Every finding on record at The Bellefontaine Healthcare Center

Based on observation, interview and record review, the facility failed to provide clean and homelike environment to one (1) of two (2) sampled residents (Resident 2), by failing to ensure:Resident 2's floor did not have scattered used gloves.Trash bin and plastic bags were accessible for Resident 2's trash.Multiple boxes (seven big boxes) of belongings were not stored in Resident 2's room. These deficient practices created an unsanitary and unsafe environment and had the potential to place Resident 2 at risk of infection and injury and had the potential to negatively affect Resident 2's quality of life.Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included multiple sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), muscle weakness and lack of coordination. During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool), dated 7/2/2026, the MDS indicated Resident 2 had independent (decisions consistent/reasonable) cognitive skills (ability to understand and make decisions) for daily decision making. The MDS indicated Resident 2 required partial/moderate assistance (helper does less than half the effort) with eating. The MDS indicated Resident 2 required substantial/maximal assistance (helper does more than half the effort) with oral, personal and toileting hygiene, and upper body dressing. The MDS also indicated Resident 2 was dependent (helper does all the effort) with lower body dressing and putting on/taking off footwear. During a review of Resident 2's Care Plan focusing on Resident 2 does not value the cleanliness of the facility, disregard the safety of other residents and staff by throwing her trash, dirty gloves that she used, tissue paper, and soiled briefs anywhere she wants to, initiated on 7/3/2023, revised on 3/24/2026, interventions included the following:Offer plastic bags to resident to use for disposing trash on her own based on preference.Continue to offer help in cleaning and organizing her environment.Trash bin, waste basket will remain accessible and emptied on regular basis. During an observation on 8/5/2026 at 8:01 AM at Resident 2's bedside, scattered used gloves were observed on Resident 2's floor and multiple boxes of the resident's belongings were placed across Resident 2's bed. There is no trash bin near Resident 2's bed. During an interview on 8/5/2026 at 8:13 AM with Resident 2, Resident 2 stated that she usually has a trash bin nearby, but the facility has not provided it (unable to recall since when). Resident 2 stated her belongings are in the boxes in front of her bed because she was not being provided with a cabinet that will fit all her belongings. During a concurrent observation and interview on 8/6/2026 at 7:15 AM with Certified Nurse 1 (CNA 1) at Resident 2's bedside, CNA 1 verified that there is no trash bin near Resident 2 and there were scattered used gloves on the floor. CNA 1 stated there is usually a trash bin near every resident's bed. CNA 1 stated that Resident 2 has a lot of belongings in the room that makes it hard for the staff to move around. CNA 1 stated there are multiple boxes and three (3) wheelchairs in front of Resident 2's bed, and Resident 2 prefers to store all the wheelchairs in the room which blocks access to the bathroom. During an interview on 8/6/2026 at 7:38 AM with Licensed Vocational Nurse (LVN 1), LVN 1 stated there is an empty cabinet set up for Resident 2 in the hallway. LVN 1 stated Resident 2 refused to use it. LVN 1 stated Resident 2 usually has a trash bin nearby like the other residents. LVN 1 stated all residents' rooms should always be clean and sanitary to prevent infection. LVN 1 stated Resident 2's room was not clean when there are used gloves on the floor next to Resident 2's bed and should have been provided with a clean and homelike environment. During an interview on 8/6/2026 at 9:25 AM with the Director of Nursing (DON), the DON stated the residents' environments should always be kept clean and free from dirt and clutter to ensure quality of care and homelike environment is provided to the resident. The DON stated that Resident 2 was already provided with 2 cabinets of her choice, but when it was assembled, Resident 2 refused to use it. The DON stated they just let Resident 2's belongings be stored in multiple boxes and kept in Resident's room instead of resolving the issue about the cabinet that Resident 2 preferred/ requested. The DON stated Resident 2's belongings stored in multiple boxes and are in Resident 2's room could potentially be a hazard and is not homelike. During a review of the P&P titled, Quality of life - Homelike Environment, revised in May 2017, the P&P indicated residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The P&P indicated staff shall provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. The P&P also indicated the facility staff, and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include:Clean, sanitary and orderly environment.Personalized furniture and room arrangements. During a review of the Policy and Procedure (P&P) titled, Accommodation of Needs, revised in March 2021, the P&P indicated the resident' s individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, are evaluated upon admission and reviewed on an ongoing basis. The P&P also indicated in order to accommodate individual needs and preferences, adaptations may be made to the physical environment, including the resident's bedroom and example of such adaptation is to arrange furniture as the resident request, providing the arrangement is safe, and roommate agrees and space allows.

Based on interview and record review, the facility failed to maintain accurate resident medical records for one (1) of two (2) sampled Residents (Resident 1) by failing to ensure Resident 1's Clothing and Possessions records (inventory list [IL] a record of personal possessions brought into a healthcare facility upon admission) had the correct resident belongings upon discharge. This deficient practice had potential for all resident belongings not to be returned to Resident 1 upon discharge and potential for increased risk of loss belongings and/ or confusion.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included generalized edema (widespread swelling across the body caused by extra fluid), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and muscle weakness. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 6/15/2026, the MDS indicated Resident 1's cognitive (ability to think and reason) skills for daily decision making was independent (decisions consistent/reasonable). The MDS indicated Resident 1 required setup or clean-up assistance (helper sets up or cleans up) with eating. The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance) with oral hygiene. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with toileting hygiene, upper body dressing, and personal hygiene. The MDS indicated Resident 1 was dependent (helper does all the effort) with shower, lower body dressing and putting on/taking off footwear. During a review of Resident 1's nurse's notes dated 7/23/2026, timed 7 PM, entered by Registered Nurse 1 (RN1), the nurse's notes indicated Resident 1 was transferred to General Acute Care Hospital (GACH) via regular ambulance, accompanied by two ambulance staff. Resident 1's cellphone and charger were given to Resident 1 on discharge. During a review of Resident 1's IL 1, the IL 1's On Admission box, signed and dated 6/8/2026, indicated the following:1 cellphone with charger1 small purse1 red magnifying glass1 green pillowcase1 black fan1 small gray coin purse1 reading glasses During a review of Resident 1's IL 2, the IL 2's On Admission box, signed and dated 7/17/2026, indicated the following:1 cellphone with charger1 small gray coin purse1 red magnifying glass1 green pillowcase1 black fan During a review of Resident 1's IL 3, the IL 3's On Discharge box, signed and dated 7/29/2026, signed by Family 1 indicated the following items:2 big bags of personal belongings1 floor fan During a concurrent record review of Resident 1's IL 1, 2 and 3, and interview on 8/4/2026 at 2:33 PM, with RN 1, RN 1 stated the IL form is completed upon admission and updated when resident has new belongings brought in by family members. RN 1 stated IL form is also completed upon the resident's discharge making sure to compare the IL upon admission or the latest IL. RN 1 verified she documented Resident 1's discharge IL on 7/29/2026 when Family 1 came to pick up Resident 1's belongings. RN 1 stated, Resident 1's IL 1 and 2 were not available at that time, that is why she started another form which is IL 3. RN 1 stated she just documented that there were 2 big bags and 1 floor fan and did not document that Family 1 refused to have it open and checked the belongings inside the 2 big bags to have a documentation of itemized items. RN 1 also stated Resident 1's IL 2 was not and should have been updated when Resident 1 was discharged to the hospital on 7/23/2026, to indicate that Resident 1 was discharged to GACH with cellphone and charger. During a concurrent record review of Resident 1's IL 1, 2 and 3 forms, and interview on 8/6/2026 at 9:14 AM, with Social Service Assistant (SSA), SSA stated Resident 1's IL 3 was produced to document that on 7/29/2026, Family 1 came to the facility to pick Resident 1's belongings. SSA verified Resident 1's IL 3 has incomplete documentation because Resident 1's belongings were not itemized, and RN 1 only documented 2 big bags and 1 floor fan. SSA stated to avoid confusion, the nurse should have documented the items inside the 2 big bags and/or documented that Family 1 refused to have the 2 big bags checked for documentation. During a concurrent record review of Resident 1's IL 1, 2 and 3, and interview on 8/6/2026 at 9:20 AM with the Director of Nursing (DON), the DON verified Resident 1's IL 3 has incomplete documentation because RN 1 only documented 2 big bags and 1 floor fan on the On Discharge box. The DON stated there is no documentation for Family 1's refusal to have the 2 big bags checked. The DON stated, incomplete documentation can lead to confusion and potential loss of the resident's belongings. During a review of Facility's Policy and Procedure (P&P) titled, Release of a Resident's Personal Belongings, revised on March 2017, the P&P indicated the following:The personal belongings of a resident transferred or discharged from the facility will be released to the Resident or authorized resident representative.Personal belongings of a resident who is temporarily transferred or discharged from the facility will be inventoried (counted and made a list of all the items you have) and stored by the facility until the resident has returned or such items have been picked up by the resident's representative. During a review of Facility's P&P titled, Charting and Documentation, revised in July 2017, indicated Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

Based on observation, interview, and record review, the facility failed to ensure the ice machine drainage had an air gap (a vertical, unobstructed space between the ice machine's drain and the buildings drainage system that prevent contaminated drain water from flowing back into the machine's clean water supply. It is a safety measure, often a simple pipe fitting or a dedicated device, that acts as a barrier, with the most common requirement being a one to two - inch gap to comply with health and plumbing codes) to ensure no contact with outside contaminated (unfit for use, or unsafe) source as indicated in the facility's policy and procedure (P&P). This failure had the potential to result in backflow of contaminated water back to the ice machine and had the potential to result in pathogen (germ) exposure to residents, which could place the residents at risk for developing foodborne illness (food poisoning; symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea and fever) and can lead to other serous medical complications and hospitalization. During an observation on 6/2/2026 at 7:40 AM inside the kitchen, an ice machine was observed to the left of the dry storage room. During an observation on 6/4/2026 at 7:30 AM inside the kitchen, the ice machine drainage pipe was observed without an air gap, draining directly into the floor drain.During a concurrent observation inside the kitchen and interview on 6/4/2026 at 9:30 AM with Dietary Supervisor (DS), the ice machine drainage pipe was observed without an air gap, draining directly into the floor drain. DS stated that there should be a gap between the drainage pipe and the floor drain. During an interview on 6/5/2026 at 12:28 PM with the Maintenance Supervisor (MS), MS stated that the purpose of having an air gap between the ice machine drainage pipe and the floor drain is to prevent dirty water from backing up into the ice machine in the event of a drain backup.During a review of the facility's P&P titled, Accident Prevention - Safety Precautions, dated 2023, the P&P indicated under Backflow Prevention/Air Gaps:An air gap is the most reliable backflow prevention device. It is the physical separation of the potable (safe to drink) and non-potable water supply systems by an air space. All steam ice machines and bins, and other equipment that discharge liquid waste or condensate (the liquid that results from the cooling and condensation of steam, often contaminated) shall be drained through an air gap into an open floor sink.An air gap between the water supply inlet (drainpipe) and the floor level rim of the plumbing fixture (floor sink drain), equipment or non-food equipment shall be at least twice the diameter of the water supply inlet and may not be less than one inch.

Based on observation, interview, and record review, the facility failed to ensure proper food handling practices in accordance with the facility's policy and procedure (P&P) by failing to ensure: Dietary Aide 1 (DA 1) wore a hairnet while inside the kitchen.Dietary Aide 2 (DA 2) perform hand hygiene between handling dirty dishes and clean dishes.One container of poultry seasoning was closed.One opened container of dill weed seasoning was labeled with an open and/or use by date.These failures had the potential for residents to be at risk for food-borne illness (illness caused by food contaminated with bacteria).These deficient practices have the potential to result in pathogen (germ) exposure to residents, which could place the residents at risk for developing foodborne illness (caused by food contaminated with bacteria) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever) and can lead to other serious medical complications and hospitalization.During a concurrent observation and interview on 6/3/2026 at :21 PM with Dietary Supervisor (DS) inside the kitchen, the following were observed:a bottle of poultry seasoning with the lid open and not closed securely.an opened bottle of dill weed seasoning that was half full without a label indicating open or use by date.DS stated the bottle of poultry seasoning's lid should be closed securely and the opened bottle of dill weed seasoning should be labeled with an open or use by date.During an interview on 6/3/2026 at 2:45 PM with DS, DS stated it is important to label anything opened with an open date because the kitchen staff need to know how long it has been opened especially since there is a difference between how long something has been open and shelf life. DS also stated it is important to ensure containers are closed properly after use to prevent anything getting inside the container.During an observation on 6/4/2026 at 6:12 AM inside the kitchen, DA 1 was observed working inside the kitchen and not wearing a hair net.During an observation on 6/4/2026 at 6:12 AM inside the kitchen, DA 2 was observed handling dirty water pitchers. Without performing hand hygiene, DA 2 walked over and pulled out clean water pitchers from the dishwasher and started placing the clean water pitchers onto a rolling cart During an interview on 6/4/2026 at 6:43 AM with DA 2, DA 2 stated he had touched the dirty water pitchers prior to touching the clean water pitchers. DA 2 state he did not and should have washed his hands before handling the clean water pitchers. During an interview on 6/4/2026 at 9:40 AM with DS, DS stated it is important that staff wear hair nets while working inside the kitchen to avoid contaminating anything, especially if staff are near food, as no one wants hair in their food. DS further stated it is important that staff wash their hands after touching dirty dishes and before touching clean dishes to avoid cross contamination.During a review of the facility's P&P titled, Labeling and Dating of Foods, dated 2023, the P&P indicated, Newly opened food items will need to be closed and labeled with an open date and used by date.During a review of the facility's P&P titled, Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, revised October 2017, the P&P indicated, Food and nutrition services employees will follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. The P&P also indicated:All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents.Employees must wash their hands:After handling soiled equipment or utensils.Hair nets of caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens. During a review of the facility's P&P titled, Hand Washing Procedure, dated 2023, the P&P indicated, Hand washing is important to prevent the spread of infection. The P&P also indicated:When hands need to be washed:[NAME] handling soiled dishes and utensils.

Based on observation, interview, and record review, the facility failed to ensure that the call light (a device used by a Resident to signal his or her need for assistance) was within reach for four (4) of six (6) sampled residents (Resident 37, 8, 113, and 137) who were reviewed for environment care area. This deficient practice had the potential to negatively impact on the psychosocial well-being (the individual's mental and emotional health and their social interactions and environment) of Residents 37, 8, 113, and 137 as a result in delayed provision of care and services. Findings: 1. During a review of Resident 37's admission Record, the admission Record indicated Resident 37 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included osteomyelitis (a serious bone infection) of vertebra, sacral and sacrococcygeal region (affecting the spinal column at the base of the spine), unspecified lack of coordination (a broad clinical classification for individuals who present with motor control deficits or balance issues, but without a definitive underlying cause), and wedge compression fracture of first lumbar vertebra (when the front part of the bone in the lower back collapses under pressure while the back part remains intact). During a review of Resident 37's Care Plan, dated 10/14/2025, the Care Plan indicated Resident 37 was at risk for fall related to compression deformity of first lumbar vertebrae. The Care Plan indicated an intervention to place Resident 37's call light within reach and encourage resident to use it for assistance. During a review of Resident 37's Minimum Data Set (MDS- a resident assessment tool), dated 4/21/2026, the MDS indicated Resident 37 was assessed having intact memory and cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 37 required substantial/maximal assistance (helper does more than half the effort) with eating and oral hygiene. The MDS indicated Resident was dependent (helper does all of the effort) with upper body dressing, shower/bathe self, rolling left and right, sit to lying, sit to stand, and chair/bed-to-chair transfer. During a review of Resident 37's Care Plan, revised on 4/16/2026, the Care Plan indicated Resident 37 had alteration in musculoskeletal status related to osteomyelitis of vertebra, sacral and sacrococcygeal region and chronic (frequently recurring) multifocal (multiple locations) osteomyelitis of the right ankle and foot. The Care Plan indicated an intervention to be sure call light is within reach and respond promptly to all requests for assistance. During a concurrent observation and interview on 6/2/2026 at 11:20 AM in Resident 37's room, Resident 37 was observed in bed watching television. Resident 37's call light was placed on a chair on the left side of the bed. Resident 37 stated he was not able to reach the call light because it was far and placed on the left side of his bed and he was not able to move his left arm. Resident 37 stated he could not call for help and would have to wait for staff to enter his room to ask for assistance. During an interview on 6/3/2026, at 2:59 PM, with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 37 had left side weakness and was only able to move the resident's right arm. CNA 1 stated Resident 37's call light should be placed on top of his chest or stomach so he can push the call light when the resident needed help. CNA 1 stated facility staff should not leave the call light on a chair on the left side of the bed because Resident 37 would not be able to use it if he needed assistance or if there was an emergency. During an interview on 6/3/2026 at 3:39 PM with Treatment Nurse 1 (TN 1), TN 1 stated residents' call lights should always be placed within the resident's reach. TN 1 stated residents could fall and get injured while trying to reach the call light if it was not placed within reach. TN 1 also stated residents would not be able to receive immediate help during an emergency if the call light was not within reach. 2. During a review of Resident 8's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of sequelae (linger aftereffect, complications or consequences of a prior disease) of cerebral infarction (stroke; occurs when a blood vessel supplying blood to the brain is blocked or significantly narrowed) and chronic (long-term) respiratory failure (lungs cannot get enough oxygen into the blood or can't remove enough carbon dioxide from the blood) with hypoxia (when the body's tissues and organs do not receive enough oxygen to function properly). During a review of Resident 8's Care Plan revised 3/15/2026, Resident 8's Care Plan indicated Resident 8 was at risk for falls and included an intervention to provide call light within reach.During a review of Resident 8's Care Plan revised 3/25/2026, Resident 8's Care Plan indicated Resident 8 was at risk for self- care deficit related to decrease in muscle strength and included an intervention to have call light within reach and to attend to Resident 8's needs promptly. During a review of Resident 8'S MDS, dated [DATE], the MDS indicated the resident was severely impaired (rarely/never makes decisions) with cognitive skills for daily decision making. The MDS indicated Resident 8 was dependent with chair/bed-to-chair transfers, going from sitting to standing, rolling left and right in bed, putting on/taking off footwear, upper and lower body dressing and personal hygiene. The MDS also indicated Resident 8 needed substantial/maximal assistance (helper does more than half the effort) with eating. During an observation on 6/2/2026 at 9:25 AM inside Resident 8's room, Resident 8 was observed lying down in bed and his call light was observed hanging down towards the floor from the right upper 1/4 bed rail (a protective bar or barrier attached to the side of a bed). During a concurrent observation and interview on 6/2/2026 at 9:33 AM with Certified Nursing Assistant 2 (CNA 2) inside Resident 8's Room, Resident 8 was observed lying down in bed with his call light hanging down towards the floor from the right side of the resident's bed near the upper right 1/4 bed rail. CNA 2 stated Resident 8's call light was hanging off the right side of Resident 8's bed and Resident 8 would not have been able to reach it. 3. During a review of Resident 113's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of sequelae of cerebral infarction and polyosteoarthritis (a degenerative joint disease that affects multiple joints simultaneously). During a review of Resident 113's Care Plan revised 8/5/2024, Resident 113's Care Plan indicated Resident 113 required bilateral upper half bed rails and included an intervention to keep call light within resident's reach.During a review of Resident 113's Care Plan revised 12/7/2025, Resident 113's Care Plan indicated Resident 113 preferred his call light cord to be wrapped around the bed rail so the resident would not lose it and would be easy for the resident to use it when needed to call someone for assistance. The care plan also indicated an intervention to ensure call light was within easy reach and to check that it is properly secured on the bedrail per patient's preference. During a review of Resident 113's Care Plan revised 1/20/2026, Resident 113's Care Plan indicated Resident 113' was at risk for falls and included an intervention to have Resident 113's call light within reach and to encourage Resident 113 to use it for assistance. During a review of Resident 113'S MDS, dated [DATE], the MDS indicated the resident was cognitively intact with cognitive skills for daily decision making. The MDS indicated Resident 113 was dependent with putting on/taking off footwear and lower body dressing and needed substantial/maximal assistance with going from lying down to sitting on the side of the bed, rolling left and right in bed and upper body dressing. The MDS also indicated Resident 113 needed supervision or touching assistance with personal hygiene and eating. During an observation on 6/2/2026 at 10:40 AM inside Resident 113's room, Resident 113 was observed lying down in bed with the resident's call light observed hanging down towards the floor off of the right side of the resident's bed near the upper bed rail. During a concurrent observation and interview on 6/2/2026 at 10:52 PM with Registered Nurse 2 (RN 2) inside Resident 113's room, Resident 113 was observed lying down in bed with the resident's call light hanging off and down towards the floor from the right side of the resident's bed near the upper bed rail. RN 2 stated Resident 113's call light was hanging off the right side of the resident's bed and out of Resident 113's reach. During an interview on 6/3/2026 at 3:05 PM with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated the purpose of a call light is for resident to use as their communication method to ask for assistance for anything whether it be for snacks, foods or drink, if they dropped something, to be changed, if they are in pain and need medicine or to notify the staff of any concerns the resident may have. LVN 3 also stated a resident's call light should not be out of the resident's reach and it is the staff's responsibility to ensure it is placed within the resident's reach prior to leaving the resident's room. LVN 3 further stated if ever a resident's call light is out of the resident's reach, it places the resident at risk for attempting to get out of bed and having an accident.During an interview on 6/5/2026 at 1:57 PM with the Director of Nursing (DON), the DON stated a call light is needed to make sure the resident's needs are provided and attended to. The DON also stated if ever a resident's call light is out of reach, the resident will not be able to communicate what they might need to the staff and puts them at risk for not receiving the appropriate care or needs that they might need at that time. 4. A review of Resident 137's admission Record, the admission Record indicated the resident was admitted on [DATE] with the following but not limited to diagnoses of gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), dehydration (a condition that occurs when your body loses more fluids and water than it takes in), dysphagia (difficulty swallowing), muscle weakness, dementia (progressive state of decline in mental abilities), anxiety (a natural emotion characterized by feelings of tension, worried thoughts, and physical changes like increased blood pressure) and depression (a common yet serious mood disorder that causes persistent sadness, hopelessness, and a loss of interest in activities). A review of Resident 137's MDS dated [DATE], the MDS indicated Resident 137 was severely impaired in cognitive skills for daily decision making. The MDS also indicated, the resident is dependent with oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. A review of Resident 137's Care Plan with focus Bed Rail, revised 5/20/2026, the Care Plan indicated to keep call light within resident's reach. A review of Resident 137's Care Plan with focus risk for fall, revised 5/20/2026, the Care Plan indicated resident's call light is within reach and encouraged resident to use it for assistance. During a concurrent observation and interview on 6/2/2026 at 10:49 AM, LVN Resident 137 was observed sliding off the bed and the call light was observed tangled with the bed cord under the bed rail. LVN 1 stated the call light should not be tangled with the bed cord under the bed rail because the call light should be within reach of the resident to ensure the resident is able to call for assistance when needed and to ensure safety of the resident. During an interview on 6/5/2026 at 10:52 AM, RN 1 stated the call light should always be within the resident's reach to ensure the resident can ask for assistance when needed. During an interview on 6/5/2026 at 4:10PM, the DON stated the resident should have the call light within reach at all times to ensure the resident is able to ask for assistance when needed. A review of the facility's undated Policy and Procedure (P&P) titled Call Lights, the P&P indicated to ensure the call light device is within the resident's reach and accessible for use whenever the resident is in the room, in bed, seated, or on the toilet.

Based on observation, interview, and record review, the facility failed to provide three (3) of 3 sampled residents (Residents 11, 43, and 139) meal trays that were appetizing and palatable (agreeable to one's sense of taste).This failure had the potential to result in dissatisfaction, decreased food intake and place Residents 11, 43, and 139 at risk for unplanned weight loss. During a review of Resident 11's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of osteomyelitis (infection of the bone and bone marrow) and protein-calorie malnutrition (a dangerous state of undernutrition caused by a lack of both dietary protein and total calories). During a review of Resident 11'S Minimum Data Set (MDS – a resident assessment tool), dated 5/20/2026, the MDS indicated the resident had intact cognitive (ability to think, remember, and reason) skills for daily decision making. The MDS indicated Resident 11 was 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) with walking 10 and 50 feet and chair/bed-to-chair transfers. The MDS indicated Resident 11 needed substantial/maximal assistance (helper does more than half the effort) with going from sitting to standing, putting on/taking off footwear and lower body dressing (the ability to dress and undress below the waist). The MDS also indicated Resident 11 needed partial/moderate assistance (helper does less than half the effort) with rolling left and right in bed, needed supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with upper body dressing (the ability to dress and undress above the waist) and was independent with eating. During a review of Resident 11's Order Summary Report, dated 6/1/2026, Resident 1's Order Summary Report indicated an order initiated on 5/24/2026 for regular diet International Dysphagia (difficulty swallowing) Diet Standardization Initiative (IDDSI; a global standard that provides a universal system for describing and classifying texture-modified foods and thickened liquids for individuals of all ages with dysphagia) regular (level 7) texture with thin liquids consistency. During a review of Resident 11's Care Plan revised 6/2/2026, Resident 11's Care Plan indicated Resident 11 was at risk for weight loss and malnutrition related to protein-calorie malnutrition and included an intervention to assess eating patterns at every meal.During an interview on 6/2/2026 at 10:25 AM with Resident 11, Resident 11 stated the food was not great, did not have flavor, served in small portions, and preferred outside food delivery service. During a concurrent observation and interview on 6/2/2026 at 12:37 PM with Resident 11 inside his room, Resident 11 was observed sitting up in bed taking a bite of brown meat from his lunch tray. Resident 11 stated he was not sure if it was meatloaf or mystery meat on his tray but it was too salty. Resident 11 further stated he would probably eat everything on the plate except for the meat. During an interview on 6/3/2026 at 2:58 PM with Resident 11, Resident 11 stated the dinner from 6/2/2026 was too salty so the resident ordered from a fast-food chain instead. Resident 11 also stated the eggs for breakfast (6/3/2026) were rubbery. During a review of Resident 43's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of fracture (broken bone) of thoracic 9 (T9; the ninth vertebrae [spine bone] of the mid-back)-thoracic 10 (T10; the 10th vertebrae of the mid-back) vertebra and protein calorie malnutrition.During a review of Resident 43'S MDS, dated [DATE], the MDS indicated the resident had intact cognitive skills for daily decision making. The MDS indicated Resident 43 needed substantial/maximal assistance with walking 10 feet and needed partial/moderate assistance with chair/bed-to-chair transfers, going from sitting to standing, putting on/taking off footwear and upper and lower body dressing. The MDS also indicated Resident 43 needed supervision or touching assistance with personal hygiene and was independent with eating. During a review of Resident 43's Order Summary Report, dated 6/1/2026, Resident 43's Order Summary Report indicated an order initiated on 5/11/2026 for consistent carbohydrate (CCHO) diet, IDDSI regular (level 7) texture with thin liquids consistency. During a review of Resident 43's Care Plan revised 6/1/2026, Resident 43's Care Plan indicated Resident 43 was at risk for weight loss and malnutrition and included interventions to assess eating patterns at every meal and to provide and encourage food intake (at breakfast, lunch, and dinner).During an interview on 6/2/2026 at 9:01 AM with Resident 43, Resident 43 stated the food was horrible and that it is salty. Resident 43 stated she eats about 20% of her meals from the facility and tends to order from outside food delivery service.During a concurrent observation and interview on 6/2/2026 at 12:52 PM with Resident 43, Resident 43 was observed sitting up in bed eating her lunch tray. Resident 43 stated the meat is very salty and the rice is tasteless. Resident 43 stated she was planning to order sushi to be delivered for lunch. During an interview on 6/3/2026 at 2:50 PM with Resident 43, Resident 43 stated she did not touch her lunch that day because it looked like dog food. Resident 43 stated it was supposed to be chicken and some rice but decided to order outside food instead.During the test tray on 6/4/2026 at 12:48 PM a regular diet, regular texture tray and a CHHO regular texture tray was sampled with white dill sauce fish, corn and fries. The corn on the regular and CHHO trays tasted bland, the fish on the CHHO tray tasted salty and the fries on both trays looked mushy.During the same test tray on 6/4/2026 at 12:48 PM with the Dietary Supervisor (DS), DS stated the corn on both regular and CHHO trays could use more seasoning and the fish on the CHHO tray was salty and was visibly more seasoned compared to the regular tray. DS further stated the inconsistency of the fish between the regular and CHHO trays was most likely due to the seasoning not being distributed evenly while being cooked.During an interview on 6/4/2026 at 1:20 PM with DS, DS stated the fish was salty on the CHHO test tray because some parts of the fish got more seasoning than others. DS also stated it is important that residents are served food that is appealing and palatable so that the residents' appetites are encouraged, the residents would want to eat what is served and to prevent any weight loss. 3. During a review of Resident 139's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with the following but not limited to diagnoses of protein-calorie malnutrition and muscle weakness. During a review of Resident 139's MDS, dated [DATE], the MDS indicated the resident was independent in cognitive skills for daily decision making. The MDS also indicated the resident required partial/moderate assistance with oral hygiene, upper body dressing and personal hygiene but required substantial/maximal assistance with lower body dressing and putting on/ taking off footwear. The MDS also indicated Resident 139 was 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) with toileting hygiene and shower/bathe self. During a review of Resident 139's Care Plan, revised 10/16/2025, the Care Plan indicated a focus on resident spitting food out after chewing related to disliking the food. The care plan interventions were to empower the resident by allowing choices in mealtime, menu selection, and dining location. During a review of Resident 139's Order Summary, dated 5/2/2026, the Order Summary indicated a regular diet. During a concurrent observation and interview on 6/2/2026 at 9:23AM, Resident 139 was observed laying in her bed. Resident 139 stated when the facility serves food, the main protein is too salty. During a concurrent observation and interview on 6/4/2026 at 12:43PM, received a test tray of regular diet with fish, bread, corn and French fries. The Dietary Supervisor 1 (DS 1) stated the fish for the regular diet and for the controlled carbohydrate diet is from the same tray. The DS 1 stated the fish was salty. During an interview on 6/5/2026 at 4pm, the Director of Nursing (DON) stated they do not have a specific policy on food palatability but added that the facility's policy on Resident Food Preferences include food palatability. During a review of the facility's Policy and Procedure (P&P) titled, Resident Food Preferences, revised 7/2017, the P&P indicated the staff will identify the residents food preferences and determine current food preferences.

Based on observation, interview and record review, the facility failed to perform a trauma informed assessment (a structured clinical approach that evaluates how an individual's past and present trauma impacts their overall functioning, relationships, and well-being) for one (1) of two (2) sampled residents (Resident 134) who has a diagnosis of Post Traumatic Stress Disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event). This deficient practice has the potential to affect Resident 134's psychological (relates to the mind, mental processes, and behavior) well-being and affects the resident's quality of life.Findings:During a review of Resident 134's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with the following but not limited to diagnoses of PTSD, anxiety (an emotion characterized by feelings of tension, worried thoughts, and physical changes like a rapid heartbeat), and depression (a common, serious mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities). During a review of Resident 134's History and Physical (H&P), dated 5/30/2026, the H&P indicated the resident has the capacity to understand and make decisions. During an interview on 6/2/2026 at 7:48 AM, Licensed Vocational Nurse 1 (LVN) 1 stated there was no trauma informed assessment that was done for Resident 134 since the resident was admitted at the facility on 5/28/206. LVN 1 also stated he does not know Resident 134's specific triggers for the resident's PTSD. During an interview on 6/4/2026 at 8:39 AM, Certified Nursing Assistant 5 (CNA 5) stated she guess on Resident 134's trigger symptoms of PTSD by experience and the general PTSD triggers but was not aware of the resident's specific triggers. During an observation and interview on 6/4/2026 at 9:24 AM, Resident 134 was observed on her phone and sitting on the resident's bed. Resident 134 stated the staff would scare her when they come into her room by yelling good morning. During an interview on 6/4/2026 at 10:04 AM, Social Services Director (SSD) stated there is no trauma informed assessment completed for Resident 134's PTSD and there should be one to ensure the safety of the resident. SSD also stated she does not know Resident 134's PTSD triggers and it is important to be aware of them to prevent any reoccurrences of the resident's PTSD. During an interview on 6/4/2026 at 11:30 AM, SSD stated the triggers should be known at the time of the resident's admission to ensure the safety and well-being of the resident. During an interview on 6/5/2026 at 3:57 PM, the Director of Nursing (DON) stated a trauma informed assessment was not performed or completed for Resident 134's trauma and that is not okay. The DON also added, the importance of completing trauma informed assessment as soon as the resident is admitted at the facility is for staff to know the triggers of Resident 134's PTSD to ensure the safety and well-being of the resident. During a review of the facility's Policy and Procedure (P&P) titled, Intervention and Monitoring Behavioral Assessment, revised 3/2019, the P&P indicated the facility will provide and residents will receive behavior health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being. The P&P also indicated behavior symptoms will be identified using facility approved behavioral screening tools (trauma informed assessment) and the comprehensive assessment.

Based on interview and record review, the facility failed to ensure an antibiotic surveillance (is the continuous tracking and analysis of how antibiotics (medicines used to treat bacterial infections by killing bacteria or inhibiting their growth] are used and how bacteria are becoming resistant to them) data collection form was completed for one (1) of two (2) sampled residents (Resident 134) who was receiving antibiotic therapy. This deficient practice had the potential for Resident 134 to be prescribed inappropriate antibiotic and increased the risk of developing antibiotic-resistant organisms (bacteria that are not controlled or killed by antibiotics).Findings:During a review of Resident 134's admission Record, the admission Record indicated the resident was admitted on [DATE] with the following but not limited to diagnoses of otitis media (middle ear infection or inflammation) of the right ear, bronchitis (an inflammation of the main airway/windpipe), and pneumonia (an infection/ inflammation in the lungs). During a review of Resident 134's Minimum Data Set (MDS - a resident assessment tool), dated 6/3/2026, the MDS indicated the resident was independent with cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated Resident 134 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with toileting hygiene, shower/bathe self, lower body dressing and putting on/taking off footwear but required supervision/touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with upper body dressing and required supervision or touching assistance (helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) with eating, oral hygiene, and personal hygiene. During a review of Resident 134's Order Summary, dated 5/31/2026, the Order Summary indicated Ciprodex Otic Suspension 0.3-0.1% (Ciprofloxacin-Dexamethasone - ear drop medicine that treats bacterial ear infections) Instill four (4) drops in right ear every 12 hours for ear infection for seven (7) days. During an interview on 6/5/2026 at 12:06 PM, the facility's Antibiotic Stewardship (the responsible and safe use of antibiotics to make sure they work when needed, now and in the future), dated 5/2026, was reviewed. Infection Preventionist Nurse (IPN) stated an antibiotic surveillance data collection form (McGeer Criteria) was not completed for Resident 134 receiving Ciprodex Otic antibiotic. IPN also stated Resident 134 should have a McGeer Criteria completed for the use of Ciprodex Otic to ensure the resident met the criteria for the antibiotic use and to ensure Resident 134 will be receiving the correct antibiotic. The IPN stated completing an antibiotic surveillance form can help prevent the resident from developing multi-drug-resistant organisms (MDRO - are bacteria resistant to more than or equal to 3 classes of antibiotics). During a review of the facility's Policy and Procedure (P&P) titled, Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes, revised 12/2016, the P&P indicated as part of the facility's antibiotic stewardship program, all clinical infections treated with antibiotics will undergo review by the infection preventionist, or designee. The P&P also indicated antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. During a review of the facility's P&P titled, Antibiotic Stewardship, revised 12/2016, the P&P indicated antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. The P&P also indicated the purpose of the facility's antibiotic stewardship program is to monitor the use of antibiotics in their residents.

Based on interview and record review, the facility failed to ensure one of two sample residents (Resident 73) reviewed for hearing care area received appropriate treatment to maintain the resident's hearing abilities by failing to ensure audiology (audiology is the branch of science and medicine concerned with the sense of hearing. Audiologists are health care professionals who diagnose, manage, and treat hearing, balance, or ear problems) appointment was arranged for the resident in accordance with physician's order.This deficient practice had the potential for Resident 73 to have increased hearing loss.Findings:During a review of Resident 73 admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with the following but not limited to diagnoses of major depressive disorder (a serious mood disorder characterized by persistent sadness, loss of interest in activities, and a range of physical and cognitive symptoms that severely disrupt daily life), asthma (a chronic [long-term] lung disease that inflames and narrows your airways, making it difficult to breathe) and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a review of Resident 73's Minimum Data Set (MDS - a resident assessment tool), dated 1/27/2026, the MDS indicated the resident was independent in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated the resident required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with eating oral hygiene, upper body dressing and personal hygiene but was 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) with toileting hygiene, shower/bathe self, lower body dressing and putting on/taking off footwear. During a review of Resident 73's Order Summary, dated 5/8/2026, the Order Summary indicated may have ENT evaluation, treatment and follow up as needed. During an interview on 6/2/2026 at 10:27 AM, Resident 73 stated she was hard of hearing and cannot hear the surveyor in a normal conversation. During an interview on 6/3/2026 at 3:39 PM, Social Services Assistant (SSA) stated Resident 73 did not have an ENT evaluation done from 5/8/2026 to 6/3/2026. During an interview on 6/4/2026 at 11:01 AM, Licensed Vocational Nurse (LVN) 1 stated Resident 73 is hard of hearing. During an interview on 6/4/2026 at 11:11 AM, Social Services Director (SSD) stated Resident 73 is hard of hearing but does not have a referral to see an ENT even though the doctor ordered it on 5/8/2026. SSD also stated Resident 73 should have a referral to see an ENT because of the resident's hard of hearing. SSD further stated because Resident 73 is hard of hearing and the ENT can help prevent further hearing loss and helps the resident communicate better with the staff. During an interview on 6/5/2026 at 10:44 AM, Registered Nurse 1 stated even though the order indicated may have ENT evaluation, Resident 73 should see an ENT because of the resident is hard of hearing. During an interview on 6/5/2026 at 4:05 PM, the Director of Nursing (DON) stated Resident 73 should get a referral to see an ENT because the resident is hard of hearing and to observe for increased hearing loss. During a review of the facility's Policy and Procedure (P&P) titled Care of Hearing Impaired Resident, revised 2/2018, the P&P indicated staff will assist hearing impaired residents to maintain effective communication with clinicians, caregivers, other residents and visitors. The P&P also indicated staff will assist the resident with locating available resources, scheduling appointments and arranging transportation to obtain needed services.

Based on observation, interview, and record review, the facility failed to ensure one (1) of five (5) sampled residents (Resident 84) observed during medication pass received Metformin Hydrochloride (drug used to lower and control blood sugar levels in people with type 2 diabetes mellitus [DM, a disorder characterized by difficulty in blood sugar control and poor wound healing)] ) with meals as indicated on the physician's order and facility's policy. This deficient practice placed Resident 84 at risk for gastrointestinal (GI, involves the mouth, esophagus, stomach, small and large intestines, rectum and anus) side effects which included nausea, diarrhea, and stomach cramping. Findings: During a review of Resident 84's admission Record, the admission Record indicated Resident 84 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included type 2 DM and gastro-esophageal reflux disease (GERD- when a valve between the stomach and food pipe does not close tightly, letting harsh stomach acid splash backward and burn the lining of the throat and chest). During a review of Resident 84's Physician's Order, dated 3/31/2025 timed at 6:58 PM, the Physician's Order indicated Metformin Hydrochloride (HCL) oral tablet 500 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) 1 tablet by mouth two (2) times a day for DM with meals. During a review of Resident 84's Minimum Data Set (MDS- a resident assessment tool), dated 5/14/2026, the MDS indicated Resident 84 had moderate impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 84 required substantial/maximal assistance (helper does more than half the effort) with shower and partial/moderate assistance (helper does less than half the effort) with oral, toileting and personal hygiene, upper and lower body dressing, and putting/taking off footwear. The MDS further indicated Resident 84 required setup assistance (helper set up; resident completes activity) with eating. During a review of Resident 84's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for the months of May and June 2026, the MAR indicated an administration time of 9 AM and 5 PM for Metformin HCL 500 mg 2 times a day with meals. During a medication pass observation on 6/4/2026 at 9:11 AM, Licensed Vocational Nurse 4 (LVN 4) administered Metformin HCL 500 mg to Resident 84 without food. During an interview on 6/5/2026 at 11:09 AM, Resident 84 stated he had finished eating breakfast at 8 AM on 6/4/2026. Resident 84 also stated he gets all his morning medications including his Metformin HCL around 9 AM every day without food. During an interview with Registered Nurse 2 (RN 2) on 6/5/2026 at 11:14 AM, RN 2 stated the licensed staff should have followed up with the physician to clarify timing of Metformin HCL administration to coincide with Resident 84's breakfast. RN 2 further stated breakfast trays arrive at the North station usually between 7:20 AM to 7:30 AM. RN 2 stated Metformin HCL should be given with food because it could cause stomach irritation. During an interview on 6/5/2026 at 11:27 AM, LVN 4 stated Resident 84's Metformin HCL should be given with meals to prevent resident from getting stomach discomfort. LVN 4 also stated the licensed staff should have contacted the physician to possibly move the morning administration time to around 8 AM to coincide with the breakfast. During a review of the facility's Policy and Procedure (P&P) titled, Administering Medications, revised 4/2019, the P&P indicated that medications are administered in a safe and timely manner, and as prescribed.

Based on observation, interview, and record review, the facility failed to observe infection control measures for two (2) of 25 sampled residents (Residents 4 and 137) as indicated in the facility policy by failing to ensure:Treatment Nurse 2 (TN 2) changed gloves and performed hand hygiene (washing hands with soap and water for at least 20 seconds, or using alcohol-based sanitizer, to effectively eliminate germs and prevent disease spread) after touching the privacy curtain (a ceiling-suspended fabric partition used to temporarily section off patient beds, exam areas, or treatment spaces to protect patient dignity, ensure confidentiality, and create semi-private spaces) and before continuing wound treatment for Resident 4.Certified Nursing Assistant 4 (CNA 4) doff (remove an item or clothing) and dispose of PPE and perform hand hygiene after providing peri-care (cleaning the genitals and anal area) to Resident 38.These failures had the potential to result in an increased risk for the spread of bacteria, viruses and pathogens (harmful microorganisms) to residents, visitors and staff throughout the facility, while increasing the risk of [preventable] infections.Findings:1. During a review of Resident 4's admission Record, the admission Record indicated the resident was admitted on [DATE] with the following but not limited to diagnoses of urinary tract infection (UTI- an infection in the bladder/urinary tract), and chronic lymphocytic leukemia (a slow-growing blood and bone marrow cancer that causes the body to produce too many abnormal white blood cells making resident vulnerable to infections). During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool), dated 4/11/2026, the MDS indicated the resident was moderately impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated the resident required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear btu required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs and provides more than half the effort) with eating, oral hygiene, upper body dressing and personal hygiene. During a wound care observation on 6/4/2026 at 9:36 AM, TN 2 was observed pulling the privacy curtain with gloves on, with the same gloves, TN 2 continued to clean Resident 4's wound. During an interview on 6/4/2026 at 9:50 AM, TN 2 stated it is not okay that she touched the privacy curtain with gloves on and with the same gloves continued the wound treatment for Resident 4 because that is infection control and can transmit infection to the resident's wound. During an interview on 6/5/2026 at 12:06 PM, Infection Preventionist Nurse (IPN) stated TN 2 should have changed gloves and performed hand hygiene after touching the privacy curtain as the privacy curtain can transfer organisms to the open wound. During an interview on 6/5/2026 at 4 PM, the Director of Nursing (DON) stated TN 2 should not have touched the privacy curtain and with the same gloves continued with Resident 4's wound treatment because that is infection control. The DON stated, TN 2 should have removed the gloves, performed hand hygiene and put on a new glove before continuing with Resident 4's wound treatment. 2. A review of Resident 137's admission Record, the admission Record indicated the resident was admitted on [DATE] with the following but not limited to diagnoses of gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), dehydration, dysphagia (difficulty swallowing), muscle weakness, dementia (progressive state of decline in mental abilities), anxiety (a natural emotion characterized by feelings of tension, worried thoughts, and physical changes like increased blood pressure) and depression (a common yet serious mood disorder that causes persistent sadness, hopelessness, and a loss of interest in activities). A review of Resident 137's Minimum Data Set (MDS - a resident assessment tool), dated 3/25/26, the MDS indicated Resident 137 was severely impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated the resident is 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) with oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. During an observation on 6/4/2026 at 2:15 PM, CNA 4 was observed providing bowel incontinence (the involuntary loss of bowel control, resulting in the unintentional leakage of stool) care for Resident 137. CNA 4 was observed using the same gloves after providing incontinence care and touched Resident 137 set of clean bed sheets/chux pads (highly absorbent, waterproof underpads used to protect mattresses) and blanket. During an interview on 6/4/2026 at 2:30 PM, CNA 4 stated she should have changed gloves and performed hand hygiene before touching Resident 137's bed sheet/ chux pads and blanket because she can spread the feces to the resident and that is infection control. During an interview on 6/5/2026 at 12:07 PM, Infection Preventionist Nurse (IPN) stated CNA 4 should have changed gloves and performed hand hygiene after providing bowel incontinence care to Resident 137 and before touching clean things, so CNA 4 does not contaminate everything. During an interview on 6/5/2026 at 4:10 PM, the DON stated the CNA should have changed gloves and performed hand hygiene after incontinence care was provided to Resident 137 and before touching the clean areas for infection control reasons. During a review of the facility's Policy and Procedure (P&P) titled Personal Protective Equipment - Using Gloves, dated 2001, the P&P indicated when gloves are indicated, use disposable single-use gloves. The P&P also indicated to use gloves when touching excretions, secretions, blood, body fluids, mucous membranes or non-intact skin. The P&P further indicated objectives to prevent the spread of infection and to protect wounds from contamination and to discard used gloves into the waste receptacle. During a review of the facility's P&P titled Handwashing/Hand Hygiene, revised 8/2019, the P&P indicated use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations such as:After handling used dressing, contaminated equipment.After contact with objects in the immediate vicinity of the resident.After contact with blood or body fluids.Before moving from a contaminated body site to a clean body site during resident care.

Based on observation, interview, and record review, the facility failed to ensure the feet of one (1) of four (4) sampled residents (Residents 20) reviewed for accident were placed on the wheelchair's footrest during wheelchair transport.This deficient practice placed Resident 20 at risk of injury and serious harm.Findings: During a review of Resident 20's admission Record, the admission Record indicated Resident 20 was admitted to the facility on [DATE] with diagnoses that included lack of coordination, enthesopathy (any damage, disease or irritation at the exact spot where the tendons or ligaments attach to the bones) and bone density and structure disorder (thin and brittle bones [a physical state where bones become fragile, weak, and structurally compromised causing them to fracture or break much more easily than normal]. During a review of Resident 20's Minimum Data Set (MDS- a resident assessment tool), dated 5/7/2026, the MDS indicated Resident 20 had severe impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 20 normally used wheelchair in the last seven (7) days and required partial/moderate assistance (helper does less than half the effort) with oral, toileting and personal hygiene, shower, upper and lower body dressing, and putting/taking off footwear. The MDS further indicated Resident 20 required setup assistance (helper set up; resident completes activity) with eating. During an observation on 6/2/2026 at 10:46 AM, Resident 20 was coming out of the activity room into the hallway in a wheelchair, with Activity Assistant 1 (AA 1) pushing the wheelchair. The wheelchair's footrests were in the open position, and the resident was foot propelling as the wheelchair moved. During an observation on 6/2/2026 at 10:50 AM, AA 1 wheeled Resident 20 back into the activity room from the hallway, with the resident's feet on the floor, foot propelling as the wheelchair moved. The wheelchair's footrests were in the open position. During an interview on 6/4/2026 at 11:47 AM, AA 1 stated Resident 20's feet should be on the wheelchair's footrests to prevent the resident's feet from accidentally being bent while being wheeled in the wheelchair. During an interview on 6/4/2026 at 2:43 PM, Occupational Therapist 1 (OT 1) stated that if Resident 20 was able to lift her feet while being wheeled, it would be acceptable; however, she could potentially be injured if she failed to raise her feet while being wheeled without the footrests in use. During an interview on 6/4/2026 at 4 PM, the MDS Coordinator stated Resident 20 was dependent on a wheelchair for mobility. The MDS Coordinator also stated that Resident 20's feet should be on the footrests to prevent her feet from potentially dragging and causing injury. During a review of the facility's Policy and Procedure (P&P) titled, Safety and Supervision of Residents, revised 7/2017, the P&P indicated the facility strives to make the environment as free from accident hazards as possible. The P&P also stated that the resident's safety, supervision and assistance to prevent accidents are facility-wide priorities.

Based on observation, interview, and record review, the facility failed to set the low air loss mattress (LAL mattress, a specialized medical bed mattress designed to prevent and treat pressure ulcers [localized damage to the skin and/or underlying tissue usually over a bony prominence] by constantly blowing a tiny amount of air through the tiny holes) in accordance with the weight for one (1) of three (3) sampled residents (Residents 117) reviewed for pressure ulcer. This deficient practice placed Resident 117 at risk for development of new pressure ulcers.Findings: During a review of Resident 117's admission Record, the admission Record indicated Resident 117 was admitted to the facility on [DATE] with diagnoses that included adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity) and protein calorie malnutrition (a condition that occurs when a person's body doesn't get the right amount of nutrients it needs to function properly). During a review of Resident 117's Physician's Order, dated 12/16/2024, timed at 6 PM, the Physician's Order indicated treatment using LAL mattress for pressure redistribution and skin integrity management. The physician's order also indicated a setting of four (4) every shift. During a review of Resident 117's Braden Scale (a tool that predicts the risk for developing a facility acquired pressure ulcer), dated 2/1/2026, timed at 10:21 AM, the Braden Scale indicated the resident was at a high risk for developing pressure ulcer. During a review of Resident 117's Minimum Data Set (MDS- a resident assessment tool), dated 4/29/2026, the MDS indicated Resident 117 had moderate impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 117 was dependent (helper does all the effort) with shower, lower body dressing, and putting/taking off footwear and required substantial/maximal assistance (helper does more than half the effort) with toileting and personal hygiene, and upper body dressing. The MDS further indicated Resident 117 required partial/moderate assistance (helper does less than half the effort) with oral hygiene and required setup assistance (helper set up; resident completes activity) with eating. The MDS indicated Resident 17 had a pressure-reducing device for the resident's bed. During a concurrent observation in Resident 117's room and interview on 6/2/2026 at 10:11 AM, Resident 117 was lying on her back in bed with the LAL mattress set at 200 pounds. Resident 117 stated she previously had a wound on her back. During another observation in Resident 117's room on 6/3/2026 at 11:10 AM, Resident 117 was lying on her back in bed with the LAL set at 200 pounds. During a concurrent interview and record review with Treatment Nurse 1 (TN 1) on 6/3/2026 at 3:03 PM, Resident 117's Monthly Weight Report for was reviewed. TN 1 stated Resident 117 weighed 135 pounds on 5/5/2026. TN 1 also stated Resident 117 was on LAL mattress for skin management because of the risk of skin breakdown since the resident stays in bed most of the time. During a concurrent observation and interview inside Resident 117's room on 6/3/2026 at 3:10 PM, TN 1 stated the resident's LAL mattress was set at 200 pounds. TN 1 also stated Resident 117's LAL mattress should not be set at 200 pounds but rather should be set based on the resident's weight, because an incorrect setting would make the mattress firmer and could increase pressure on the resident's bottom, potentially causing a pressure ulcer. TN 1 further stated the physician's order should have been clarified by the licensed staff because LAL mattress settings are based on the resident's weight in pounds, not on preset levels. During an interview on 6/4/2026 at 3:16 PM, Licensed Vocational Nurse 3 (LVN 3) stated the LAL mattress should be based on the residents' weight to help relieve pressure on the residents' bony prominences to prevent pressure ulcers, especially for those that are high risks for impaired skin integrity. During a concurrent interview and record review with TN 1 on 6/5/2026 at 11:49 AM, the policy and procedure on was reviewed. TN 1 stated the support surfaces guidelines policy which included guides in selecting appropriate pressure relieving devices included the LAL use for residents at risk for developing pressure ulcers. During an interview on 6/5/2026 at 1:58 PM, the Director of Nursing (DON) stated LAL mattress should be based on the residents' weight to prevent skin issues. The DON also stated Resident 117's order on the LAL mattress should have been clarified with the physician to ensure the LAL was set correctly based on the weight of the resident. During a review of the facility's Policy and Procedure (P&P) titled, Support Surface Guidelines, revised 9/2013, the P&P indicated its purpose was to provide guidelines for the assessment and appropriate pressure reducing and relieving devices for residents at risk for skin breakdown. The P&P also indicated any individual at risk for developing pressure ulcers should be placed on a redistribution support surface, such as foam, gel, static air, alternating air, or air loss or gel when lying in bed.

Based on observation, interview, and record review, the facility failed to ensure a language communication board was placed at bedside for one (1) of (1) sampled resident (Resident 5) reviewed for language/communication area in accordance with the facility's policy. This deficient practice had the potential to result in Resident 5 experiencing a delay in receiving appropriate care and services due to the staff not being able to properly communicate with the resident.Findings: During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was admitted to the facility on [DATE] with a primary language of Japanese. The admission Record also indicated Resident 5 was admitted with diagnoses that included general muscle weakness, lack of coordination, and anxiety disorder (a mental health disorder characterized by feeling of worry, or fear that are strong enough to interfere with one's daily activities). During a review of Resident 5's Minimum Data Set (MDS- a resident assessment tool), dated 4/20/2026, the MDS indicated Resident 5's preferred language was a non-English language (Language 1). The MDS also indicated Resident 5 had intact cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS further indicated Resident 5 required supervision (helper provides cues) with shower, lower body dressing, and putting/taking off footwear and required setup assistance (helper set up; resident completes activity) with eating, oral, toileting and personal hygiene, and upper body dressing. During an observation in Resident 5's room on 6/2/2026 at 3:47 PM, a communication board was not observed anywhere in the resident's room. Certified Nursing Assistant 3 (CNA 3) who was in the resident's room asked the resident if she needed something in English and the resident responded, No English. CNA 3 checked Resident 1's bedside table drawer and did not find a language communication board. During an interview on 6/3/2026 at 4:25 PM, the Activity Director (AD) stated a communication board in the residents' primary language should be in the residents' room for residents that do not speak fluent English to help the residents communicate their needs with the staff including how they are feeling and if they are in pain. During a concurrent observation and interview on 6/3/2026 at 4:47 PM, CNA 3 stated a communication board in Language 1 should be in Resident 5's room for the staff to be able to communicate with the resident and in turn, for the resident to be able to communicate her needs with the staff. During a concurrent interview and record review on 6/4/2026 at 3:33 PM, the MDS Coordinator stated Resident 5 did not have a language and communication Care Plan indicating Resident 5 primary language was Language 1. MDS Coordinator also stated a care plan should have been developed and implemented to ensure Resident 5 was provided with communication tools for translation to be able to effectively communicate his needs or concerns and given proper care. During an interview on 6/4/2026 at 3:53 PM, the Director of Nursing (DON) stated a communication board should have been kept in Resident 5's room to help the resident communicate his needs and for the staff to be able to attend and provide the resident's needs. DON also stated Resident 5 should have a Care Plan on language/communication so that the staff could effectively communicate and attend to the residents' needs. During a review of the facility's Policy and Procedure (P&P) titled, Translation and/or Interpretation of Facility Services, revised 5/2017, the P&P indicated that the facility's language access program will ensure that the individual with limited English proficiency (LEP, a person cannot speak, read, write, or understand English fluently enough to easily navigate daily life) shall have meaningful access to information and services provided by the facility. The P&P also indicated that to provide meaningful access to services provided by the facility, translation and/or interpretation must be provided in a way that is culturally relevant and appropriate to the LEP individual.

Based on observation, interview and record review, the facility failed to develop an individualized resident-centered care plan (a care plan that prioritizes the unique health needs and desired outcomes of the resident) with measurable objectives, timeframe, and interventions for two (2) of 25 sampled residents (Residents 73 and 2):Resident 73 did not have a care plan to address the resident's hard of hearing.Resident 2 did not have a care plan to address the resident's diagnosis of dementia (progressive state of decline in mental abilities).This deficient practice has the potential to delay in the necessary care and services for Resident 73 and 2.Findings:1. During a review of Resident 73 admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with the following but not limited to diagnoses of major depressive disorder (a serious mood disorder characterized by persistent sadness, loss of interest in activities, and a range of physical and cognitive symptoms that severely disrupt daily life), asthma (a chronic [long-term] lung disease that inflames and narrows your airways, making it difficult to breathe) and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a review of Resident 73's Minimum Data Set (MDS - a resident assessment tool), dated 1/27/2026, the MDS indicated the resident was independent in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated the resident required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with eating oral hygiene, upper body dressing and personal hygiene but was 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) with toileting hygiene, shower/bathe self, lower body dressing and putting on/taking off footwear. During a review of Resident 73's Order Summary, dated 5/8/2026, the Order Summary indicated may have ENT (Ears, Nose and Throat) evaluation, treatment and follow up as needed. During a concurrent observation and interview on 6/2/2026 at 10:27 AM, Resident 73 stated he is hard of hearing and cannot hear the surveyor in a normal conversation. During a concurrent interview on 6/4/2026 at 11:01 AM, Resident 73's Care Plans, dated 1/21/2026 to 6/2/2026, were reviewed. Licensed Vocational Nurse 1 (LVN 1) stated Resident 73 is hard of hearing and the resident does not have a care plan to address the resident's concerns with hearing and Resident 73 should have a care plan to address the resident's hard of hearing. During an interview on 6/5/2026 at 10:44 AM, Registered Nurse 1(RN 1) stated Resident 73 does not have a care plan for hearing issue and should have a care plan for resident's hearing deficit. 2. During a review of Resident 2's admission Record, the admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with the following but not limited to diagnoses of dementia, depression (a serious mood disorder), schizophrenia (a mental illness that is characterized by disturbances in thought) and anxiety (an emotion characterized by feelings of tension, worried thoughts, and physical changes like a racing heart or sweating). During a review of Resident 2's MDS, dated [DATE], the MDS indicated the resident is moderately impaired in cognitive skills for daily decision making. The MDS also indicated the resident required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with upper body dressing but required substantial/maximal assistance (helper does more than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with toileting hygiene, shower/bathe self, lower body dressing and putting on/taking off footwear. The MDS further indicated that the resident has a dementia diagnosis. During an interview on 6/5/2026 at 10:08AM, Resident 2's Care Plans, dated 1/9/2024 to 6/2/2026, were reviewed. Registered Nurse 1 (RN 1) stated Resident 2 had no care plans for dementia and there should be a care plan to address Resident 2's diagnosis of dementia. RN 1 also stated each resident with dementia are different and required different types of redirections and communication which should have been in the care plan interventions. RN 1 further stated because each dementia resident is different, the resident would need a comprehensive person-centered care plan. During a review of the facility's Policy and Procedure (P&P) titled Comprehensive Person-Centered Care Plans, revised 3/2022, the P&P indicated a comprehensive, person-centered care plan that includes measurables objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Based on observation, interview and record review, the facility failed to ensure an accurate assessment and documentation of the resident's hearing ability were reflected in the resident's Minimum Data Set (MDS - a resident assessment tool) for one (1) of 1 sampled resident (Resident 73) reviewed for vision and hearing. This deficient practice had the potential for the facility to not develop and implement a resident centered care plan for Resident 73 to receive care and services to maximize and/or improve Resident 73's functional ability in hearing.Findings:A review of Resident 73's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with the following but not limited to diagnoses of major depressive disorder (a serious mood disorder characterized by persistent sadness, loss of interest in activities, and a range of physical and cognitive symptoms that severely disrupt daily life), asthma (a chronic [long-term] lung disease that inflames and narrows your airways, making it difficult to breathe) and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). A review of Resident 73's Minimum Data Set (MDS - a resident assessment tool), dated 1/27/2026, the MDS indicated the resident was independent in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated the resident required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with eating oral hygiene, upper body dressing and personal hygiene but was 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) with toileting hygiene, shower/bathe self, lower body dressing and putting on/taking off footwear. The MDS indicated Resident 73's hearing is adequate (no difficulty in normal conversation). During a concurrent observation and interview on 6/2/2026 at 10:27 AM, Resident 73 stated she is hard of hearing and has difficulty hearing the surveyor. During an interview on 6/4/2026 at 11:01 AM, Licensed Vocational Nurse (LVN 1) stated Resident 73 is hard of hearing. During an interview on 6/4/2026 at 11:11 AM, Social Services Director (SSD) stated Resident 73's MDS dated [DATE] is inaccurate and it should indicated the resident has difficulty hearing. During an interview on 6/4/2026 at 12:22 PM, MDS Director stated Resident 73 have hearing difficulty and the resident's MDS dated [DATE] is not correct as it indicated resident's hearing is adequate. During an interview on 6/5/2026 at 10:44 AM, Registered Nurse 1 (RN 1) Supervisor stated Resident 73 have hearing difficulty. During an interview on 6/5/2026 at 4:05 PM, the Director of Nursing (DON) stated Resident 73 have hearing difficulties. A review of the facility's Policy and Procedure (P&P) titled Resident Assessments, revised 3/2022, the P&P indicated all persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information. The P&P also indicated the user Resident Assessment Instrument (RAI) (a standardized framework used in long-term care facilities, such as nursing homes, to evaluate each resident's clinical, physical, and functional status) annual provides a detailed information on timing and submission of assessments. A review of the facility's Centers for Medicare and Medicaid Services (CMS- a federal agency within the United States Department of Health and Human Services (HHS) that administers the Medicare program and works in partnership with state governments to administer Medicaid, the Children's Health Insurance Program (CHIP), and health insurance portability standards) Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual Version 1.20.1, dated October 2025, indicated on chapter 2, the Resident Assessment Instrument (RAI) process is the basis for the accurate assessment of each resident.

Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS- a resident assessment tool) admission Comprehensive Assessment (a clinical evaluation required for all new admission in skilled nursing homes) was completed within the required timeframe of 14 days after admission for two (2) of 25 sampled residents (Resident 141 and 137). This deficient practice had the potential to negatively affect the provision of necessary care and services for Resident 141 and 37. Findings: 1. During a review of Resident 141's admission Record, the admission Record indicated Resident 141 was admitted to the facility on [DATE] with diagnoses that indicated hepatic failure (a life threatening condition where the liver loses its ability to function adequately), dependence on renal dialysis (life sustaining treatment that performs the work of failing kidneys by filtering waste, toxins, and excess fluids from the blood), and heart failure (a condition where the heart muscle becomes too weak or stiff to pump enough oxygen-rich blood to meet the body's needs). During a concurrent interview and record review on 6/4/2026, at 10:08 AM, with the Minimal Data Set Coordinator (MDS), Resident 141's MDS admission Comprehensive Assessment was reviewed. MDS stated Resident 141 was admitted on [DATE]. MDS stated Resident 141's MDS admission Comprehensive Assessment, under Section O (Special Treatments, Procedures, Programs) for dialysis and Section J (Health Conditions) for pain indicated the assessment was still in progress and not complete. MDS stated different departments in the facility were responsible for completing their designated sections in the MDS admission Comprehensive Assessment. MDS stated that all sections of Resident 141's MDS admission Comprehensive Assessment should have been completed 14 days after admission which was on 5/28/2026. MDS stated the timeline for completion of comprehensive assessments on the Resident Assessment Instrument manual (RAI-a comprehensive guidebook created by the Centers for Medicare & Medicaid Services [CMS] that provides long-term care facilities and nursing homes with the standardized instructions and coding guidelines needed to evaluate resident clinical status and develop individualized care plans) was not followed. MDS stated the MDS admission Comprehensive Assessment was not completed on time because MDS was busy and did not have enough time to make sure the assessments were completed on time. During an interview on 6/5/2026, at 12:43 PM with the Director of Nursing (DON), the DON stated Resident 141's MDS admission Comprehensive Assessment should have been completed by 5/28/2026 so Resident 141 could receive appropriate care and treatment based on the resident's diagnoses and the assessment findings. 2. A review of Resident 137's admission Record, the admission Record indicated the resident was admitted on [DATE] with the following but not limited to diagnoses of gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), dehydration, dysphagia (difficulty swallowing), muscle weakness, dementia (progressive state of decline in mental abilities), anxiety (a natural emotion characterized by feelings of tension, worried thoughts, and physical changes like increased blood pressure) and depression (a common yet serious mood disorder that causes persistent sadness, hopelessness, and a loss of interest in activities). During a review of Resident 137's admission MDS on PointClickCare (PCC - Resident electronic medical record) on 6/4/2026 at 3:30PM, the PCC indicated 5/19/2026 as the resident's most recent admission date (entry date to the facility). The MDS indicated the assessment reference date (ARD - observation end date) of 6/1/2026 (3 days overdue). During a concurrent interview on 6/4/2026 at 3:24PM, Resident 137's admission MDS, dated [DATE] was reviewed. The MDS Coordinator stated Resident 137's admission MDS was not completed within 14 days from the resident's admission date, 6/1/2026. The MDS coordinator also stated Section K (Swallowing/Nutritional Status – includes swallowing disorder, height and weight, weight loss, weight gain, nutritional approaches and percent intake by artificial route) of the MDS was not completed and because that section was not completed, the facility is unable to submit the MDS in a timely manner. A review of the facility's Policy and Procedure (P&P) titled Resident Assessment, revised 3/2022, the P&P indicated the resident assessment coordinator is responsible for ensure that the interdisciplinary team conducts timely and appropriate resident assessments and reviews according to the OBRA (Omnibus Budget Reconciliation Act of 1987-the baseline of care, patient's rights, and safety regulations that all Medicare and Medicaid-certified nursing homes must legally follow) required assessments. A review of the facility's Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual Version 1.20.1, dated October 2025, indicated for the admission assessment, the MDS completion date must be no later than 14 calendar days of the residents admission.

Based on interview and record review, the facility failed to follow its policy to ensure the resident was free from unnecessary medication (medication prescribed or consumed without a valid clinical indication for an excessive duration, at too high a dose, or when their potential risks outweigh the benefits) use for one (1) of five (5) sampled residents (Resident 57) reviewed for unnecessary medications, by failing to have a specific indication for Resident 57's use of lorazepam (Ativan- a medication used to treat anxiety disorder [a group of mental health conditions characterized by persistent, excessive, and uncontrollable fear, worry, or dread that interferes with daily life]). This deficient practice had the potential to increase the risk for Resident 57 to experience adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to psychotropic medication (drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior), possibly leading to impairment or decline in the resident's mental, functional, or psychosocial status. Findings:During a review of Resident 57's admission Record, the admission Record indicated Resident 57 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia (progressive decline in mental ability severe enough to interfere with daily life), depression (a common , serious mental health condition characterized by a persistent low mood, loss of interest in activities, and a sense of numbness or emptiness), and anxiety disorder. During a review of Resident 57's Minimum Data Set (MDS- a resident assessment tool), dated 5/27/2026, the MDS indicated Resident 57 was assessed having moderately impaired (decisions poor; cues/supervision required) cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 57 required setup or clean-up assistance with eating and oral hygiene. The MDS indicated Resident 57 required substantial/maximal assistance (helper does more than half the effort) with upper body dressing and rolling left and right. The MDS further indicated Resident 57 was dependent (helper does all of the effort) with toileting hygiene, shower/bathe self, lower body dressing, sit to stand, and toilet transfer. During a review of Resident 57's Order Summary Report, dated 6/5/2026, the Order Summary Report indicated a physician order for the following:Lorazepam Intensol Oral Concentrate 2 milligrams (mg-unit of measurement for weight)/milliliter (ml- unit if measurement for liquid) give 1 mg by mouth every four hours as needed for anxiety/agitation, ordered on 5/21/2026.Add up all behaviors exhibited from previous month for antianxiety medication Ativan/lorazepam use. Every night shift starting on the 5th and ending on the 5th of every month for antianxiety medication use. Specify number of behaviors being monitored in the supplementary documentation below. During an interview on 6/5/2026, at 11:55 AM, with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 57 was calm and quiet most of the time but occasionally yelled and said he (Resident 57) was scared. CNA 1 stated Resident 57 did not say what he was scared of. During an interview on 6/5/2023, at 11:59 AM, with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated Resident 57 never seemed anxious but sometimes yelled and said help. LVN 2 stated Resident 57 did not answer when facility staff asked him what the resident needed. LVN 2 stated she has not seen Resident 57 get agitated when she took care of Resident 57. LVN 2 stated Resident 57 was prescribed Ativan only after the resident was placed under hospice care (specialized medical care for terminally ill residents with a prognosis of six months or less). During a concurrent interview and record review on 6/5/2026, at 12:09 PM with Treatment Nurse 1 (TN 1), Resident 57's Ativan order was reviewed. TN 1 stated Resident 57 was never anxious and was always cooperative during wound care. TN 1 stated Resident 57 was ordered Ativan after the resident was admitted to hospice. TN 1 stated Resident 57's Ativan was indicated for anxiety and agitation, and it was too broad and needed to include the specific behavior Resident 57 showed when he was anxious and agitated. TN 1 stated if Resident 57's specific behavior for anxiety and agitation was not indicated, then Resident 57's behavior cannot be accurately monitored by the staff which can lead to Ativan being administered unnecessarily. During an interview on 6/5/2026, at 12:16 PM, with the Director of Nursing (DON), the DON stated Resident 57's only documented anxious behavior was on 10/3/2025 when Resident 57 was not able to calm down before the surgeon removed the resident's sutures (medical stitch or the specialized thread used by doctors and surgeons to hold body tissues together after an injury or surgery) on the left side of the resident's face. The DON stated Resident 57 has not displayed any anxious and agitated behavior since 10/3/2025. The DON stated Resident 57 was ordered Ativan again on 5/21/2026 after the resident was admitted to hospice. The DON stated Ativan should only be administered if Resident 57 had the specific behavior that Ativan was specifically ordered for. The DON stated Resident 57's Ativan order did not include the specific behavior Resident 57 displayed when the resident was agitated or anxious such as pacing. The DON stated Resident 57's Ativan order should indicate the target behavior to make sure the need and effectiveness of the medication was monitored, however, Reisdent 57 is not showing any sign and symptoms of agitation and anxious. During a review of the facility's policy and procedure (P&P), titled, Psychotropic Medication Use, dated 7/2022, the P&P indicated:Residents will not receive medications that are not clinically indicated to treat a specific condition.Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: anti-anxiety medications.Residents who have not used psychotropic medications are not prescribed or given these medications unless the medication is determined to be necessary to treat a specific condition that is diagnosed and documented in the medical record. Consideration of the use of any psychotropic medications is based on comprehensive review of the Resident. This includes evaluation of the resident's signs and symptoms in order to identify underlying causes.

Based on observation, interview, and record review, the facility failed to ensure one (1) of four (4) dumpsters (a movable waste container) and 1 trash can were covered and closed per facility policy and procedure (P&P). This failure had the potential to attract vermin (animals that are believed to be harmful, carry diseases such as rodents, parasitic worms, or insects), pests (any living thing that has a negative effect on humans), and wildlife (undomesticated animal species), increasing the risk of disease transmission and health issues for residents, staff, and the surrounding community.During an observation on 6/2/2026 at 7:35 AM outside to the left of the building next to the facility driveway, one gray trash can was observed overflowing with brown paper, plastic bags and a surgical mask with no cover or lid. One dumpster was also observed with the lid propped open with a cardboard box. During an interview on 6/3/2026 at 2:45 PM with Dietary Supervisor (DS), DS stated it is important that dumpster lids are not propped open because it is unsanitary. DS added that keeping the lids closed prevents pests from going inside of them. During an interview on 6/5/2026 at 12:28 PM with Maintenance Supervisor (MS), MS stated the gray trash can outside is the maintenance trash can. MS stated it does have a lid that they can use to cover it. MS added the trash can should be covered to prevent pests from getting into it. During a review of the facility's P&P titled, Miscellaneous Areas, dated 2023, the P&P indicated under garbage and trash and trash procedure that, Garbage and trashcans must be inspected daily that no debris is on the ground of surrounding area, and that all the lids are closed.

DPS:Based on observation, interview and record review, the facility failed to administer an intravenous (IV -within a vein) medication at the prescribed infusion rate for one of two sampled residents (Resident 3). This failure resulted in Resident 3's Vancomycin (Vanco- a medication used to treat infections caused by bacteria) being administered slower than prescribed, with the potential to lead to ineffective treatment or bacterial resistance for Resident 3.Findings:During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included, but not limited to, urinary tract infection (UTI- an infection in the bladder/urinary tract), gout (a painful form of arthritis [joint pain or swelling, stiffness, and tenderness] caused by too much uric acid [a waste product left over from normal chemical processes in the body] in the blood) and fracture (a crack or break in a bone) of the right femur (thigh bone) neck. During a review of Resident 3's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 11/25/2025, the MDS indicated Resident 3 had intake cognitive (ability to understand and make decisions) skills for daily decision making. The Minimum Data Set (MDS - a federally mandated resident assessment tool) also indicated Resident 3 needed substantial/maximal assistance (helper does more than half the effort) with toileting and personal hygiene, bathing, and dressing and partial/moderate assistance (helper does less than half the effort) with oral hygiene. During a review of Resident 3's Order Summary Report, dated 12/1/2025, the Order Summary Report indicated an order for Vancomycin Hydrochloric acid (HCl- is a solution of hydrogen chloride in water) intravenous solution 750 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) intravenously every 24 hours for antibiotic for methicillin-resistant staphylococcus aureus (MRSA - a bacteria that does not respond to antibiotics) related to UTI for seven (7) days. During a concurrent observation and interview on 12/8/2025 at 9:45 with Registered Nurse 1 (RN 1) at Resident 3's bedside, Resident 3's IV Vancomycin was observed with a label dated 12/4/2025 that indicated for a registered nurse to infuse Vancomycin 750 mg in 250 milliliter (ml - a metric unit for measuring volume) normal saline (NS-a saltwater solution) and infuse over 90 minutes every 24 hours for MRSA. Resident 3's Vancomycin was also observed being administered to Resident 3's IV by gravity (the method of administering IV fluids or medications where the natural force of gravity, not a pump, pushes the liquid from a raised bag down through tubing and into a resident's vein). RN 1 stated she was responsible for administering Resident 3's Vancomycin and started the administration at 9:00 AM and it should be finished at 10:30 AM. RN 1 was not able to confirm the infusion rate of Resident 3's Vancomycin infusion and stated it because she did not have the dial-a-flow infusion tubing (a medical device used to manually control the rate of IV fluids or medications delivered to a resident) at the time Resident 3's Vancomycin was started. RN 1 also stated since she cannot confirm the Vancomycin rate, she cannot ensure the infusion will be completed in 90 minutes as ordered. RN 1 stated it was important to ensure the Vancomycin is being administered at the ordered rate and time to ensure Resident 3 is receiving the proper dosage of medication and it is not given too quick or too slow. During an observation on 12/8/2025 at 11:00 AM at Resident 3's bedside, Resident 3's IV Vancomycin was observed still infusing. During an interview on 12/8/2025 at 11:48 AM with the Director of Nursing (DON), the DON stated per facility protocol, a dial-a-flow infusion set is used for IV medications including Resident 3's Vancomycin. The DON stated if it is important to give Vancomycin as ordered to prevent fluid overload (a condition where there's too much fluid in the blood) or any adverse reactions (an undesired harmful effect resulting from a medication or other intervention)to Vancomycin like shortness of breath. During an interview on 12/8/2025 at 2:00 PM with Pharmacist 1, Pharmacist 1 stated Resident 3's Vancomycin 750mg/250 ml infusion rate was calculated according to his height, weight and indication and was ordered to infuse the full 250 ml exactly in 90 minutes. During a review of the facility's policy and procedure (P&P) titled Administering an Intermittent [IV] Infusion, dated 7/2023, the P&P indicated administration procedures that included for licensed nurses are to verify physician order, medication/solution and prescribed flushing agents and to open the clamp and set rate as prescribed (via pump/rate controller as appropriate). During a review of the facility's P&P titled Administering Medications, dated 4/2019, the P&P indicated that medications are administered in a safe and timely manner, as prescribed including any required time frame.

Based on interview and record review, the facility failed to provide treatment and services in accordance with professional standards of practice (guidelines and expectations that define competent and ethical conduct within specific profession) for one of two sampled residents (Resident 1) who had a diagnosis of other sequalae of cerebral infarction (the long-term conditions and complications that result from brain tissue damage due to reduced blood supply), other interval disc (a cushion of cartilage found between the vertebrae (bones) of the spine) lumbar region (the lower back region of your spinal column or backbone), other spondylosis with radiculopathy - lumbar region (a condition where the degenerative changes of spondylosis [osteoarthritis of the spine] lead to compression of spinal nerve roots, resulting in radiculopathy symptoms. Spondylosis itself refers to the general wear and tear of the spine, while radiculopathy is the specific symptom of a pinched nerve) and status post (S/P- underwent surgery) lumbar decompression and fusion (a surgical procedure that addresses lower back pain and nerve compression by removing pressure from the spinal nerves and fusing the vertebrae together to stabilize the spine) posterior (further back position) on [DATE] from General Acute Care Hospital (GACH) by failing to: 1. Ensure Registered Nurse (RN) 1 reviewed and verified with the facility's attending physician (Physician 1) Resident 1's GACH records dated [DATE] and relayed the completed and accurate discharge order from GACH's neurosurgeon (Physician 2- a surgeon specializing in surgery on the nervous system, especially the brain and spinal cord) of Resident 1's Plavix (brand name for clopidogrel- medication to prevent blood clots) 75 milligram (mg, unit of measurement) to start on [DATE] (9 days from the day of admission). 2. Ensure facility provided continuity of care to Resident 1's S/P lumbar decompression and fusion posterior in accordance with MD2's order to start Plavix 75 mg on [DATE] when the facility licensed nurses administered Plavix 75 mg to Resident 1 starting [DATE] to [DATE] (4 days). 3. Ensure Resident 1 was assessed and monitored for signs and symptoms of bleeding/ hematoma (pool of mostly clotted blood that forms in an organ, tissue, or body space)/ hemorrhage (bleeding from a damaged blood vessel) specifically for Resident 1's S/P lumbar decompression and fusion posterior, and Plavix use from [DATE] to [DATE]. As a result, Resident 1 had a change of condition (COC) on [DATE] at 1:05 PM, as evidenced by Resident 1 unresponsive to external stimuli (external changes or events that trigger a response in the nervous system. These stimuli can be anything from sights and sounds to smells, tastes, and physical sensations like pain or touch). Resident 1 was transferred to GACH via 911 emergency services (EMS - provides emergency medical care) on [DATE] at 1:30 PM and was admitted to the Emergency Department. Resident 1 underwent Computerized Tomography scan (CT scan - imaging using x-ray technique to create detailed images of the body) of the head in GACH and result showed an acute (sudden) right subdural (occurring between the dura mater [the tough outermost membrane enveloping the brain and spinal cord] and the arachnoid membrane [a thin, spiderweb- like membrane that surrounds the brain and spinal cord] of the brain and spinal cord) hematoma measures 14 millimeters (mm- unit of measurement) in width. The CT scan result also showed there was an adjacent right temporal intraparenchymal (bleeding within the brain tissue [parenchyma] specifically located in the right temporal lobe [one of two brain lobes responsible for processing sensory information, especially sounds, and plays a role in memory, emotional processing, and spatial awareness] of the brain) hematoma measuring 3.7 x 2.8 x 4.2 centimeters (cm- unit of measurement). In addition the CT scan result there was subfalcine (the most common form of intracranial herniation and occurs when brain tissue is displaced under the falx cerebri [a sickle-shaped vertical fold of dura mater that separates the two cerebral hemispheres {one of the two symmetrical halves of the cerebrum, the largest part of the brain} and helps in preventing certain types of brain herniation]), uncal herniation (occurs when rising intracranial pressure causes portions of the brain to move from one intracranial compartment to another) and subacute (between acute and chronic) hemorrhage in the left parietal lobe (left side of the brain) measuring 2.7 cm x 2.7 cm. Resident 1 died in GACH on [DATE] at 12:17 AM and Resident 1's immediate cause of death was nontraumatic intracranial hemorrhage (bleeding within the brain tissue that is not the result of head trauma or surgery- can be caused by blood clotting problems. It's a serious condition that can lead to stroke and potentially be fatal). On [DATE] at 3:59 PM, while onsite at the facility, the California Department of Public Health (CDPH) identified an Immediate Jeopardy situation (IJ, a situation in which the providers' noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) regarding the facility's failure to ensure Resident 1, who had a diagnosis of other sequalae of cerebral infarction, other interval disc lumbar region, other spondylosis with radiculopathy - lumbar region and S/P lumbar decompression and fusion posterior on [DATE] from GACH received treatment and services in accordance with professional standards of practice . The team notified the Administrator (ADM) and Director of Nursing (DON) of an IJ situation on [DATE] at 3:59 PM, due to the facility's failure to: ensure RN 1 reviewed and verified with the Physician 1 Resident 1's GACH records dated [DATE] and relayed the completed and accurate discharge order from Physician 2 of Resident 1's Plavix 75 mg to start on [DATE] (9 days from the day of admission), ensure facility provided continuity of care to Resident 1's S/P lumbar decompression and fusion posterior in accordance with MD2's order to start Plavix 75 mg on [DATE] when the facility licensed nurses administered Plavix 75 mg to Resident 1 starting [DATE] to [DATE] (4 days) and ensure Resident 1 was assessed and monitored for signs and symptoms of bleeding/ hematoma/ hemorrhage specifically for Resident 1's S/P lumbar decompression and fusion posterior, and Plavix use from [DATE] to [DATE]. On [DATE] at 6:04 PM, the ADM provided an acceptable IJ Removal Plan (a detailed plan to address the IJ findings). While onsite and after the surveyor verified/confirmed the facility's full implementation of the IJ Removal Plan through observation, interview and record review, and determined the IJ situation was no longer present, the IJ was removed onsite, in the presence of the ADM and DON. After the IJ was removed, the surveyor verified that the facility's non-compliance remained at a lower scope and severity (refers to the seriousness of the harm to the residents) of isolated (refers to the deficiencies affecting a very limited number of resident/s), actual harm (means the resident have experienced a negative outcome or injury due to the non-compliance), that was not immediate jeopardy. The IJ Removal Plan dated [DATE], included the following: -On [DATE], the DON and designee provided in-service education to all licensed nurses and direct care staff regarding reviewing and verifying any discrepancies with the ordering physician by clarifying the faxed medication discharge order and the GACH discharge papers that were given to the resident. In addition, clarify medication orders that are missing the start and end dates. -On [DATE], the DON and designee provided in-service education to all licensed nurses and direct care staff regarding monitoring the resident status post-surgery and the use of anticoagulant therapy (using medications to prevent or reduce blood clotting) for potential side effects such as signs/symptoms of bleeding. -On [DATE], the DON and designee provided in-service to the licensed nurses regarding: 1. Review and verify GACH discharge orders with facility's attending physician. 2. Status post-surgery residents with anticoagulant use and signs/symptoms of bleeding. 3. Following GACH discharge orders. Any licensed staff, who were not present, the DON will do in-service education upon returning to work. -Thirty- eight (38) residents were on anticoagulants and were assessed for any signs/symptoms of bleeding, potential side effects of anticoagulant use and black box warning (the most serious type of warning mandated by the U.S. Food and Drug Administration [FDA] for prescription drug labeling) monitoring. -The Registered Nurse (RN) Supervisor will check clinical alerts report daily for any COC and any signs/symptoms of bleeding. -DON, ADON or RN Supervisor/designee will conduct medication reconciliation (the process of comparing a patient's medication orders to all of the medications that the patient has been taking) with the residents GACH discharge orders and admitting orders carried out by licensed nurse. -Starting [DATE], newly admitted residents will have random audits following GACH discharge orders and completion of medication reconciliation. Three (3) residents weekly for four (4) weeks, Then two (2) residents weekly for 2 weeks Then 2 residents a month for two months. Inservice would be given to licensed nurses involved. Findings will be presented in the monthly QAA (Quality Assurance Agency) meeting. -DON implemented a Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) for the following: 1. Review and verify GACH discharge orders with attending physician 2. Use of anticoagulant and its side effects. 3. Following GACH discharge orders. - PIP resulted in DON/ADON doing daily audits in reviewing compliance for following GACH discharge orders, continuity of care, use of anticoagulant and identification of potential adverse side effect (an undesired effect of a drug) of the medication. - The Quality and Safety (QS) RN/Consultant will complete 3 audits weekly on medication reconciliation, the use of anticoagulants, and its side effects for newly admitted residents. -ADM, DON or Designee will submit audit findings to QAA committee monthly for 3 months until compliance is met. -The facility will develop a QAPI-PIP for the use of anticoagulant to be submitted in the next QAA committee meeting on [DATE]. -ADM and DON are responsible for implementing, monitoring and evaluating the Plan of Correction (POC). Findings: During a review of Resident 1's Admission Record, the Admission Record indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses that included intervertebral disc displacement (breakdown of one or more disc that separates the bones) in lumbar region (lower back), spondylosis with radiculopathy (herniated [bulging of an organ] cervical discs that press on the spinal nerve roots and cord) and hypertension (high blood pressure). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated [DATE], the MDS indicated Resident 1was severely impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated the resident required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with eating and oral hygiene but was 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.) with toileting hygiene, shower/bathe self, upper body dressing, lower body dressing and putting on/taking off footwear. During a review of Resident 1's GACH records dated from [DATE] to [DATE], it indicated Resident 1's CT of the brain without contrast (without the use of a special dye. This type of scan is used to detect acute problems like bleeding or to assess the general health of the brain, bone and tissue) was done on [DATE], showed no bleed or large infarct (an area of brain tissue death) in the brain. The GACH records also indicated Resident 1 was diagnosed at GACH with other sequalae of cerebral infarction, other interval disc lumbar region, other spondylosis with radiculopathy - lumbar region and S/P lumbar decompression and fusion posterior on [DATE] in GACH. During a review of Resident 1's facsimile (fax- an exact copy or reproduction of something, often used in the context of transmitting documents electronically or over a phone) GACH Discharge Medication List, dated [DATE], indicated Plavix 75 milligrams (mg - unit of measure) Tab (did not indicate start date). During a review of Resident 1's GACH pended (awaiting completion) discharge orders, dated [DATE], the discharge orders indicated Plavix 75mg Tablet Daily will start on [DATE]. During a review of Resident 1's GACH discharge medication list, dated [DATE], the medication list indicated to start Plavix 75mg tablet on [DATE]. During a review of Resident 1's Physician Orders at the facility, dated [DATE], the Physician Order indicated Plavix Oral Tablet 75 mg. Give one (1) tablet by mouth one time a day for cardiovascular accident (CVA) prophylaxis (PPX, preventive treatment). During a review of the facility's Pharmacy Records for Resident 1, dated [DATE], the Pharmacy Records indicated Plavix tab 75mg was dispensed (the process of preparing and giving medicine on the basis of a prescription) to the facility. During a review of the Facility's Pharmacy Receipt, dated [DATE], the receipt indicated Resident 1's medication of Plavix Tab 75 mg delivered with 14 tablets. During a review of Resident 1's Care Plan with focus Antiplatelet (medications that prevent blood platelets [cell in the blood that involves in clotting] from sticking together and forming clots. They work by inhibiting certain phases of the blood clotting process, making the blood less sticky and less prone to forming clots in arteries) use related to Clopidogrel Bisulfate (same as Plavix), revised [DATE], the Care Plan indicated resident will be free from signs/symptoms of abnormal bleeding. During a review of Resident 1's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) from the facility, dated [DATE], the MAR indicated Plavix was given to Resident 1 on [DATE] to [DATE]. During a review of Resident 1's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated [DATE] at 1:05 PM, the SBAR indicated the Resident 1 was unresponsive to external stimuli and was sent to GACH via 911 (time not indicated). During a review of Resident 1's Emergency Department (ED) to GACH Admission Record, dated [DATE], the GACH Admission Record indicated the Resident 1 went to CT scan of the head and was found to have an acute right subdural hematoma measures 14 mm in width, there was also an adjacent right temporal intraparenchymal hematoma measuring 3.7 x 2.8 x 4.2 cm and these resulted in significant leftward shift (when the natural centerline of the brain is pushed to the left) with 2 cm leftward shift, subfalcine and uncal herniation. The CT scan result also showed subacute hemorrhage in the left parietal lobe (Left side of the brain) measuring 2.7 cm x 2.7 cm. During a review of Resident 1's GACH discharge summary, dated [DATE] at 12:35 PM, the GACH discharge summary indicated Resident 1 had worsening of mental status requiring intubation (a process where a healthcare provider inserts a tube through a person's mouth or nose, then down into their trachea [airway/windpipe]. The tube keeps the trachea open so that air can get through. The tube can connect to a machine that delivers air or oxygen) and found intracranial hemorrhage (brain bleed) with poor neurological prognosis (a low likelihood of recovery from a neurological condition, with the potential for death, persistent unconsciousness, or severe disability) and progression to brain death. Resident was pronounced dead on [DATE] at 12:17 PM. During an interview on [DATE] at 12 PM, Registered Nurse 2 (RN 2) stated when a resident is admitted from the hospital to the nursing facility, the hospital discharge medication list should be clarified with attending physician to obtain orders to continue the orders or not. RN 2 stated, the GACH discharge paper works that came with Resident 1 when the resident was admitted on [DATE] should have been thoroughly reviewed by the admitting license nurse to ensure they can obtain the complete and/ or accurate order from Physical for Resident 1's Plavix. During an interview on [DATE] at 1:43 PM, the Medical Records (MR) stated an admission audit would be done the next day for residents admitting or readmitting to the facility. MR also stated during the audit, the hospital discharge papers and orders from the admitting nurse would be reviewed to ensure they match. During an interview on [DATE] at 2 PM, Physician 1 stated if the Nursing Facility notified Physician 1 of the Plavix being held until [DATE] by MD 1, he would have ordered to hold Plavix until [DATE]. Physician 1 stated GACH discharge orders needed to be followed for continuity of care and to avoid worsening of the resident's condition. During a concurrent record review and interview on [DATE] at 2:20 PM with the DON of Resident 1's admitting medication orders and GACH discharge medication list, dated [DATE], the DON stated during admission, the nurse admits a resident, then medical records department would do the audit of the resident's medical record to ensure the discharge orders from the hospital matches the physician orders. The DON also stated Resident 1's admitting orders to give the resident's Plavix with start date of [DATE] did not match Resident 1's GACH discharge medication list/ orders to start the Plavix on [DATE]. The DON further stated it is important to follow the discharge orders from the hospital for accurate care of the resident and that nurses should have clarified the GACH discharge orders with the resident's physician upon admission. During an interview on [DATE] at 4:21 PM, RN 1 stated Resident 1's admitting medication orders and Resident 1's GACH discharge medication list does not match but should have matched to ensure continuity of care and that the Plavix was given to Resident 1 on [DATE] and not on [DATE]. RN 1 also stated she used the medication list that was faxed by the GACH nurses to the facility (no start dates) and not the GACH discharge medication list (with start dates) that was given to the Resident 1. RN 1 also stated, there was no documented evidence in Resident 1's medical records that the facility assessed, monitored and documented Resident 1 for specific signs and symptoms of bleeding/ hematoma / hemorrhage specifically for Resident 1's S/P lumbar decompression and fusion posterior, and Plavix use from [DATE] to [DATE]. During an interview on [DATE] at 12 PM, Physician 2 stated he would generally wait 2 weeks after surgery before ordering to give an anticoagulant to patients. Physician 2 also stated if the nurses start a medication when they should not have, then that is wrong. Physician 2 stated sometimes the healthcare provider give dangerous medications to the reisdent and it can cause adverse effect. During an interview on [DATE] at 12:25 PM, Physician 3 (GACH's doctor) stated Resident 1 had a surgery prior to being admitted in the skilled nursing facility on [DATE]. Physician 3 stated Resident 1 received Plavix from the facility earlier than it should have been given. Physician 3 stated, this placed Resident 1 at risk for bleeding and/ or brain bleed. Physician 3 stated, Plavix increased the risk of bleeding. During an interview on [DATE] at 2:57 PM, Pharmacist 1 stated there was no documentation indicating Resident 1 was post spinal surgery. Pharmacist 1 also stated if the facility informed the pharmacy that Resident 1 was status post spinal surgery, administering Clopidogrel Bisulfate medication would have been questioned. During an interview on [DATE] at 4 PM, MR stated while auditing Resident 1's admission record, she reviewed the hospital faxed medication list (no start dates) and not the hospital discharge medication list (with start dates) that was given to Resident 1. MR also stated she should have reviewed the hospital discharge medication list when auditing the admission record but rather reviewed the fax medication list instead. MR stated the medication orders MR also stated, there was no documented evidence in Resident 1's medical records that the licensed nurses assessed, monitored and documented Resident 1 for specific signs and symptoms of bleeding/ hematoma / hemorrhage specifically for Resident 1's S/P lumbar decompression and fusion posterior, and Plavix use from [DATE] to [DATE]. During a review of Resident 1's Nurse Notes, dated [DATE] at 2:09 PM, the Nurses Notes indicated Family 1 came to notify the facility that Resident 1 passed away at the GACH on [DATE]. During a review of Resident 1's Death Certificate, printed on [DATE], the Death Certificate indicated immediate cause for death is nontraumatic intracranial hemorrhage. During a review of the facility's Policy and Procedure (P&P) titled Admission Assessment and Follow Up: Role of the Nurse, revised ,d+[DATE], the P&P indicated reconcile the list of medications from the medication history, admitting orders, the previous MAR, and the discharge summary from the previous institution. During a review of the facility's P&P titled Medication and Treatment Orders, revised ,d+[DATE], the P&P indicated orders for medications must include number of doses, start and stop date, and/ or specific duration of therapy. During a review of the facility's P&P titled Physician Orders, revised ,d+[DATE], the P&P indicated all orders must be specific and complete with all necessary details to carry out the prescribed order without any questions. During a review of the facility's P&P titled Anticoagulation, revised [DATE], the P&P indicated as part of the initial assessment, the physician and staff will identify individuals who are currently anticoagulated (treated or rendered unable to clot); for example, those who have recent surgery. The P&P also indicated the physician will prescribe anticoagulation therapy appropriately, consistent with recognized guidelines (piece of information that suggests how something should be done).

Based on interview and record review, the facility failed to provide the necessary care and services for one of two sampled residents (Resident 1), in accordance with facility's policy and procedure, and recognized standards of practice to meet the needs of the resident, by failing to: 1. Ensure Resident 1 received prompt nursing interventions and to follow the physician orders [REDACTED]. 2. Monitor and assess Resident 1's bowel movement (BM, evacuation of the bowels) amount, and consistency (such as hard, soft, normal, diarrhea (loose, watery stools)), and to promptly send Resident 1's stool sample to the laboratory as ordered for testing. 3. Ensure that Resident 1 who was diagnosed with [REDACTED]. 4. Failed to address Resident 1's episodes of diarrhea during an interdisciplinary team ((IDT) a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the patient) conference. 6. Conduct complete neurological assessments (an assessment of brain functions and level of consciousness) after Resident 1 sustained a fall. As a result, Resident 1's BM was not monitored, and the resident's C[NAME] was not promptly identified. Resident 1 was transferred to a general acute care hospital (GACH) via 911 (emergency services) per family's request and was admitted to the hospital's in critical condition with [DIAGNOSES REDACTED]. *Cross references F656 and F692 Findings: A review of Resident 1's Face Sheet (admission record) indicated that resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS, a resident assessment and care screening tool), dated 7/24/18, indicated that Resident 1's cognitive (ability to think and process information) was intact. The resident required extensive assistance (resident involved in actives and staff provide weight-bearing- support) with one-person assist for bed mobility, transfers, eating, dressing, toilet use, and personal hygiene. A review of Resident 1's Resident Progress Notes, dated 8/13/18, and timed at 3:14 a.m., indicated that Resident 1 complained of having loose stools, weakness, and poor appetite and that the stool softener was placed on hold and that a message was left for Resident 1's physician. A review of Resident 1's Change of Condition-C[NAME]/Interact Assessment Form (SBAR), dated 8/13/18, and timed at 7:07 p.m., indicated that resident at 4 p.m. (13 hours later), stated that he felt weak and had diarrhea, and that Resident 1's physician ordered blood laboratory (blood test) and to collect a stool sample. A review of Resident 1's Resident Progress Notes indicated that there were no nursing notes from 8/17/18 to 8/21/18. A review of Resident 1's SBAR, dated 8/22/18, and timed at 9:44 p.m., indicated that Resident 1's family reported that resident had ongoing diarrhea and the physician was aware and that per family request Resident 1's physician ordered a stool culture. A review of Resident 1's Care Plan, dated 8/22/18, indicated that resident had diarrhea, and that the nursing approach was to collect stool, and to record the duration and frequency of diarrhea, characteristics, consistency, and quality of stool. A review of Resident 1's Resident Progress Notes, dated 8/23/18, and timed at 5:02 a.m., indicated that at 4:30 a.m., Resident 1 had a soft mucoid yellowish stool with foul smell and that a stool sample was collected. A review of Resident 1's SBAR, dated 8/25/18, and timed at 5:06 p.m., indicated that Resident 1 was noted with a positive C- Diff results and resident was placed in contact isolation. A review of Resident 1's untimed Physician order [REDACTED]. A review of Resident 1's Physician and Telephone Orders, dated 9/6/18, and timed 3 p.m., indicated for resident to receive [MEDICATION NAME] (no dose provided) for 14 days not 21 days. A review of Resident 1's Medications Flowsheet, dated from 8/26/18 to 8/31/18, indicated that resident received [MEDICATION NAME] 125 mg/2.5 ml, amount administered 5 ml, oral four times a day (for a total of six days). A review of Resident 1's Medications Flowsheet, dated from 9/1/18 to 9/7/18, indicated the resident received [MEDICATION NAME] 125 mg/2.5 ml, amount administered 5 ml, oral four times a day (for a total of seven days). A review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR), dated 9/13/18, and timed at 2:15 p.m., indicated that Resident 1 had an unwitnessed fall inside his room. A review of Resident 1's SBAR, dated 9/22/18, and timed at 7:48 a.m., indicated that resident had four episodes of loose foul smelling bowel movements and abdominal discomfort. A review of Resident 1's Progress Notes, dated 9/24/18, and dated 2:40 p.m., indicated that at 1:30 p.m., Resident 1's family requested to transfer resident to the hospital and that Registered Nurse 1 (RN 1) explained to resident's family that he (RN 1) needed to do his assessment prior to him calling 911. The notes indicated that resident was noted with cool extremities, weaker, increased respiratory rate, oxygen saturation (a test that measures the amount of oxygen being carried by red blood cells) at 84% (normal 95%-100%), and that at 1:35 p.m., RN 1 was not able to obtain a blood pressure. The notes indicated that at 1:37 p.m., Resident 1's physician ordered one liter of normal saline (sterile fluid) bolus (rapid administration of fluid) and to transfer resident via 911. A review of Resident 1's GACH Emergency Documentation dated 9/24/18, and timed at 2:46 p.m., indicated that Resident 1's blood pressure was 67/50 milliliter of mercury (mm/Hg) (low, normal is 120/90) and that the resident was thin. A review of Resident 1's GACH Emergency Documentation dated 9/24/18, and timed at 10:30 p.m., indicated that Resident 1 received broad-spectrum antibiotics (medication for infection) [MEDICAL CONDITION] and septic shock, and that a rectal Foley (tube in rectum) was placed due to perfuse watery diarrhea in the emergency room . The GACH notes indicated that Resident 1 was admitted to an Intensive Care Unit (ICU, unit for patients in critical condition) in critical condition with [DIAGNOSES REDACTED]. A review of Resident 1's GACH Perioperative Procedural Record, dated 9/26/18, and timed at 6:40 p.m. indicated on 9/25/18, Resident 1 abdominal surgery under general endotracheal (tube in trachea) anesthesia in hopes of saving resident's life. The record indicated that Resident 1's preoperative (before surgery) and postoperative (after surgery) [DIAGNOSES REDACTED]. A review of Resident 1's GACH Perioperative Procedural Record, dated 9/27/18, and timed at 10:21 p.m., indicated that Resident 1 underwent a second surgery. A review of Resident 1's GACH Discharge Documentation dated 10/9/18, and timed at 3:01 p.m., indicated that Resident 1 was admitted to the hospital from 9/24/18 and was discharged on [DATE]. The Discharge Documentation indicated that Resident should get a gastrostomy tube placement (a tube inserted through the abdomen that delivers nutrition directly to the stomach) and that there was a possibility that Resident 1 would never regain swallow. During a telephone interview on 10/10/18 at 7:29 a.m., Resident 1's Family Member 1 (FAM 1) stated that on 9/24/18 she requested facility's staff to transfer Resident 1 to the hospital because Resident 1 looked horrible, lost weight, and had diarrhea which was not controlled at the facility. During an interview on 10/10/18 at 2:41 p.m., Registered Nurse 1 (RN 1) stated that Certified Nursing Assistants (CNAs) were supposed to document episodes of BM so that they (licensed nurses) could establish a trend. RN 1 stated that the CNAs did not document Resident 1's BM episodes from 9/20/18 to 9/24/18 and that there were other entries that were not readable and some dates were not completely filled out. RN 1 stated that CNAs were supposed to document the actual number of Resident 1's BM. During an interview on 11/6/18 at 11:03 a.m., RN 2 stated that licensed nurses were supposed to actually see Resident 1's stool and to describe and document the stool. During a telephone interview on 11/9/18 at 11:33 a.m., the facility's Medical Director (MD 2) stated that the nurses were supposed to follow Resident 1's physician orders [REDACTED]. During a review of Resident 1's medical record on 11/6/18 at 11:53 a.m., RN 2 stated that there were discrepancies between CNAs and licensed nurses BM documentation's. RN 2 stated that here was a nine day delay to obtain a stool sample, no description of Resident 1's BM, and that some CNAs notes were unreadable and some without documentation. During a review of Resident 1's 72 Hours Neuro Check List on 11/6/18 at 2:35 p.m., RN 2 stated that the neurological assessment was incomplete. RN 2 stated that the purpose of neurological exam was to assess for any neurological changes. A review of the facility's policy and procedure titled [MEDICAL CONDITION], with a revised date of (MONTH) (YEAR), indicated that measures would be taken to prevent the occurrence of [MEDICAL CONDITION] infections among residents and precautions would be taken while caring for residents with [MEDICAL CONDITION] to prevent transmission to other residents. The policy indicated that suspected infection with [MEDICAL CONDITION] would be verified by evidence by of positive cytotoxin assay and to transport to the laboratory as soon as possible. A review of the facility's policy and procedure titled Bowel Disorders-Clinical Protocol, with a revised date of (MONTH) (YEAR), indicated that the nurse should assess and document quantitative and qualitative description of diarrhea (how many episodes in what period of time, amount consistency, etc.), and that the staff and physician would monitor the individual's response to interventions and overall progress. A review of the facility's policy and procedure titled Change in a Resident's Condition or Status, with a revised date of (MONTH) (YEAR), indicated that the facility should promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition. A review of the facility's policy and procedure titled Assessment, fall, with a date revised of (MONTH) 2014, indicated that the facility required staff to observe for delayed complications of a fall for approximately seventy-two hours and document.

Based on interview and record review, the facility failed to provide nutrition and hydration to prevent weight loss and dehydration (a severe reduction in the amount of water in the body) for one of two sampled residents (Resident 1). For Resident 1, the facility: 1. Failed to implement its policy on Weight Assessment and Interventions, when licensed nurses did not notify Resident 1's Physician (Physician 1) and the Registered Dietitian (RD - a healthcare professional licensed to assess, diagnose, and treat nutritional problems) for follow up recommendation when Resident 1 had a significant weight change. 2. Failed to implement its policy on Resident Hydration and Prevention of Dehydration, when nursing staff did not provide Resident 1 enough hydration as assessed by the RD. 3. Failed to implement its policy on Change in a Resident's Condition or Status by licensed nurses not notifying Physician 1 of Resident 1's weight loss of 24 pounds (lbs.) in one month. 4. Failed to implement its policy on Calculating Percentages at Meal Times when Certified Nursing Assistants (CNAs) did not accurately document Resident 1's meal intake. As a result, Resident 1 sustained a severe weight loss of 24 lbs. in one month without medical and nutritional interventions. On 9/24/18, Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) via 911 (emergency services). *Cross-references F656 and F684 Findings: A review of the Admission Record indicated Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Signs and symptoms include cramping, stomach pain, bloating, gas, and diarrhea (loose stools) or constipation (difficulty in emptying the bowels, usually associated with hardened feces, having fewer than three bowel movements a week), or both). A review of the Minimum Data Set (MDS - standardized assessment and care-planning tool), dated 7/24/18, indicated Resident 1 had no cognitive (ability to think and process information) problem and the resident required extensive assistance (resident involved in activity, staff provided weight-bearing support) with one-person assist for bed mobility, transfers, eating, dressing, toilet use, and personal hygiene. A review of the Nutritional Observation Notes, completed by RD 1, dated 7/26/18, indicated Resident 1's estimated kilocalories (kcals is 1,000 calories, in nutrition terms, the word calorie is commonly used to refer to a unit of food energy) needs were 1,800 - 2,000 kcals. Resident 1's fluid intake needs were greater than 1,500 milliliters (ml). The note did not include Resident 1's usual body weight range. A review of Resident 1's Weight Record Form, dated 8/9/18 to 9/18/18, indicated Resident 1's weights were as follows: On 8/9/18, 224 lbs., two lbs. weight gain (admission weight = 222 lbs.) On 9/7/18, 200 lbs., 24 lbs. weight loss in one month. On 9/19/18, 196 lbs., four lbs. weight loss in 12 days. A review of the Resident Progress Notes dated 8/13/18, timed at 3:14 a.m., indicated Resident 1 complained of having loose stools, weakness, and poor appetite. A review of the Resident Progress Notes dated 8/14/18 to 8/17/18, indicated Resident 1 did not have any episodes of loose stools. There were no nursing notes from 8/17/18 to 8/21/18. A review of the Resident Progress Notes dated 8/22/18, timed at 8:30 p.m., indicated FM 1 informed Registered Nurse (RN 4) that Resident 1 had smelly diarrhea for two weeks. FM 1 was concerned that Resident 1 might have infection. RN 4 notified Physician 1 and obtained order to collect stool for sampled to test for [MEDICAL CONDITION]. A review of the Resident Progress Notes dated 8/26/18, timed at 6:06 a.m., indicated Resident 1 received the first dose of [MEDICATION NAME] (antibiotic), 250 milligram (mg)/5 milliliter (ml), by mouth, three time a day, for 21 days, for [MEDICAL CONDITION]. A review of the Resident Progress Notes dated 9/13/18, timed at 9:30 a.m., indicated RD 1 noticed Resident 1 with a significant weight loss of 24 lbs. in thirty days. RD 1 requested to obtain blood tests to evaluate Resident 1's nutritional status, and recommended weekly weight. A review of the Resident Progress Notes dated 9/13/18 timed at 3:46 p.m., indicated Registered Nurse 3 (RN 3) received RD 1's recommendations to obtain weekly weight for 4 weeks. The notes did not indicated RN 3 notified Physician 1 regarding RD 1's request to obtain the blood tests to check Resident 1's nutritional status. A review of the Resident Progress Notes dated 9/16/18, at 2:20 p.m., indicated FM 1 approached Licensed Vocational Nurse 4 (LVN 4) and requested LVN 4 to obtain a blood test for Resident 1. A review of the Dietary Recommendations dated 9/20/18, indicated RD 1 recommended for Resident 1 to receive vitamin C and zinc sulfate (nutritional supplements) for fourteen days, and Active Liquid Protein® sugar-free (ALP SF is a ready-to-use liquid form of protein supplement), 30 ml twice a day, check weekly weights, and monitor Resident 1's weight loss. A review of the Resident Progress Notes dated 9/21/18, timed at 9:09 a.m., indicated RD 1's recommendations for the nutritional and protein supplements were not relayed to Physician 1 for implementation. A review of nursing Progress Notes dated 9/24/18, indicated at 1:30 p.m., FM 1 requested to transfer Resident 1 to the hospital. Registered Nurse 1 (RN 1) explained to FM 1 that he needed to do his assessment before calling 911. Resident 1 had cool extremities, weakness, increased respiratory rate, the oxygen saturation (a test that measures the amount of oxygen carried by red blood cells) was 84% (normal 95%-100%), and RN 1 was not able to obtain a blood pressure. At 1:37 p.m., RN 1 called Physician 1, who ordered one liter of normal saline (sterile fluid) intravenous (through veins) bolus (rapid administration of liquid) and to transfer Resident 1 to a GACH via 911. A review of GACH 1 emergency room Documentation dated 9/24/18, timed at 2:46 p.m., indicated Resident 1's blood pressure was 67/50 millimeters of mercury (mmHg - normal level was 120/90), and Resident 1 was thin. At 10:30 p.m., Resident 1 received broad-spectrum antibiotics (medication for infection) [MEDICAL CONDITION] and septic shock (life-threatening infection), placement of a rectal tube for profuse watery diarrhea. Resident 1 was admitted to ICU in critical condition with [DIAGNOSES REDACTED]. During a telephone interview on 10/10/18 at 7:29 a.m., FM 1 stated on 9/24/18 she asked the nurses to transfer Resident 1 to a GACH because Resident 1, Looked terrible, had lost weight, and uncontrolled diarrhea. On 10/10/18 at 1:35 p.m., during an interview with the Director of Staff Development (DSD) and a review of Resident 1's record, the DSD stated the licensed nurses did not address Resident 1's weight loss. On 10/10/18 at 3:18 p.m., during an interview with RN 1 and a review of Resident 1's clinical record, RN 1 stated the nurses did not follow RD 1's recommendations. RN 1 was unable to find documentation Physician 1 was informed about Resident 1's weight loss. RN 1 stated there was no plan of care addressing Resident 1's weight loss. During an interview on 10/10/18 at 3:20 p.m., Licensed Vocational Nurse 1 (LVN 1) stated on 9/24/18 the night shift endorsed to her Resident 1 had loose stools during the night. LVN 1 stated Resident 1 looked pale, and his blood pressure was low, and she informed RN 1. During an interview on 11/6/18 at 11:03 a.m., RN 2 stated the facility did not monitor Resident 1's fluid intake. RN 2 stated there was no documentation in Resident 1's clinical record to show that Resident 1 received the needed amount of fluids. On 11/6/18 at 11:44 a.m., during a review of Resident 1's CNA Daily Charting for the month of 9/2018 with the DSD indicated that on 9/23/18, Resident 1 refused to eat dinner. The resident had extreme lose BM and had to be changed six times. The DSD stated CNAs were supposed to report to the licensed nurses when Resident 1 refused meal and had extreme lose BM. During a review of Resident 1's medical record on 11/6/18 at 11:53 a.m., with RN 2, RN 2 stated the nurses did not notify Physician 1 about Resident 1's weight loss, and there was no weight loss care plan developed. RN 2 stated that Resident 1's weight loss was a change of condition, and the nurses had to inform Physician 1. During a telephone interview on 11/7/18 at 1:29 p.m., RD 1 stated that nursing staff was responsible for notifying Physician 1 about Resident 1's weight loss. During a telephone interview on 11/9/18 at 11:33 a.m., the facility's Medical Director (MD) stated she was not aware of Resident 1's condition, and she expected the licensed nurses to report the weight loss to Physician 1. During a telephone interview on 11/9/18 at 2:40 p.m., Physician 1 stated the nurses did not inform him about Resident 1's weight loss. A review of the facility's policy and procedure titled, Weight Assessment and Interventions, revised on 6/2015, indicated nursing would notify the physician and dietitian for follow up recommendation when there is any significant weight change. A review of the facility's policy and procedure titled, Resident Hydration and Prevention of Dehydration, revised on 10/2017, indicated the facility would strive to provide adequate hydration, prevent, and treat dehydration. The intake would be documented in the medical records, and CNAs would report intake of fewer than 1200 ml per day to the nursing staff. A review of the facility's policy and procedure titled, Change in a Resident's Condition or Status, revised on 5/2017, indicated to promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition. A review of the undated facility's policy and procedure titled, Calculating Percentages at Meal Times, indicated nursing to make the charts available to the CNAs to assure accurate meal intake charting.

Based on observation, interview and record review the facility failed to ensure an indwelling catheter (tube which is inserted into the bladder and left in place to drain urine) was not used unless there was a valid medical justification and failed to provide for Resident 2's catheter the appropriate care and services to prevent infections, for one of three sample residents (Resident 2). Resident 2, who was on blood thinner medications, had no physician order for [REDACTED]. Findings: A review of the most recent readmitted residents to the facility indicated Resident 2 was readmitted to the facility on [DATE]. Resident 2's face sheet indicated the resident was readmitted to the facility on [DATE], (face sheet not updated) with [DIAGNOSES REDACTED]. (The urethra is the tube that carries the urine from the bladder out of the body). During an interview with Resident 2's family member, on 4/15/16, at 2:20 p.m., she stated Resident 2 returned to the facility from the hospital on [DATE] with a catheter and the family was unsure why he still had the urinary catheter in place. On 4/15/16 at 2:37 p.m., during an interview, a licensed vocational nurse (LVN 1) reviewed Resident 2's medical record and verified there were no orders or notes to indicate the medical justification for the use of the urinary catheter and the Interfacility Transfer, dated 4/10/16, indicated the resident was to have a follow-up with a urologist (The medical specialist concerned with the urinary system) in to consider the discontinuation of the urinary catheter. During an interview on 4/15/16, at 2:39 p.m., the treatment nurse stated, Resident 2 was originally admitted to the facility on [DATE] with a urinary catheter without a medical justification. She stated the physician was called to clarify the use of the urinary catheter and he stated the resident required a urologist consultation. On 4/15/16 at 2:51 p.m., during an interview with the director of nursing (DON), she reviewed Resident 2's medical record and was unable to find neither the order for the use of [REDACTED]. During a record review, on 4/15/16, at 3:05 p.m., the treatment nurse reviewed Resident 2's medical record and was unable to find documentation of monitoring for signs and symptoms of infection while Resident 2 had a catheter. There was no documentation Resident 2 was bleeding and/or that the physician was notified. During an observation with the treatment nurse, on 4/15/16, at 3:13 p.m., she opened Resident 2's diaper and bright red blood was draining from the resident's urethra opening (The duct by which the urine is conveyed out of the body) from the bladder) and was on the catheter tubing. The treatment nurse stated Resident 2 had dislodged his catheter recently but she was not aware it was bleeding. On 4/15/16, at 3:18 p.m., during a review of Resident 2's medical record, LVN 1 stated the urinary catheter was dislodged on 4/13/16 and Resident 2 was transferred to the acute care facility and was readmitted to the facility on [DATE]. LVN 1 verified the readmission orders [REDACTED] A review of the Transfer Record, dated 4/13/16, indicated Resident 2 had a catheter with hematuria (blood in urine) and was being transferred to the acute care facility for elevated blood pressure and decreased heart rate. During an interview on 4/15/16, at 3:21 p.m., LVN 2 stated no one had followed-up with the urologist consultation. A review of Resident 2's readmission orders [REDACTED]. A review of Resident 2 ' s most recent laboratory report, dated 4/14/16, indicated the coagulation [MEDICATION NAME] (clotting tendency of the blood) was high with a level of 31 seconds (normal range <14.5 seconds) placing the resident at risk for bleeding.

Based on observation, interview and record review, the facility failed to thoroughly investigate, and report in a timely manner to the State agency and protect a resident from abuse (Resident 21); one resident out of a sample of 24 residents. For Resident 21, the facility failed to protect the resident from further psychological harm, after he had verbalized to the facility staff his mental anguish as a result of multiple altercations with Resident 11. The last altercation on 3/23/16, between Resident 11 and 21, Resident 11 threatened to kill Resident 21, which placed Resident 21's safety at risk and not feeling safe in the facility. Findings: During an interview with Resident 11, on 3/29/16, at 7:35 a.m., he informed the surveyor that another resident pushed him from his wheelchair during a verbal altercation. A review of Resident 11 ' s record admitting Face Sheet, indicated the resident was admitted to the facility on [DATE], and readmitted [DATE], with [DIAGNOSES REDACTED]. Additionally, Resident 11's most recent transfer to the acute care facility on 11/2/15 was on a psychiatric 5150 hold secondary to being a danger to others and gravely disabled. The Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 2/16/16, indicated Resident 11 was understood by others, was able to understand others and required supervision with the activities of daily living. During an interview with Resident 11, on 3/30/16, at 7:18 a.m., the resident stated Resident 21 pushed him off his wheelchair. The altercation was heard and witnessed by staff. Resident 11 added he was found on the floor by the certified nursing assistant (CNA 2). During an interview with CNA 2, on 3/30/16, at 7:23 a.m., she stated she heard the altercation between Resident 11 and 21 and when she arrived she found Resident 11 on the floor next to his wheelchair. A review of the clinical record for Resident 11, the Social Services Notes dated 2/29/16, indicated the Resident 11 was seen by another resident to have a knife in his possession. The notes further documented the resident was concerned about his safety. The following Social Service Note dated 3/1/16, indicated Resident 11 became aggressive, screaming, yelling, cursing and verbally abusive towards Resident 21 using derogatory slurs. The third note dated 3/23/16, indicated Resident 11 had another episode of disruptive behavior, screaming and cursing, using derogatory slurs towards Resident 21. The note additionally indicated the resident continued to exhibit aggressive inappropriate behaviors. Seven days after the 3/23/16 incident, Resident 11 was observed on 3/30/16, at 8:22 a.m., in his wheelchair in the hallway near his room. The resident's hands were handcuffed by a law enforcement officer while another law enforcement officer questioned the resident about having a knife in his possession. Resident 11 responded yes. The resident was immediately wheeled out of the facility. Outside the facility the law enforcement officer searched the resident's hand bag and found three knives (two pocket knives and one 12 inch knife). Resident 11 was taken from the facility via ambulance to the acute care facility on a 5150 hold for danger to others. During an interview with the Administrator, on 3/31/16, at 1:48 p.m., when asked about any allegations of abuse in the last three months, he stated there were none. He was asked about the incident on 3/23/16 at 4:00 a.m., and he stated it was not an allegation of abuse. He further added Resident 11 and Resident 21 have been going at it for a while and Resident 11's behavior is loud, aggressive and confrontational since admission. The Administrator was then asked of any other incidents between residents that have been investigated in the last three months. The administrator stated in the last three months he had investigated two incidents, one on 2/25/15, an allegation a resident hit another resident and the incident on 3/23/16 between Resident 11 and Resident 21. The Administrator was further asked if any of these allegations were reported to the State agency and he stated no because he does not report allegations that are made by resident that have a psychiatric [DIAGNOSES REDACTED]. He only reports if the allegation has the potential to be true. During an interview with Resident 21, on 3/31/16, at 3:24 p.m., he stated he had multiple altercations with Resident 11 and the facility did nothing about it to make him feel safe. The last incident was on 3/23/16, Resident 11 threatened him by saying he was going to kill him. Resident 21 further stated he was enraged because he felt verbally abused by Resident 11 and had no protection from the facility. A review of the admitting Face Sheet for Resident 21 indicated the resident was admitted to the facility on [DATE], and readmitted [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 2/4/16, indicated Resident 21 was understood by others, was able to understand others and required supervision to limited assistance with the activities of daily living. Resident 21's most recent psychological consultation, dated 3/2/16, indicated the resident reported he had an interaction with Resident 11 that caused him frustration. The psychologist consulted with the social worker regarding the conflict. During an interview with the social services designee (SSD), on 4/1/16, at 9:28 a.m., she was asked about the facility's procedure for a resident to resident altercation. She stated the residents are separated, a room change is made if necessary, the incident is investigated, a body check is conducted for a physical altercation, a psychological consult is provided and the victim is asked if he or she feels safe in the facility. The SSD further stated the investigation of the altercation should be documented in both the aggressor's and victim's medical record. The SSD reviewed the clinical record for Resident 21, who was the victim of multiple altercations with Resident 11, and was unable to find documentation of the incident on 3/23/16. The SSD stated she went to Resident 21's room to ask him what happened and how he was feeling but Resident 21 was not in his room on 3/23/16. Later that day she told Resident 21 to write a statement but failed to follow up with the resident on how he was feeling or the incident. There was no documentation indicating the facility thoroughly investigated the incident to protect the Resident 21 from further potential abuse. The facility policy and procedure titled Abuse Investigation Policies and Procedures dated 6/4/10, under the section of Reporting Abuse to Facility Management Policies and Procedures, Based on observation, interview and record review, the facility failed to thoroughly investigate, report in a timely manner to the State agency and protect a resident from abuse (Resident 21). For Resident 21, the facility failed to protect the resident from further psychological harm, after he had verbalized to the facility staff his mental anguish as a result of multiple altercations with Resident 11. The last altercation on 3/23/16, between Resident 11 and 21, Resident 11 threaten to kill Resident 21, which place Resident 21's safety at risk and not feeling safe in the facility.