands down at night when she was not there to watch the resident. FM 1 stated Resident 1 had dementia and was confused. FM 1 stated Resident 1, Always tried to get up and would stand up. FM 1 stated she had asked nursing staff to place Resident 1 on 1:1 supervision at night and was told there was not enough staff to accommodate the family ' s request. FM 1 stated she told staff to call her day or night and she would come to watch Resident 1. FM 1 stated, It was my nightmare leaving her [Resident 1] at night that she ' d pull the trach out. FM 1 stated she did receive a call (on [DATE]) that Resident 1 had pulled her trach out and staff had to perform CPR (cardiopulmonary resuscitation-a hands on procedure to revive a person) and send the resident to the hospital via 911. FM 1 stated Resident 1 died four days later at the hospital. A review of Resident 1 ' s Minimum Data Set Assessment (MDS, a comprehensive assessment tool) dated [DATE], indicated the brief interview of mental status was not completed due to the resident ' s severe cognitive impairment. On [DATE] at 1:55 P.M., an interview was conducted with certified nursing assistant (CNA) 1. CNA 1 stated she often took care of Resident 1 during the daytime and that the resident was confused and would be, Moving around too much. CNA 1 stated Resident 1 required close monitoring, but in the daytime the resident ' s daughters were in the facility to watch her. CNA 1 stated Resident 1 ' s daughters cared for their mom and, Helped a lot with taking care of her during the day. CNA 1 stated when Resident 1 was awake and alone in bed, Resident 1 would try to get up and would start grabbing things. A review of Resident 1 ' s progress notes indicated: [DATE], a licensed nurse (LN) documented, .Gtube was dislodged and replaced [DATE] at 6:23 A.M., a LN documented, .Resident is alert with bouts of confusion .Several times tried to get out of bed, found once sitting on the floor [DATE], a LN documented, .At around 0400H [4 A.M.] pt [patient] was found with her Gtube out [DATE] at 9:53 P.M., a respiratory therapist (RT) documented, .Pt is restless and refuses to stay in bed. Pt removes trach collar often and needs continuous supervising. RN [registered nurse] is aware [DATE], a LN documented, @ 2042H [At 8:42 P.M.] medication nurse went to give her due medication, nurse noted Pt ' s skin looked from pale to yellowish but warm. Nurse tried to shake pt on the shoulder to wake her up but there was no response. Upon checking her neck, nurse found out that her tracheostomy was gone .Pt has no pulse and not breathing . CPR started .@2050H [At 8:50 P.M.] 911 responders came .they left the facility with the pt @2109H [9:09 P.M.] [DATE], a RT documented, .Pt was received on trach collar stable but restless at the beginning of shift . At around 8:50 pm she was found unresponsive and without a pulse after self decannulation. Immediately trach tube was reinserted and CPR was initiated On [DATE] at 2:10 P.M., a joint interview and record review was conducted with licensed nurse (LN) 2. LN 2 stated Resident 1 required the trach and could not adequately breathe on her own without it. LN 2 stated Resident 1 was confused and had dementia. LN 2 stated Resident 1 ' s behavior was manageable in the daytime because the resident ' s family was present to watch the resident and kept her busy. LN 2 stated Resident 1 ' s hands were always moving, and when the resident ' s daughter was not there, staff had to sit the resident at the nurses ' station for increased supervision. LN 2 stated the resident liked to be in a place where she could see everyone. LN 2 stated staff would give her linens to fold, and it kept her busy. LN 2 stated she would hear from the NOC (night shift from7 P.M. to 7 A.M.) nurses that Resident 1 was difficult to take care of at night and was sometimes combative. LN 2 reviewed Resident 1 ' s clinical record and stated there should have been a written plan of care to address the resident ' s dementia and behavior especially at night. LN 2 stated Resident 1 would pull her life sustaining tubes (g-tube/trach) and that this was a dangerous behavior and an immediate safety concern. LN 2 stated Resident 1 could not be redirected in this behavior and did not comprehend the implications of pulling her life sustaining tubes. LN 2 stated when Resident 1 pulled out her g-tube on [DATE] and [DATE], was found sitting on the floor on [DATE], and was pulling at her trach collar on [DATE], these were behaviors that should have been immediately discussed with the interdisciplinary team (IDT) and a plan of care developed to address it. LN 2 stated she did not see any documentation the resident ' s unsafe behaviors had been addressed by the IDT or care planned. A review of Resident 1 ' s physician ' s order dated [DATE], indicated the resident was to receive quetiapine 50 mg (milligrams) every six hours as needed for pulling at life sustaining tubes. There was also an order dated [DATE] to monitor the episodes of this behavior of pulling at the life sustaining tubes. A review of Resident 1 ' s medication administration record (MAR) for [DATE], indicated the resident ' s behavior of pulling at life sustaining tubes had been observed: 2 times on [DATE], 5 times on [DATE], 5 times on [DATE], 2 times on [DATE]. The same MAR indicated that Resident 1 had not been administered a quetiapine dose on ,d+[DATE], ,d+[DATE], ,d+[DATE], and [DATE]. On [DATE] at 2:51 P.M., a joint interview and record review was conducted with LN 4. LN 4 stated she was familiar with Resident 1. LN 4 stated Resident 1 was confused and had dementia. LN 4 reviewed Resident 1 ' s clinical record and stated when Resident 1 pulled out her g-tube on [DATE] and [DATE], was found sitting on the floor on [DATE], and pulled at her trach collar on [DATE], these were behaviors that should have been immediately discussed with the IDT and a plan of care developed to address it. LN 4 stated in the daytime, Resident 1 ' s daughters were in the facility and there were more staff and activities taking place. LN 4 stated there should have been an individualized dementia care plan that addressed Resident 1 ' s supervision and behavioral needs at night. LN 4 stated having a plan of care that addressed Resident 1 ' s behavior and supervision needs may have prevented her from pulling out her trach on [DATE]. LN 4 reviewed Resident 1 ' s quetiapine order dated [DATE] and the [DATE] MAR. LN 4 stated when the LN first observed Resident 1 pulling at life sustaining tubes, the resident should have been administered a dose of quetiapine. LN 4 stated, There ' s a reason for the quetiapine order. It should have been followed. LN 4 reviewed Resident 1 ' s progress note on [DATE] at 9:53 P.M., and authored by the RT. LN 4 stated she did not see documentation that the RT ' s concern about Resident 1 needing continuous supervision had been acted upon. LN 4 stated there was no documentation that Resident 1 had been provided increased supervision. LN 4 stated at a minimum, the resident should have been put on Q15 monitoring (checking up on a resident every 15 minutes). LN 4 stated when there was a risk to the airway, Q15 monitoring would not be frequent enough. On [DATE] at 3:55 P.M., a joint interview and record review, was conducted with LN 4 and the medical records director (MRD). Resident 1 ' s electronic medical record, paper chart, and the medication cart binders were reviewed. Both LN 4 and the MRD stated there was no documentation Resident 1 had been placed on increased or scheduled supervision such as Q15 monitoring. LN 4 and the MRD stated if Resident 1 had received increased or scheduled supervision it would have been documented in the EMR, paper chart, or medication cart binders. On [DATE] at 4:26 A.M., an interview was conducted with RT 1. RT 1 stated she was familiar with Resident 1. RT 1 stated Resident was confused and would often pull at her trach and the oxygen mask that was applied to it. RT 1 stated if Resident 1 was really agitated or touching and pulling at her trach, then she needed to be placed on 1:1 supervision. RT 1 stated Resident 1 required the trach in order to adequately breathe. On [DATE] at 4:46 A.M., a joint interview and record review was conducted with LN 3. LN 3 stated Resident 1 was confused most of the time. LN 3 stated Resident 1 would become anxious at night after her daughters left. LN 3 stated Resident 1 would pretend to sleep, and as soon as her daughters left, she would start getting up and asking to go home. LN 3 stated she started her shift on [DATE] at 7 P.M. and saw Resident 1 sometime between 7 P.M. to 8 P.M. LN 3 stated she had observed Resident 1 to be agitated and pulling at her trach and oxygen mask. LN 3 stated Resident 1 needed 1:1 supervision at that time, but there was no one to do it. LN 3 stated there was not enough staff. LN 3 reviewed Resident 1 ' s clinical record and stated when she went into Resident 1 ' s room at 8:42 P.M., she thought the resident was asleep in bed. LN 3 stated Resident 1 had her blanket pulled up to her chin and could not visualize her trach site. LN 3 stated when Resident 1 did not respond, she pulled the blanket down and found the resident ' s trach next to her hip on the bed. LN 3 stated Resident 1 was dependent on the trach and could not adequately breathe without it. LN 3 stated, She needed a sitter [1:1 supervision] at night when agitated. LN 3 stated she could have called Resident 1 ' s daughter to come in but had not done so. LN 3 stated she did not attempt to place mittens (restraint device that prevents finger grasping) on the resident or call the physician. LN 3 stated she was the only LN on the subacute unit on [DATE], and she was just too busy. LN 3 stated there should have been enough staff available to provide the supervision that Resident 1 required on [DATE]. LN 3 further stated she did not report the staff shortage in a timely manner to management. On [DATE] at 5:42 A.M., an interview was conducted with CNA 2. CNA 2 stated, It was hard taking care of her [Resident 1] at night. CNA 2 stated he worked day and NOC shift, and the resident ' s daughters took care of her needs during the day. CNA 2 stated at night, Resident 1 kept trying to get out of bed and was restless. CNA 2 stated Resident 1 was quick and that he had to reapply the resident ' s oxygen mask several times after the resident removed it from her trach. CNA 2 stated there were a couple times when he worked that he briefly provided 1:1 supervision for Resident 1 when the resident was agitated. CNA 2 stated Resident 1 would calm down when someone was there and responded well to 1:1 supervision. CNA 2 stated Resident 1 needed 1:1 supervision when she was awake at night because she was impulsive. On [DATE] at 6:20 A.M., a joint interview and record review was continued with LN 3. LN 3 reviewed Resident 1 ' s physician order dated [DATE], indicating the resident was to receive a dose of quetiapine every six hours as needed for pulling out life sustaining tubes. LN 3 stated when she observed Resident 1 attempting to pull at her trach on [DATE], she should have administered a quetiapine dose. LN 3 stated quetiapine would not work immediately but it could have helped, and should have been given. A review of the facility census, dated [DATE], indicated the subacute unit was at maximum occupancy with 16 resident and one resident listed as a bed hold (out on leave). On [DATE] at 10:30 A.M., an interview was conducted with the director of staff services (DSD). The DSD stated, It was a full house [maximum occupancy] on the subacute unit on [DATE] which was too much for one nurse to manage. The DSD stated the facility management should have been notified promptly that a LN did not show up to work so a replacement could have been found. The DSD stated if a resident required 1:1 then extra staff should have been provided to meet the resident ' s needs. On [DATE] at 12:05 P.M., a joint interview and record review was conducted with the director of nursing (DON) and assistant director of nursing (ADON). The DON and ADON reviewed Resident 1 ' s clinical record. The DON stated Resident 1 ' s family was present to watch the resident during the day. The DON stated Resident 1 was a special case and the facility allowed the family to stay at night to watch the resident. The DON stated the family should have been called to come in to watch Resident 1 when LN 3 noticed the resident was agitated and pulling at her trach. The DON acknowledged it was the facility ' s responsibility to supervise the resident. The DON stated Resident 1 ' s behavior should have been discussed as an IDT and care planned. The DON further stated when LN 3 observed Resident 1 pulling at her trach, the resident should have been administered a quetiapine dose as was ordered. The DON stated LN 3 should have taken immediate action when she noticed Resident 1 ' s behavior on [DATE]. The DON stated Resident 1 should have been provided 1:1 supervision. The DON stated, More could have been done. A review of Resident 1 ' s hospital documentation titled Discharge Summary dated [DATE], indicated, .Diagnoses . Anoxic brain injury . overall poor prognosis . family decided to transition to comfort care and the patient passed away on [DATE] at 1855 [6:55 P.M.] On [DATE] at 3:05 P.M., a virtual interview was conducted with hospital medical doctor (MD) 1. Also present during the interview was the hospital director of regulatory affairs. MD 1 stated he was a pulmonologist (physician specializing in the respiratory system) and ICU (intensive care unit) physician and had treated Resident 1 during her hospital ICU stay ([DATE] through [DATE]). MD 1 stated he could not say with 100% certainty that Resident 1 ' s self-removal of her trach (on [DATE] at the skilled nursing facility) was the direct or only cause of her anoxic brain injury. MD 1 stated Resident 1 ' s self-removal of her trach on [DATE] was, Most definitely a contributing cause of the anoxic brain injury. MD 1 further stated residents with cognitive impairment and behavioral issues, who were attempting to pull on their trach, should have a sitter (1:1 supervision), be given a psychotropic medication to calm them down, or placed in restraints (device such as mittens) as a last resort. A review of the facility ' s undated policy titled Accident Intervention, indicated, Policy .The purpose is to ensure that the facility provides an environment that is free of hazards over which the facility has control and provides appropriate supervision to each resident to prevent avoidable accidents. This includes systems and processes designed to: identify hazard(s) and risk(s); evaluate and analyze hazard(s) and risk(s); implement interventions to reduce hazard(s) and risk(s)

Based on observation, interview, and record review, the facility failed to prevent a resident, Resident 1, from falling out of bed while having a [CONDITION(S)] (a sudden, uncontrolled surge of electrical activity in the brain, resulting in uncontrolled muscle and body movements) when, A) Resident 1 was left unattended with the bed in a high position, at an unsafe level. B) Certified nurse's assistants (CNAs) were not trained on procedures to protect the resident during a [CONDITION(S)]. As a result, Resident 1 suffered a fractured ankle and head trauma and required transfer to the hospital. In addition, Resident 1 stated she no longer felt safe in the facility and had increased pain. Findings: A review of the Admission Record was conducted on 10/26/22, the document indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses including chronic [CONDITION(S)], [CONDITION(S)] (tube in trachea used for breathing), and [CONDITION(S)] (abnormal nerve cell activity in the brain resulting in seizures). A review of the History and Physical, dated 10/14/22, the document indicated, Resident 1 was . [AGE] year-old s/p (status post) readmission secondary to [CONDITION(S)]; L (left) distal tibia/fibula (lower leg bones); proximal fibular neck fracture secondary to fall from [CONDITION(S)] (fractured lower leg bones). The review of the MDS (Minimum Data Set)(a mandated standardized assessment tool), dated 9/8/2022, Section G0400, indicated Resident 1 had a Functional Limitation in Range of Motion . A. Upper extremity (shoulder, elbow, wrist, hand) the score was 2 indicating an impairment on both sides) . B. Lower extremity (hip, knee, ankle, foot) the score was 2 (impairment on both sides). A) The Director of Nursing (DON) was interviewed on 10/26/22 at 1 P.M. The DON stated, The CNA went to Resident 1's room on 10/8/22 to provide care. The DON stated, The bed was in a high position because the CNA was about to provide care . During care, the resident had a [CONDITION(S)] . The CNA did not know what to do; she turned to call the nurse . As the CNA turned away to call the nurse, the resident fell on the ground. The CNA's statement was reviewed on 10/26/22 at 1:15 P.M. The statement dated 10/10/22 indicated, . I came out to pick up the linen to change (Resident 1). I noticed she was having a [CONDITION(S)] more intense than usual . Because I got scared, I poked my head out of the room and yelled for the nurse. The nurse headed my way . I heard the patient fall out of bed. I turned around and saw the patient on the floor. A concurrent observation and interview were conducted on 10/26/22 at 1:30 P.M. with Resident 1. Resident 1 was observed lying in bed on her left side in her room. Resident 1's eyes were open and tracking bedside activity. Resident 1 had a [CONDITION(S)] which was capped (capping a [CONDITION(S)] allows the patient to breathe in and out through their nose and mouth and speak). Resident 1's arms and legs were observed to be contracted (a permanent tightening of the muscles, tendons, skin, and nearby tissues, causing the joints to shorten and become stiff). Resident 1's bed was in a low position, and there was a landing mat on the left and right sides of the bed. During the interview, Resident 1 stated, I remember the day I fell out of my bed. The CNA came in to clean me. I had a [CONDITION(S)]. The CNA left me alone, and the bed was in a high position when I fell . There was no mat on the floor. Resident 1 further stated, I broke my ankle. I don't feel safe here. Licensed Nurse (LN 1) was interviewed on 10/26/22 at 1:45 P.M. LN 1 stated, I was the Licensed nurse taking care of [Resident 1] on 10/8/22. The CNA was changing [Resident 1]. The bed was flat and in a high position when she stepped out to get me. [Resident 1] fell on the left side of the bed. There was no landing mat. The CNA left the bedside for 5 to 10 seconds to get me. The nurses' progress notes dated 10/8/22 at 2:06 P.M. were reviewed on 10/26/22. The progress notes indicated, Resident 1 . found on the floor at 1330 [1:30 P.M.]. CNA stated had started to prepare supplies to change patient's [Resident 1] brief. Stated, upon entering room, patient. [Resident 1] was on the floor, [head at the foot of bed]. Patient [Resident 1] no longer seizing when entering the room. Pt A and O x 4 [Alert, oriented to self, place, time, and event]. Patient [Resident 1] tearful. Pt [Resident 1] stated having hit head . Pattient [Resident 1] was found with her left lower leg bent behind her left thigh . patient. [Resident 1] further assessed and found laceration on left great toe-at nail bed . Patient [Resident 1] states pain is more than her usual pain/cramping in legs. A review of the nursing progress note dated 10/8/22, at 22:37 hours was conducted on 10/26/22. The note indicated, . X-ray from left leg completed. The results documented on the Radiology Interpretation report dated 10/8/22, indicated, LEFT TIBIA-FIBULA 2 VIEWS: Shift distal tibial cortical disruption consistent with a fracture in a study limited by patient's condition. IMPRESSION: Distal tibial fracture (significant Findings). A concurrent review of Resident 1's Fall Risk Evaluation dated 3/2/22, and interview with the DON was conducted on 10/26/22 at 2 P.M. Resident 1's Fall Risk Evaluation indicated; Resident 1's score was 15 out of a possible 15 (High risk). On 6/2/22, Resident 1's Fall Risk Evaluation was 13 out of a possible 15 (High risk). On 9/2/22, Resident 1's Fall Risk Evaluation was 12 out of possible 15 (High risk). The DON stated, A score of 10 or more indicates high risk for falls. A review of nursing progress note dated 10/9/22 at 6:19 A.M. was conducted on 10/26/22. The progress note indicated, . Patient continues to c/o [complain of] pain to left lower area of the leg with evident swelling and bruising. A review of nursing progress note dated 10/9/22 at 10:34 A.M. was conducted on 10/26/22. The progress note indicated, . Patient x-ray results showed a left distal tibial fracture. Reported to Physician 1 (P 1) and Physician 2 (P2). Physician 1 ordered to send out to hospital for evaluation on 10/9/22 at 10:20 hours .RN provided report to EMT (Emergency Medical Technician) .Informed that patient. was having elevated HR (heart rate)-Informed that pt. blood thinner was held related to X-ray results indicating a break . Patient left facility at 12:25 hours with ambulance . A review of the Hospital Discharge Summary dated 10/9/22 was conducted on 10/26/22. The progress note indicated, Reason for visit . Leg pain, Fever . Tibial and Fibular fractures, [CONDITION(S)] . B) The Director of Staff Development (DSD) was interviewed on 10/26/22 at 2:15 P.M. The DSD said he oversaw the training of the Certified Nurses Assistants. The DSD stated, CNAs were trained during orientation and as needed. The DSD stated during orientation, CNAs were taught never to leave a resident alone when providing care. The CNA taking care of [Resident 1] said she just turned her head then the patient fell . The bed was in a high position because she was providing care, and the resident needed to be changed. The DSD further stated, [CONDITION(S)] training is not part of my lesson plan. I've never given an in-service on [CONDITION(S)] training. A concurrent interview and a review of the Order Listing Report . Anticonvulsants, dated 10/1/22 -11/30/22 was conducted with the DON On 10/28/22 at 11:15 A.M. The DON stated, We have 21 residents with [CONDITION(S)] disorders. The Order Listing Report .Anticonvulsants, document indicated nine residents were on the list. Resident 1 was prescribed eight anticonvulsant medications, Resident 2 was prescribed three anticonvulsant medications, Residents 3 and 4 were each prescribed two anticonvulsant medications. Residents 5, 6, 7, 8, 9 and 10 were each prescribed one anticonvulsant medication. The DON stated, We don't have a policy for [CONDITION(S)] precautions. The DON further stated, The nurses use their own discretion when applying pads to bedside rails and placing landing mats at the bedside. The CNAs have never been trained on what to do if a resident has a [CONDITION(S)]. [CONDITION(S)] precautions is the responsibility of the licensed nurse. CNA 1 was interviewed on 11/2/22 at 4:30 P.M. CNA 1 stated, I have been working here for four months. If a resident has a [CONDITION(S)], I ask them to calm down and wait 3 to 5 seconds until the [CONDITION(S)] is done. I would not touch them. I would just wait for someone who knows the resident better to help me. CNA 1 said she was never trained on what to do if a resident has a [CONDITION(S)]. CNA 2 was interviewed on 11/2/22 at 5:15 P.M. CNA 2 stated, I've worked in this facility for four years. If a resident that I am taking care of has a [CONDITION(S)], I would wait for the resident to calm down. I would make sure she was in the middle of the bed and pillows were around her to protect her from injury. CNA 2 stated, I have not had an in-service on [CONDITION(S)] training since working here. CNA 3 was interviewed on 11/2/22 at 5:25 P.M. CNA 3 stated, I've worked here for ten years. If a resident has a [CONDITION(S)], I will let the nurse know. I would wait for the [CONDITION(S)] to calm down, and I would not do anything to the resident. CNA 3 further stated, I have not had an in-service on [CONDITION(S)] precaution since working in this facility. An interview with the DSD On 11/3/22 at 11:45 A.M. The DSD stated, CNAs should be educated on [CONDITION(S)] training because they are the ones who provide bedside care and assist with ADLs (Activities of daily living). Resident 1's nursing progress notes dated from 9/9/22 at 3:27 A.M. through 11/8/22 at 7:37 A.M. were reviewed on 10/26/22. The notes dated 9/9/22 through 10/8/22 prior to when Resident 1 fell out of bed on 10/8/22 1:30 P.M. indicated no complaints of pain by Resident 1. Further review of Resident 1's nursing progress notes indicated, on 10/8/22 at 2:06 P.M., . Patient tearful . Patient requesting for pain medication for left leg . states pain is more than her usual pain . A review of progress note dated, 10/14/22 at 12:34 P.M. indicated, Resident in visible severe pain related to left tibial break. A review of a progress note dated 10/27/22 at 9:42 A.M. indicated, .Pt is requesting to go to the hospital due to having severe right leg pain . A review of a nursing progress note dated, 10/29/22 at 9:04 A.M. indicated, Resident verbalized anxiety AEB (As evidenced by) crying during patient care related to worrying she's going to fall out of bed. A review of a progress note dated 11/3/22 at 03:44 A.M. indicated, Resident visible and audible pain AEB crying out loud during patient care related to tibial fracture in left leg. A review of a progress note dated, 11/5/22 at 08:31 A.M indicated, Resident given [MEDICATION(S)] for anxiety. Resident verbalized she is falling .grabbing on to padded side rails . On 11/7/22 at 08:07 A.M. a nursing progress note indicated, Resident crying out, visibly anxious. Pt states, [I'm scared I'm going to fall out of bed]. A review of Resident 1's nursing progress note dated 11/8/22 at 1:32 P.M. indicated, Patient is alert and verbalized anxiety. Patient stated, [I don't want to fall] Further review of Resident 1's nursing progress note indicated, . she was crying throughout this shift .Received [MEDICATION(S)] for left foot pain . A concurrent interview and review of Resident 1's progress notes dated 9/9/22 at 3:27 A.M. through 11/8/22 at 7:37 A.M. were conducted on 11/9/22 at 2:30 P.M. During the interview, the DON stated, I haven't spoken to [Resident 1]. I did not notice if she was crying. The DON further stated, She (Resident 1) has not seen a psychologist or social services for psychological support (mental health support) after she fell . A review of the policy titled Fall Management System, dated January 2022, was conducted on 11/09/22. The policy indicated, . 1. On admission, the Fall Risk Evaluation will be completed to determine his/her risk for sustaining a fall. 2. Residents with high risk factors identified on the Fall Risk Evaluation will have an individualized care plan developed that includes measurable objectives and timeframes . a. The care plan interventions will be developed to prevent falls by addressing the risk factors and will consider the elements of the evaluation that put the resident at risk . 3. When a resident sustains a fall, a physical assessment will be completed by a licensed nurse, with results documented in the medical record. A. The Attending Physician and Resident Representative shall be notified of the fall and the resident's status.

Based on observation, interview and record review, the facility failed to ensure that range of motion was provided for 2 of 15 sampled residents (36, 38) and 3 randomly selected residents (37, 29, 10), as ordered by the physician. Failure to provide range of motion had the potential to cause harm to residents due to decrease and/or further decrease in range of motion. Resident 36, who was identified as having limitation on one side of his lower extremity in 9/2014, had been identified currently as having limitation to both sides of the resident's lower extremities. Findings: 1. Resident 36 was admitted to the facility on [DATE]. Per the History and Physical dated 2/25/14, the resident had [DIAGNOSES REDACTED]." A review of the resident's Minimum Data Sheet (MDS) assessment (a tool for implementing standardized assessment) with an assessment reference date (ARD) of 9/5/14, indicated that the resident had limitation in range of motion (ROM) to one side of his lower extremity. A review of Resident 36's physician's orders [REDACTED]." A review of the Resident 36's Restorative Participation Report Roster, from 9/1/14 thru 11/19/14, indicated that AROM were provided to the resident on 9/2/14 and 9/4/14, and were attempted on 9/6/14 and 9/9/14. There was no other documentation that would indicate that AROM was attempted and provided for Resident 36. An interview with certified nurse assistant (CNA) 23 was conducted on 11/19/14 at 12:00 P.M. CNA 23 was also a restorative (helps provide a resident-specific program designed by the rehab disciplines that seeks to promote the highest level of functioning in the residents ' ADLs and mobility)nursing assistant (RNA). CNA 23 was asked about Resident 36's upper and lower extremities ROM. CNA 23 stated that the resident had no ROM limitation on his upper extremities. However, CNA 23 stated that the resident had limitations on both his lower extremities. A joint observation of Resident 36's range of motion was conducted with physical therapist (PT) 22 on 11/19/14 at 2:30 P.M. Resident 36 sat in his wheelchair and PT 22 was holding on to the resident's lower right leg as she extended the resident's leg. While PT 22 was extending the resident's right lower leg, the resident verbalized "Awww" (pain). PT 22 performed the same procedure to the resident's left lower leg and the resident again verbalized "Awww." When asked whether or not the resident had limitations to his lower legs, PT 22 stated that for PT, they would consider Resident 36's lower legs as "within functional limits." An interview with licensed nurse (LN) 13 and PT 22 was conducted on 11/19/14 at 2:45 P.M. LN 13 was informed of PT 22's assessment of Resident 36's lower extremities. LN 13 stated that was a change from the previous MDS assessment. LN 13 stated that Resident 36 had limitation only to his left leg. LN 13 stated that, the resident now had limitation to both legs due to pain. An observation of skin assessment and skin treatment was conducted with licensed nurse (LN) 23 on 11/20/14 at 8:50 A.M. LN 23 was attempting to lift Resident 36's left lower leg to visualize the deep tissue injury (a pressure-related injury to subcutaneous tissues under intact skin) on the resident's left heel. In the process of lifting the left leg, the resident verbalized "Aww." LN 23 also lifted the right lower leg to visualize the resident's right heel. In the process of lifting the right leg, the resident verbalized "Aww." LN 23 stated that she had been working with Resident 36 for 2 weeks and that the resident had not been able to lift both of his legs even then. Resident 36 had an order, written on 9/10/14, to receive AROM to both upper and lower extremities 3x/week. There were no documented evidence that the AROM was provided for the month of October and November. The documentation did not reflect that staff attempted to provide AROM to the resident 3x/week, as ordered by the physician. The resident was assessed in 9/2014 as having limitation to one side of his lower extremity. Currently, the resident has limitations to both lower extremities. An interview with the Administrator (ADM) was conducted on 11/19/14 at 12:15 P.M. The ADM stated that she knew that there was a problem with the RNA program but did not know how bad it was. An interview with the ADM and the acting director of nursing (DON) was conducted on 11/20/14 at 2:30 P.M. The ADM acknowledged that the physician's orders [REDACTED]. 2. Resident 38 was admitted to the facility on [DATE], per the Face Sheet. According to the History and Physical, dated 11/1/13, the resident had [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED].(three times per week) x 90 days." A review of Resident 38's Restorative Participation Report Roster, from 9/1/14 thru 11/19/14, showed no documented evidence that AROM was offered and provided to the resident from September thru November. The documentation did not reflect that staff implemented the physician's orders [REDACTED]. An interview with the Administrator (ADM) was conducted on 11/19/14 at 12:15 P.M. The ADM stated that she knew that there was a problem with the RNA program but did not know how bad it was. An interview with the ADM and the acting director of nursing (DON) was conducted on 11/20/14 at 2:30 P.M. The ADM acknowledged that the physician's orders [REDACTED]. 3. Resident 37 was admitted to the facility on [DATE], per the Face Sheet. According to the History and Physical, dated 1/6/14, the resident had [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]." A review of Resident 37's Restorative Participation Report Roster, from 9/1/14 thru 11/19/14, showed no documented evidence that AROM was offered and provided to the resident from September thru November. The documentation did not reflect that staff implemented the physician's orders [REDACTED]. An interview with the Administrator (ADM) was conducted on 11/19/14 at 12:15 P.M. The ADM stated that she knew that there was a problem with the RNA program but did not know how bad it was. An interview with the ADM and the acting director of nursing (DON) was conducted on 11/20/14 at 2:30 P.M. The ADM acknowledged that the physician's orders [REDACTED]. 4. Resident 29 was readmitted to facility on 3/2/13. Per the History and Physical, dated 4/15/14, indicated that the resident had [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. 90 days." A review of Resident 29's Restorative Participation Report Roster, from 9/1/14 thru 11/19/14, indicated that passive range of motion (PROM - the therapist, RNA, or equipment moves the joint through the range of motion with no effort from the patient) and not AROM were provided on 9/3/14, 9/5/14, and 9/8/14. There were no documented evidence that AROM were attempted and provided from September thru November, as ordered by the physician. An interview with the Administrator (ADM) was conducted on 11/19/14 at 12:15 P.M. The ADM stated that she knew that there was a problem with the RNA program but did not know how bad it was. An interview with the ADM and the acting director of nursing (DON) was conducted on 11/20/14 at 2:30 P.M. The ADM acknowledged that the physician's orders [REDACTED]. 5. Resident 10 was admitted to the facility on [DATE]. A review of the physician's orders [REDACTED]. A review of the physician's orders [REDACTED]./wk (three times per week) x 90 days." A review of Resident 10's Restorative Participation Report Roster, from 9/1/14 thru 11/19/14, showed no documented evidence that AROM were attempted and provided to the resident from September thru November. The documentation did not reflect that staff implemented the physician's orders [REDACTED]. An interview with the Administrator (ADM) was conducted on 11/19/14 at 12:15 P.M. The ADM stated that she knew that there was a problem with the RNA program but did not know how bad it was. An interview with the ADM and the acting director of nursing (DON) was conducted on 11/20/14 at 2:30 P.M. The ADM acknowledged that the physician's orders [REDACTED]. Five of 5 residents did not receive the services as ordered by the physician related to range of motion.

Based on interview and record review, the facility failed to provide care for 1 of 8 unsampled resident (30). The facility had not provided services to address Resident 30's incontinence needs which resulted in mental anguish, anger and "feeling verbally abused and neglected." Findings: Resident 30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A group interview was conducted on 11/18/14 at 10:30 A.M. The residents were asked in a confidential group meeting if they were treated with dignity and respect by staff. Resident 30 stated certified nursing assistant (CNA)2 treated her badly when she was left in the bathroom with a "diaper" full of diarrhea and told to clean herself. Resident 30 stated that she reported the incident approximately 6 weeks ago to the Director of Staff Development (DSD) and the Administrator. A review of Resident 30's Minimum Data Set (MDS - a tool for implementing standardized assessment and for facilitating care management in nursing homes), dated 10/30/14, was conducted. Resident 30's MDS assessment indicated a Brief Interview for Mental Status (BIMS) score of 15. A BIMS score of 13-15 indicated that the resident was cognitively intact. A private interview was conducted with Resident 30 on 11/20/14 at 10:00 A.M. Resident 30 was asked to describe the incident she reported during the confidential group meeting. Resident 30 stated that she had an accident with very loose stool in her "diaper". She stated that she pressed the call light and CNA 2 responded. Resident 30 told CNA 2 that she needed to be changed. CNA 2 gave Resident 30 a wet cloth and told Resident 30 that she was "perfectly capable" of cleaning herself. Resident 30 asked for help and CNA 2 walked out of the room. Resident 30 pressed the call light again, CNA 4 responded and helped Resident 30 get cleaned up. Resident 30 asked the surveyor to interview CNA 4, since she was a witness to the incident. Resident 30 stated that she felt the treatment provided to her by CNA 2 was neglectful and she felt verbally abused. During this interview, Resident 30's speaking volume continued to increase with increasing hand gestures. An interview was conducted with CNA 4 on 11/20/14 at 10:40 A.M. CNA 4 stated that she remembered an incident between Resident 30 and CNA 2 regarding diarrhea. CNA 4 stated that she answered Resident 30's call light. Resident 30 needed help getting cleaned up as she had diarrhea in her brief. CNA 4 stated that she helped her get cleaned up. CNA 4 acknowledged it was CNA 2 who was responsible for Resident 30 that day. A telephone interview was conducted with CNA 2 on 11/20/14 at 10:45 A.M. CNA 2 stated that she answered Resident 30's call light and was told by Resident 30 that she needed to be changed. CNA 2 stated that she handed Resident 30 a washcloth and soapy water in a basin. CNA 2 stated that she was taught to allow residents to be independent and that is why she did not help Resident 30 clean herself. CNA 2 stated she knew Resident 30 was upset about the incident when the Administrator and DSD talked to her about it 3 weeks ago. CNA 2 stated that the DSD and Administrator changed her assignments so that she did not have Resident 30 as one of her residents. CNA 2 acknowledged that Resident 30 had felt neglected and verbally abused. An interview was conducted with the DSD on 11/20/14 at 10:05 A.M.. The DSD stated Resident 30 had come to her and the Administrator with a report of CNA 2 telling her to clean herself and to be more independent. Resident 30 reported to the DSD that she could not clean herself because she had bowel movement (BM) on her, but CNA 2 did not help her. The DSD stated that she spoke to CNA 2 and CNA 2 was no longer assigned to Resident 30. An interview was conducted with the Administrator on 11/20/14 at 11:00 A.M.. The Administrator acknowledged Resident 30 had informed her of an incident between her and CNA 2. The Administrator stated that she did not view the incident as an abuse. The Administrator further stated that she thought that the incident was about a call light not being answered. The Administrator acknowledged that she did not report the incident as abuse. The administrator acknowledged that she should have asked more questions when investigating the incident and acknowledged that the incident "sounds to me as neglect."

Based on observation, interview and record review, the facility failed to prevent pressure ulcer formation, for 1 of 15 sampled residents (Resident 36). The facility failed to identify, assess and prevent the resident's skin breakdown which resulted in the formaiton of pressure ulcers (areas of damaged skin caused by staying in one position for too long.) Findings: Resident 36 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observations were conducted on 11/19/14 at 8:00 A.M., 9:00 A.M., 10:00 A.M. and 11:00 A.M. Resident 36 was observed laying slightly on right side, from 8:00 A.M. until 11:00 A.M., a total of 3 hours. A review of Resident 36's "Completed Care Tasks," dated 11/17/14 for 6:30 A.M. to 11:00 PM, was conducted. Certified nurse assistant (CNA) 2, A.M. shift, documented, "No skin concerns." CNA 1, PM shift, documented, "No skin concerns." A review of Resident 36's "Wound Healing Progress Report", dated 11/19/14, was conducted. This record identified 3 wounds: 1. Abrasion Left Upper Arm" measuring 4.7 cm (centimeters) x 2.5 cm. 2. DTI (deep tissue injury - a pressure - related injury to subcutaneous (under the skin) tissues, as a result of prolonged compression) Right Heel measuring 1.2 cm x 1.2 cm. 3. Skin Tear Upper Head" measuring 2.4 cm x 1.4 cm. A wound observation was conducted on 11/20/14 at 8:50 A.M. with licensed nurse (LN) 2. Resident 36 was observed to have 8 wounds as follows:( important contributing factors to the development of pressure ulcers.) 1. Left upper arm skin tear, 2. Left elbow skin tear, 3. Left great toe blood filled blister measuring 1.5 cm x 1.5 cm. 4. Left heel black circle measuring 2 cm x 1.5 cm 5. Left shin abrasion 6. Forehead abrasion, 7. Right sacrum discoloration (reddened) 8. Left sacrum scab. The observation had not correlate with the facility's report of Resident 36's "Wound Healing Progress Report." All of Resident 36's current alterations in skin integrity were not adequately identifed by the facility. A review of Resident 36's care plan for: "At risk for skin breakdown R/T (related to) decreased mobility, advanced Alzheimer, fragile skin, incontinency," dated 2/22/14, indicated approaches as: "1. observe for s/s (signs and symptoms) of skin breakdown, 2. encourage fluids as ordered, 3. shower per schedule, 4. assist with turning PRN (as needed), 5. handle extremities with care, 6. notify MD if s/s (signs & symptoms) present, pressure reduction mattress." There was no documented evidence of care plan acceleration after the identification of skin breakdown. A review of Resident 36's "Departmental Notes," dated 11/2/14 at 9:44 P.M., indicated: "Noted 2 new wounds when doing a quick skin assessment. Wound #1 on R front of calf 3cmx2cm skin tear. Cleaned wound and covered with adhesive bandage. Wound #2 on R big toe 1cm x1cm appears to be blister with slight black in wound bed. Cleaned wound and covered with band-aid. Will continue to monitor." There was no other evidence in Resident 36's clinical record that would indicate that the above identified wounds were further assessed and treated since it was identified on 11/2/14. The notes identified the blister's location as right big toe. During a joint observation with LN 2 of the resident's skin, on 11/20/14, the blister was observed on the left great toe and not the right. The blister now measured 1.5 cm x 1.5 cm. from previous measurement of 1cm x 1 cm. There was no documented evidence that the physician was notified regarding the wounds. An interview was conducted on 11/20/14 at 9:35 A.M. with CNA 3. CNA 3 was asked to describe all wounds for Resident 36. CNA 3 stated Resident 36 has wounds on his arms, legs and head. She stated that he has had that scab on his left sacrum ( bone at the base of the spine) for a while. She stated that the resident has not used any special mattresses ( skin pressure relief mattresses to prevent pressure ulcers) since she has known him and he was unable to turn by himself. An interview was conducted with licensed nurse (LN) 2 on 11/20/14 at 10:15 A.M. LN 2 acknowledged that Resident 36's right heel DTI's location was inaccurately documented. LN 2 also acknowledged that the wound on the left great toe had not been assessed nor treated. LN 2 stated that she would describe the toe wound as a "blister." LN 2 stated that wounds were to be assessed weekly on Thursdays. LN 2 acknowledged that the physician's orders [REDACTED]. A review of the facility's policy and procedure titled, "Pressure Ulcer Prevention Program," undated, was conducted. This policy defined a Stage 2 pressure ulcer as "The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater." This policy indicated procedure as "Institute Weekly Pressure Ulcer Report if skin breakdown is present on admission or occurs during facility stay." There was no documented evidence of complete weekly skin assessments. In addition, this policy indicated procedure as: "Notify physician of skin breakdown and ask which treatment protocol is preferred." There was no documented evidence that the physician was notified of the left great toe blister. The blister procressed in size. An interview was conducted with the Director of Nursing (DON) on 11/20/14 at 4:15 P.M. The DON stated that she did a thorough skin assessment "last night" and identified a small scab on the right heel of Resident 36. There was no documented evidence that the scab on the resident's right heel was previously identified, assessed, and treated. A review of Resident 36's "Physician Orders," dated 11/2014, was conducted. This document indicated wound treatment orders for an abrasion on the left upper extremity, abrasion to the occipital head, DTI on right heel, and skin tear on the right shin. Resident 36's other wounds that were identified during the observation, on 11/20/14, did not have orders for treatment. A review of Resident 36's "Minimum Data Set" (MDS/assessment) dated 9/5/14 and 3/5/14, was conducted. The MDS indicated the resident's bed mobility as "Extensive Assistance" and "Total Dependence" respectively. A review of Resident 36's "Departmental Notes," dated 7/15/14, was reviewed. This record indicated "Wt (weight) loss 14.9# (pounds) X 1 mo (month) (8.4%). Wt loss 14.1# X 3 mos (7.9%), sig(significant) wt change...Res (resident) receives [MEDICATION NAME] for appetite stimulant/antidepressant... Meal intakes past week 0-100%... Rec (recent) increasing house shake to tid ( three times a day) with meals." A review of Resident 36's "Braden Risk Assessment Report," (tool to assess resident's risk for skin breakdown) dated 2/22/14, 5/28/14, 7/27/14 and 11/19/14, consistently indicated a "Risk Score" of 15 and "Risk Level" of Mild. This assessment report indicated "Friction & Shear" as a "Potential Problem" described as "Moves feebly (sic) or requires minimum assistance." This assessment report also indicated nutrition as "Adequate" described as "Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products) each day. Occasionally will refuse a meal, but will usually take a supplement if offered." However, these assessments did not match the resident's mobility and nutritional assessments as documented in the resident's MDS and Departmental Notes. An interview was conducted with LN 2 on 11/20/14 at 10:25 AM. LN 2 stated that she would not consider Resident 36's nutritional status adequate. LN 2 also stated that Resident 36 required maximum assist with bed mobility. LN 2 acknowledged that the "Braden Risk Assessment Report" was inaccurate and Resident 36 should be at moderate risk for pressure ulcer development. The facility failed to demonstrate a cohesive approach in the identification, assessment and interventions, for the prevention of pressure ulcer formation for Resident 36.