Every finding on record at The Care Center on Hazeltine, LLC

Based on observation, interview, and record review the facility failed to: 1. Reconcile (the process of comparing transactions and activity to supporting documentation) two (2) medication emergency kits ([eKIT] - storage container for emergency use medications) containing Controlled Substances ([CS]- medications which have a potential for abuse and may also lead to physical or psychological dependence, also known as Controlled Medications) for 12/2025, in one (1) of one (1) inspected Medication Rooms (Medication room [ROOM NUMBER].) 2. Reconcile one (1) medication eKIT containing CSs for 12/2025, in one (1) of two (2) inspected Medication Carts (Medication Cart 1.) As a result, control and accountability of CSs and availability of medications did not follow state and federal regulations and facility policy and procedures. These deficient practices increased the opportunity for CS diversion (the transfer of a controlled medication or other medication from a lawful to an unlawful channel of distribution or use,) and the risk that residents in the facility could have accidental exposure to harmful medications and delayed medication treatment during emergencies possibly leading to physical and psychosocial harm, and hospitalizationFindings: During an observation on 12/16/2025 at 10:18 a.m., with Licensed Vocational Nurse (LVN) 3, in Medication Cart 1, there was: 1. One (1) medication eKIT containing CSs stored at room temperature and labeled 16, without an accountability log for the reconciliation of CS inventory count at every shift change for 12/2025. During a concurrent interview, LVN 3 stated that all CSs, including medication eKITs containing CSs should be reconciled and counted at every shift. LVN 3 stated the eKIT labeled 16 containing CSs in Medication Cart 1 was not reconciled with a count at every shift in 12/2025, and it was important to account for all CSs to ensure accountability and prevent CS diversion. During an observation on 12/15/2025 at 12:40 p.m., with LVN 2, in Medication room [ROOM NUMBER], there was: 1. One (1) medication eKIT containing CSs stored in the refrigerator and labeled 24, without an accountability log for the reconciliation of CS inventory count at every shift change for 12/2025. 2. One (1) medication eKIT containing CSs stored at room temperature and labeled 8, without an accountability log for the reconciliation of CS inventory count at every shift change for 12/2025. During a concurrent interview, LVN 2 stated that all CSs, including medication eKITs containing CSs, should be reconciled at every shift. LVN 2 stated the eKIT labeled 24 in the refrigerator and the eKIT labeled 8 at room temperature containing CSs in Medication room [ROOM NUMBER] was not reconciled for inventory count at every shift in 12/2025, and it was important to account for all CSs to ensure accountability and prevent CS diversion. During an interview on 12/16/2025 at 3 p.m., with the Assistant Director of Nursing (ADON,) the ADON stated medication eKITs containing CSs needed to be counted and reconciled at every shift change to ensure accountability and prevent CS diversion. The DON stated eKIT labeled 16 in Medication Cart 1, the eKIT labeled 24 in the refrigerator in Medication room [ROOM NUMBER] and the eKIT labeled 8 at room temperature in Medication room [ROOM NUMBER], all contained CSs and were not reconciled at every shift in 12/2025. During a review of the facility's Policy and Procedures (P&P,) titled Safeguarding Controlled Substances, last reviewed 1/28/2025, the P&P indicated: The facility has established guidelines for safe handling receiving, storing, administering, reconciling, and safeguarding controlled substances. Purpose: To minimize the time between identification and actual loss or diversion of medications or suspected controlled substance diversion involving any employee, determination of the extent of loss or diversion and to safeguard patients and their property. Definitions: Controlled Medications are substances that have an accepted medical use (medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V), have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence. 13. Controlled substances will be counted at the onset and completion of each shift by two nurses and verified accurately through each nurses' signature on the reconciliation log. Controlled Drug Count/Change of Shift Reconciliation 1. Each individual controlled substance must be counted when there is a change in shift nurse.2. The on-coming licensed nurse will view and verify each medication supply and amount[s) remaining, while the off-going nurse calls out the resident name, medication, and amounts remaining on controlled logs.3. The count should be completed in a diligent manner and the oncoming nurse should examine tablets and medications carefully during the count.4. Narcotic e-kits should be checked & verified as present/sealed or reconciled as indicated.5. Both on-coming, and off-going licensed nurses will sign the controlled drug count verification form when deemed accurate. Following this procedure and confirmation of controlled substance accuracy, the on-coming nurse may take accountability of the medication cart and keys. During a review of the facility's P&P, titled Emergency Pharmacy Services and Emergency kits, last reviewed 1/28/2025, the P&P indicated: Accountability for controlled substances stored in the emergency kit is maintained as follows:c. The incoming and outgoing nurses verify the inventory of controlled substances at each change of shift or exchange of keys.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and proper food handling practices by failing to: 1. Ensure bins containing potatoes and onions were labeled with a date of when they were received. 2. Ensure one sweet and sour sauce container was clean with no residue left outside of the container. 3. Ensure the ice machine water filter was changed according to its replace date and according to the manufacturer's policy. 4. Ensure the residents' refrigerator temperature log was updated daily for three dates. 5. Ensure chocolate milk and vanilla and chocolate ice cream inside the residents' refrigerator were labeled with name and date. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to food borne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 44 of 46 medically compromised residents who received food and ice from the kitchen. Findings: 1. During a concurrent kitchen observation and interview on 12/15/2025 at 7:53 a.m., with [NAME] 1 (CK 1), observed one bin with potatoes and one bin with onions not labeled with the date it was received. CK 1 verified and stated that all perishable (usually food, that is likely to spoil, decay or go bad) food should be labeled with the date when it was received to be able to know what to use first when serving food. During an interview on 12/15/2025 at 3:25 p.m., with the Dietary Supervisor (DS), the DS stated that all perishable food delivered to the facility should be labeled with the date when it was received due to food safety. During a review a review of facility's policy and procedure (P&P) titled, Food Receiving and Storage, revised on 1/2025, the P&P indicated, When food, food products or beverages are delivered to the nursing home, facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all foods stored. 2. During a concurrent observation and interview on 12/15/2025 at 8:14 a.m., with CK 1, observed one sweet and sour sauce container with residue left outside of the container. CK 1 verified and stated that the sweet and sour sauce container was dirty, and it should be clean with no residue left prior to returning it back to the refrigerator. During an interview on 12/15/2025 at 3:25 p.m., with the DS, the DS stated that they need to clean the sauce containers after each use due to possible risk of contamination and food safety. During a review a review of facility's P&P titled, Safe Food Preparation, revised on 1/2025, the P&P indicated, Facility follows proper sanitation and food handling practices to prevent the outbreak of foodborne illness. 3. During a concurrent observation and interview on 12/16/2025 at 11:12 a.m., with the DS, observed the ice machine water filter. The ice machine water filter was labeled installed on 5/16/2025 and replace 11/16/2025. The DS validated and stated that the ice machine water filter was supposed to be changed to make sure water was filtered properly due to possible water contamination which can lead to possible foodborne illness if ingested. During a review a review of facility's P&P titled, Ice Machine and Storage Chests, revised on 1/2025, the P&P indicated, Ice machines and ice storage/distribution chests will be used and maintained per manufacturer's guidelines to ensure the safe and sanitary supply of ice. During a review of the ice machine manufacturer's instructions, undated, the ice machine manufacturer's instructions indicated, All the components and surfaces exposed to water or ice cubes, like the ice storage bin, water tank, evaporator, water pump, silicone tube, water outlet pipe, etcetera should be cleaned six (6) months after the first use. 4. During a concurrent observation, interview, and record review on 12/15/2025 at 8:31 a.m., with the Director of Maintenance (DOM), observed the residents' refrigerator. Observed chocolate milk and vanilla and chocolate ice creams not labeled with resident's name and date. The DOM stated that facility staff needs to label all the food with the resident's name and the date when it was received since they must throw away the food after three (3) days. Reviewed the residents' refrigerator temperature log which indicated missing daily temperatures for the dates of 12/12/2025, 12/13/2025, and 12/14/2025. The DOM validated the missing refrigerator temperature checks for the three (3) days and stated that the facility was supposed to check the temperature of the residents' refrigerator and record it using the facility's Refrigerator/Freezer Temperature Log.During an interview on 12/15/2025 at 3:25 p.m., with the DS, the DS stated that it was important to check the temperature of the residents' refrigerator daily. The DS stated all food put in the residents' refrigerator should have labels with name and date when it was received, due to the possibility of food poisoning if the food was not in the proper temperature and if the food was left for too long. During a review of the facility's policy and procedure (P&P) titled, Use and storage of food brought to resident, revised on 6/2025, the P&P indicated, To ensure safe food practices and the prevention of foodborne illnesses, the facility shall provide safe and sanitary storage of food brought to residents by family and visitors for a period not to exceed 48 hours. The P&P indicated, Temperature Control of perishable (usually food, that is likely to spoil, decay or go bad) foods must be refrigerated at 41-degree Fahrenheit (unit for temperature) or below. The P&P also indicated, All food brought in should be labeled with resident name, and date delivered.

Based on interview and record review, the facility failed to provide a resident's representative with information regarding formulating an advance directive (AD- a legal document indicating resident preference on end-of-life treatment decisions) for one of 12 sampled residents (Resident 16).This deficient practice had the potential for Resident 16 and their representative to not be informed of their right to formulate an advance directive and not honor the resident's wishes regarding end-of-life care.Findings: During a review of Resident 16's admission Record, the admission Record indicated the facility originally admitted the resident on 1/30/2025 with diagnoses including anxiety disorder (a mental health condition where you experience excessive, persistent worry, fear, or nervousness that doesn't go away and interferes with daily life) and history of falling. During a review of Resident 16's Minimum Data Set (MDS- a resident assessment tool) dated 11/4/2025, the MDS indicated the resident`s cognitive skills for daily decision making was intact. The MDS further indicated that Resident 16 required partial to moderate assistance with activities of daily living (ADL- activities related to personal care).During a review of Resident 16`s History and Physical dated 1/30/2025, the H&P indicated that the resident does not have the capacity to make healthcare decisions; however able to decide for activities of daily living and able to make needs known. During a concurrent interview and record review on 12/18/2025 at 9:30 a.m., with the Social Services Director (SSD), reviewed Resident 16`s H&P 1/30/2025. The SSD stated that the AD was offered to Resident 16 but Resident 16 declined assistance. The SSD stated that he (SSD) should have offered assistance to Resident 16`s responsible party regarding formulating an AD since Resident 16 has no capacity to make health care decisions.During a review of the facility`s policy and procedure (P&P) titled, Advance Directive, last reviewed on 1/28/2025, the P&P indicated, Residents have the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.if a resident is unable to make health care decision, a decision by the resident`s legal representative to forego treatment may, subject to State requirements, be equally binding on the facility.

Based on interview and record review, the facility failed to follow a physician's order by failing to notify a resident's physician regarding a resident having signs and symptoms of bleeding for one of six sampled residents (Resident 2). This deficient practice had the potential to result in worsening symptoms and negatively affect the delivery of care and services to Resident 2.Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 8/14/2025 with diagnoses including ventricular fibrillation (life-threatening heart rhythm), myocardial infarction (heart attack-when blood flow to a part of the heart muscle gets blocked), and end stage renal disease (ESRD-a medical condition in which a person's kidneys [organ in the body that filters waste and excess fluid from the blood] stop functioning on a permanent basis). During review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 11/21/2025, the MDS indicated Resident 2 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and needed maximal assistance from staff for activities of daily living (ADLs- activities related to personal care). The MDS also indicated Resident 2 was receiving anticoagulant (medication used to treat and prevent blood clots [gel-like clumps of blood]) medication. During a review of Resident 2's Care Plan (CP- a document that summarizes a resident's needs, goals, and care/treatment) dated 8/19/2025, the CP indicated that Resident 2 was high risk for bleeding, bruising, and/or skin discoloration related to anticoagulant therapy. The CP indicated a goal that the resident will remain free of abnormal bleeding or bruising with interventions to monitor/document and report to physician for signs and symptoms of bleeding (abnormal or unexplained bruising, petechiae [tiny pinpoint sized red, purple or brown on the skin or mucous membrane], internal bleeding, nosebleeds, bleeding gums, abnormal bleeding). During a review of Resident 2's Order Summary Report, the Order Summary Report indicated the following orders:- Clopidogrel bisulfate (anticoagulant medication) 75 milligrams (mg- unit of measurement) by mouth (PO) one time a day (QD), ordered 9/5/2025.- Eliquis (anticoagulant medication) 2.5 mg PO two times a day, ordered 11/3/2025.- Eliquis and clopidogrel bisulfate: monitor signs and symptoms of bleeding (abnormal or unexpected bruising, petechiae, internal bleeding, nosebleeds, bleeding gums, abnormal bleeding) by documenting (+) yes or (-) no every shift and notify physician if (+) yes, ordered 11/28/2025.During a review of Resident 2's Medication Administration Record (MAR, a report detailing the medications administered to a resident by the licensed nurse in the facility), the MAR indicated a (+) yes for signs and symptoms of bleeding on the following dates and shifts: - 12/6/2025, 7 am-3 pm shift. - 12/13/2025, 7 am-3 pm, 3 pm-11 pm, and 11 pm-7 am shifts. - 12/14/2025, 7 am-3 pm, 3 pm-11 pm, and 11 pm-7 am shifts. - 12/15/2025, 7 am-3 pm, 3 pm-11 pm, and 11 pm-7 am shifts. - 12/16/2025, 7 am-3 pm, 3 pm-11 pm, and 11 pm-7 am shifts. During a concurrent interview and record review on 12/17/2025 at 10:53 a.m., with Registered Nurse 1 (RN 1), reviewed Resident 2's progress notes and Situation, Background, Assessment, Recommendation (SBAR- a form filled out by licensed nursing staff for the purpose of communicating information about a resident's condition or other issue to other members of the health care team, including a resident's doctor). Resident 2's progress notes and SBAR indicated there was no documentation regarding any signs and symptoms of bleeding and no documentation indicating Resident 2's physician was notified. RN 1 stated that since staff documented that Resident 2 has been having signs and symptoms of bleeding, the staff have to notify the physician and document on the resident's progress notes and/or SBAR. RN 1 also stated that it is important to monitor for signs and symptoms of bleeding and notify Resident 2's physician since Eliquis and clopidogrel bisulfate are high risk medications. During an interview on 12/17/2025 at 11:15 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 2 had some multiple bruising/ skin discolorations on the left upper chest and left upper arm since admission. LVN 1 stated they were not aware that Resident 2 had some new bruising since staff recently had been documenting (+) yes for signs and symptoms of bleeding. LVN 1 stated that if there was any signs and symptoms of bleeding, per the physician order, staff need to report to the physician and document since Resident 2 is high risk for bleeding due to his anticoagulant medication use. During a review of the facility's policy and procedure (P&P) titled, Anticoagulation Clinical Protocol, revised on 1/2025, the P&P indicated, Facility provides care and services consistent with current standards of practice for residents who use anticoagulants. The P&P also indicated, If an individual on anticoagulation therapy shows signs of bruising, hematuria, hemoptysis, or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant.During a review of the facility's P&P titled, Documentation Policy, revised on 1/2025, the P&P indicated, Physician communications as required by regulations (unless using the SBAR form) or additional communications that may arise regarding physician communications should be under what can or should be charted in nursing or other notes.

Based on interview and record review, the facility failed to notify the State Long-Term Care (LTC) Ombudsman (advocates for residents of nursing homes, board and care homes, and assisted living facilities) of a resident's discharge from the facility for one of three sampled residents (Resident 54). This deficient practice had the potential for the ombudsman to not be aware of any potential issues from the discharge.Findings:During a review of Resident 54's admission Record, the admission Record indicated the facility initially admitted Resident 54 on 9/12/2025 with diagnoses including difficulty walking, nicotine dependence (a chronic, compulsive need for nicotine [found in tobacco, cigarettes]), and anxiety disorder (a mental health condition where you experience excessive, persistent worry, fear, or nervousness that doesn't go away and interferes with daily life).During a review of Resident 54's History and Physical (H&P) dated 9/13/2025, the H&P indicated Resident 54 did have the capacity to make medical decisions. During a review of Resident 54's Minimum Data Set (MDS - a resident assessment tool) dated 9/17/2025, the MDS indicated Resident 54 could make herself understood and could understand others. The MDS indicated Resident 54 was independent when eating and required partial assistance from facility staff for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 54's Discharge Summary progress note dated 11/11/2025, the progress note indicated Resident 54 was discharged on 11/11/2025 back to her home at an assisted living facility with all of her belongings and discharge instructions.During a concurrent interview and record review on 12/18/2025 at 9:17 a.m., with the Social Services Director (SSD), reviewed Resident 54's Notice of Transfer form dated 11/11/2025. The SSD stated Resident 54 initiated the discharge on ce her intravenous (IV- medication administered through a vein) antibiotic therapy (medication to treat a bacterial infection) was complete. The SSD stated he (SSD) gave the Notice of Transfer form to Resident 54 but never faxed the form to the Ombudsman because he was advised by the Director of Nursing (DON) that faxing the Notice of Transfer to the Ombudsman is not necessary when the resident initiates the discharge. The SSD stated the DON was out on leave.During an interview on 12/18/2025 at 12:04 p.m., with Registered Nurse 3 (RN 3), RN 3 stated she (RN 3) and another RN had been assisting with DON duties while the DON was on leave. RN 3 stated the Ombudsman should have been notified just in case there was a concern.During a review of the facility's policy and procedure (P&P) titled, Documentation of Discharge or Transferring a Resident, last reviewed 1/2025, indicated the facility will forward a copy of the notices of transfer to the Ombudsman.

Based on observation, interview, and record review, the facility failed to ensure a resident's indwelling urinary catheter (a tube that is inserted into the bladder, allowing urine to drain) tubing was not coiled and allowed the contents to flow freely into the urinary catheter bag (container that connects to a urinary catheter and collects urine) for one of one sampled resident's (Resident 9).This deficient practice had the potential for Resident 9 to develop a urinary tract infection (UTI- an infection in the urinary system). Findings: During a review of Resident 9's admission Record, the admission Record indicated the facility admitted Resident 9 on 10/20/2025 with diagnoses including urinary tract infections, neuromuscular disfunction of the bladder (a condition where the nerves that control the bladder are damaged, preventing it from emptying properly), and chronic kidney disease (a long-term condition where the kidneys are damaged and gradually lose their ability to filter blood properly). During a review of Resident 9's History and Physical (H&P) dated 11/3/2025, the H&P indicated the resident did not have the capacity to make decisions or needs known. During a review of Resident 9's Minimum Data Set (MDS - a resident assessment tool) dated 11/14/2025, the MDS indicated Resident 9 can sometimes make self-understood and can sometimes understand others. During a review of Resident 9's Order Summary Report, the Order Summary Report indicated Resident 9 had an order for an indwelling catheter #FR 16 (French, 16 is the size of the tubing) x 10 milliliter (ml- a unit of volume measurement) to drainage bag due to diagnosis of neurogenic bladder, ordered 10/21/2025.During a review of Resident 9's Care Plan (CP- a document that summarizes a resident's needs, goals, and care/treatment) for at Risk for UTI dated 10/20/2025, the CP indicated an intervention to check the tubing for kinks each shift. During an observation on 12/15/2025 at 9:08 a.m., inside Resident 9's room, observed Resident 9 lying down in bed with a urinary catheter bag hanging on the left side of Resident 9's bed frame. Observed the urinary catheter tubing hung below the middle-left side of the bed and had coils with a kink. The coiled portion of the urinary catheter tubing contained yellow liquid. During a concurrent observation and interview on 12/15/2025 at 9:16 a.m., inside Resident 9's room, with Licensed Vocational Nurse 1 (LVN 1), observed Resident 9's urinary catheter tubing. LVN 1 stated Resident 9's urinary catheter tubing was coiled and contained yellow liquid. LVN 1 stated the urinary catheter tubing should be straight and without kinks in order to drain the urine into the urinary catheter bag. LVN 1 further stated Resident 9 had a history of UTI's and if the urine is not draining properly, the resident could get an infection. During an interview on 12/18/2025 at 12:34 p.m., with Registered Nurse 3 (RN 3), RN 3 stated the urinary catheter tubing should not be coiled or kinked and should be below the bladder level. RN 3 stated that if the urinary catheter tubing is coiled, it can possibly become kinked leading to back flow and possible infection. During a review of the facility's policy and procedure (P&P) titled, Indwelling Catheter Use, last reviewed 1/2025, the P&P indicated the policy of the facility is to provide catheter care to reduce the risk of infections and to position the tubing lower than the body to facilitate drainage. During a review of the facility-provided indwelling catheter insert directions, not dated, the insert indicated to maintain unobstructed free flow of the catheter and tubing.

Based on observation, interview, and record review, the facility failed to store medications in accordance with manufacturer specifications, professional principles and facility policy and procedures, in one (1) of two (2) inspected medication carts (Medication Cart 1) by failing to ensure eye drops were stored separately from orally administered medications.This deficient practice had the potential to increase the risk of infections for residents in the facility and to receive medications in the wrong route (internal versus external routes) possibly leading to adverse health consequences. Findings: During a concurrent observation and interview on 12/16/2025 at 10:18 a.m. with Licensed Vocational Nurse (LVN) 3, in Medication Cart 1, the following medications were stored in a manner contrary to the facility's P&P:a. One (1) eye drop solution stored with sodium chloride oral tablet, glucosamine oral capsule and oyster shell calcium oral tablets in the same bin of the medication cart.LVN 3 stated that orally administered medications and eye drops should be stored separately in their own sections/bins, not together, to prevent errors in wrong route administration. LVN 3 stated the eye drop solution should have been separated from sodium chloride oral tablet, glucosamine oral capsule and oyster shell calcium oral tablets. During an interview on 12/16/2025 at 3 p.m. with the Assistant Director of Nursing (ADON), ADON stated internally (such as oral, intravenous) and externally (such as eyes, ears, nose, skin) administered medications should be stored separately to prevent wrong route administration, infections and contaminations. The DON stated the facility failed to store eye drops in Medication Cart 1 separately from the oral medications such as sodium chloride oral tablet, glucosamine oral capsule and oyster shell calcium oral tablets. During a review of the facility's Policies and Procedures (P&P,) titled Pharmaceutical Services - Labeling and Storage, last reviewed 1/28/2025, the P&P indicated: Externally used drugs in liquid, tablet, capsule or powder form shall be stored separately from drugs for internal use.

Based on observation, interview, and record review, the facility failed to ensure a resident's water pitcher was not placed on the floor for one of one sampled resident (Resident 16).This deficient practice had the potential to result in contamination of the drinking water that can lead to waterborne diseases caused by pathogens (bacteria, viruses, parasites) spread through contaminated water, leading to symptoms like diarrhea and vomiting. Findings: During a review of Resident 16's admission Record, the admission Record indicated the facility originally admitted the resident on 1/30/2025 with diagnoses including anxiety disorder (a mental health condition where you experience excessive, persistent worry, fear, or nervousness that doesn't go away and interferes with daily life) and history of falling. During a review of Resident 16's Minimum Data Set (MDS- a resident assessment tool) dated 11/4/2025, the MDS indicated the resident`s cognitive skills for daily decision making was intact. The MDS further indicated that Resident 16 required partial to moderate assistance with activities of daily living (ADL- activities related to personal care).During an observation on 12/15/2025 at 11:15 a.m., observed two (2) water pitchers on the floor by Resident 16's bedside while the resident was in bed sleeping. During a concurrent observation and interview on 12/15/2025 at 12:09 p.m., with the Director of Staff Development/Infection Preventionist Nurse (DSD/IPN), the DSD/IPN stated that residents' water pitchers are replaced twice a day and when staff bring in the pitchers it must be placed on the clean nightstand or bedside table. The DSD/IPN confirmed by stating that two water pitchers were on the floor by Resident 16's bedside. The DSD/IPN stated that the water pitchers should not be on the floor since the floor is considered a dirty surface and the content of the water pitchers can get contaminated which can result in the residents getting sick with waterborne diseases. During a review of the Centers for Disease Control and Prevention (CDC, national public health agency) source material, Guidelines for Environmental Infection Control in Health-Care Facilities, updated 7/2019, indicated floors can become rapidly contaminated from airborne microorganisms and those transferred from shoes, equipment wheels, and body substances.

Based on interview and record review the facility failed to implement its policy and procedure titled Abuse Prohibition and Prevention Program, for one of three sampled residents (Resident 1) by failing to ensure Licensed Vocational Nurse 1 (LVN 1) was not assigned to Resident 1 after an allegation of emotional abuse was made. This deficient practice resulted to Resident 1 feeling uncomfortable and had the potential to place Resident 1 at risk for further abuse that could have resulted in Resident 1 needing additional care or emotional support. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated the facility admitted Resident 1 on 9/17/2024 with diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) with exacerbation (an increase in the severity of the disease) and generalized muscle weakness. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 10/31/2024, the MDS indicated the resident had intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). The MDS indicated Resident 1 was dependent on staff with toileting hygiene, shower/bathing, and dressing. During a review of Resident 1's Change of Condition (COC- a significant change in resident's health status) form, dated 11/7/2024, timed at 8:41 a.m., the COC indicated Resident 1 reported an allegation of emotional abuse. During a review of the facility's Investigation Conclusion Report dated 11/13/2024 indicated Resident 1 alleged that LVN 1 (while providing care and treatment) told Resident 1 that she (Resident 1) was taking too long and that everyone was laughing at her (Resident 1). The Investigation Conclusion Report indicated LVN 1 was suspended on 11/7/2024 due to the allegation and while the investigation is ongoing. The Investigation Conclusion Report further indicated LVN 1 will no longer be assigned to Resident 1 moving forward. During a phone interview on 11/19/2024 at 9:44 a.m. with Family Member 1 (FM 1) and FM 2, FM 1 stated Resident 1 had asked Licensed Vocational Nurse 1 (LVN 1) for a kind word and LVN 1 replied that she would not say anything kind and laughed at her. FM 1 stated LVN 1 then told Resident 1 everyone makes fun of her. FM 2 stated they (FM 1 and FM 2) learned about this incident on 11/7/2024, then spoke to the Administrator (ADM) about it and ADM stated LVN 1 would no longer come into Resident 1's room or provide care for Resident 1 again. However, FM 2 stated LVN 1 did go into Resident 1's room and gave Resident 1 her medications on at least one more occasion after the discussion with ADM on 11/7/2024. During a concurrent interview and record review on 11/19/2024 at 12:34 p.m. with LVN 1, Resident 1's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 11/2024 indicated LVN 1 administered medications to Resident 1 on 11/10/2024. LVN 1 stated she (LVN 1) was suspended on 11/7/2024, but the Director of Nursing (DON) called her the next day and said she (LVN 1) was able to come back, but she would need to bring another staff member in the room with her if she needed to care for Resident 1. LVN 1 stated she did give Resident 1 her (Resident 1's) medications on 11/10/2024 with a registered nurse (not specified) present in the resident's room with her. During a concurrent interview and record review on 11/19/2024 at 2:32 p.m. with the ADM, the facility's Investigation Conclusion Report dated 11/13/2024 was reviewed. The ADM stated Resident 1 preferred for LVN 1 to not be Resident 1's nurse moving forward however, he (ADM) had spoken to Resident 1 on 11/9/2024 and Resident 1 was okay with LVN 1 providing care if another staff member was present. During a follow-up phone interview on 11/19/2024 at 3:53 p.m. with FM 1, FM 2, and Resident 1, Resident 1 stated when she (Resident 1) spoke with ADM before LVN 1 had returned to work, she (Resident 1) told ADM she (Resident 1) did not want LVN 1 anywhere near her or in her room anymore. Resident 1 stated she was told that LVN 1 would not care for her any longer. Resident 1 stated no one informed her (including ADM) that LVN 1 might be assigned to her care and treatment, and that another staff member would be present with LVN 1. Resident 1 stated she (Resident 1) never agreed to that. Resident 1 stated she (Resident 1) felt uncomfortable because LVN 1 was assigned to her again and administered her medications after Resident 1 verbalized she (Resident 1) does not want LVN 1 anywhere near her. During an interview on 11/19/2024 at 4:19 p.m. with the DON, the DON stated if Resident 1 is uncomfortable with LVN 1, the facility should have not assigned LVN 1 to Resident 1. The DON further stated there would always be at least one other nurse available that could give Resident 1's medications or care for her. During an interview on 11/19/2024 at 4:27 p.m. with the ADM, the ADM stated if a resident is not comfortable with a nurse, the facility should accommodate the resident's needs and preference and not have the nurse work with the resident anymore. During a review of the facility's policy and procedure (P&P) titled, Abuse Prohibition and Prevention Program, last revised in 4/2024, the P&P indicated it is the facility's policy to ensure protection for the health, welfare and rights of each resident residing in the facility and to assure the facility is doing all that is within its control to prevent occurrences of abuse.

Based on interview and record review the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm by one resident towards another) for one of three sampled residents (Resident 33) when on 11/3/2024 at 7:00 a.m., Resident 47 (roommate) threw a cup at Resident 33 hitting Resident 33's forehead. This deficient practice resulted in Resident 33 being subjected to physical abuse by Resident 47 while under the care of the facility. Resident 33 sustained a laceration (a deep cut or tear in the skin) on the forehead and required transfer to General Acute Care Hospital 1 (GACH 1). Resident 1 received sutures (a stitch or a row of stitches holding together the edges of a wound). Based on the Reasonable Person Concept (the usual behavior of an average person under the same circumstances), due to Resident 33's severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and medical condition, an individual subjected to physical abuse may have physical pain, psychological pain (mental or emotional) effects including feelings of hopelessness (a feeling or state of despair or lack of hope), helplessness (the belief that there is nothing that anyone can do to improve a bad situation, and humiliation (the feeling of being ashamed or losing respect for own self). Findings: a. During a review of Resident 33's Face Sheet (admission record), the Face Sheet indicated the facility admitted Resident 33 on 10/06/2023 with diagnoses including dementia (a progressive state of decline in mental abilities) and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of Resident 33's Minimum Data Set (MDS - a resident assessment tool), dated 10/10/2024, the MDS indicated Resident 33 had severely impaired cognition. The MDS indicated Resident 33 was dependent (helper does all the effort; resident does none of the effort to complete the activity) on staff with dressing, toileting, and personal hygiene. During a review of Resident 33's Situation, Background, Assessment, Recommendation Report (SBAR- a form used to facilitate prompt communication regarding a change in a resident's health condition), dated 11/3/2024, the SBAR indicated on 11/3/2024 at 7:00 a.m., Resident 33's roommate (Resident 47) acted aggressively towards Resident 33, hit the resident (Resident 33) with a plastic cup which caused Resident 33 to sustain a laceration measuring four (4) centimeters (cm, a unit of measure in length). The SBAR indicated a Certified Nursing Assistant (CNA [CNA 4]) found Resident 33 bleeding on his face. The SBAR indicated 911 (emergency number used to request emergency assistance) was called due to the laceration continuously bleeding, paramedics (a person who is trained to give medical help in emergency situations) came at 7:18 a.m. and took over the care. During a review of Resident 33's Nursing Progress Notes, dated 11/3/2024, the Nursing Progress Notes indicated on 11/3/2024 at 7:18 a.m., the paramedics came and took over Resident 33's care. The Nursing Progress Note indicated the paramedics took Resident 33 to GACH 1 for further evaluation. During a review of Resident 33's GACH 1 emergency room Discharge Summary, dated 11/3/2024, the discharge summary indicated Resident 33 received treatment for a four cm forehead laceration between the eyes, which was repaired with sutures. During a review of Resident 33's Nursing Progress Notes, dated 11/3/2024 at 2:05 p.m., the Nursing Progress Notes indicated Resident 33 returned from GACH 1 with six stitches on the mid (middle area) forehead. During a review of Resident 33's Physician's Orders, dated 11/3/2024, the Physician Orders indicated an order to cleanse the mid forehead laceration with sutures with normal saline (a salty solution used for cleaning wounds), pat dry, paint with betadine (used to reduce the risk of infection), and cover with a dry dressing (a dressing that absorbs moisture from a wound), every day shift for 14 days. During a review of Resident 33's Care Plan (CP) for Abuse, created 11/03/2024, the CP indicated Resident 33 received physical aggression (any behavior which involves attacking another person with the intent of harming) from the roommate. The care plan indicated a goal that Resident 33 will not have any negative outcomes related to the altercation through the next review. The care plan indicated interventions including informing local law enforcement, notifying the physician, and for nursing department to monitor for signs of emotional distress (a general term for a range of negative emotional reactions that can result from a stressful event or situation). b. During a review of Resident 47's Face Sheet, the Face Sheet indicated the facility admitted Resident 47 on 8/28/2024 and readmitted on [DATE] with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 47's MDS, dated [DATE], the MDS indicated Resident 47 had intact cognition. The MDS indicated Resident 47 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying as resident completes an activity) with oral hygiene, dressing, and wheeling self in wheelchair. During a review of Resident 47's SBAR, dated 11/3/2024, the SBAR indicated Resident 47 initiated physical aggression towards another resident. The SBAR indicated Resident 47 complained the roommate (Resident 33) repeatedly called him the N-word, which upset him and verbalized (told) throwing the plastic cup at the roommate (Resident 33). The SBAR indicated when Resident 47 was asked if he is aware that the roommate is bleeding because of the laceration Resident 33 sustained from his (Resident 47's) action; Resident 47 stated, I don't care, nobody can call me the N-word. During a review of Resident 47's Social Services Progress Note, dated 11/4/2024, the Social Services Progress Note indicated the Social Services Director (SSD) spoke with Resident 47 regarding the incident on 11/3/2024 with his old roommate (Resident 33). The Social Services Progress Note indicated that Resident 47 stated that he (Resident 47) threw his empty coffee cup at his roommate (Resident 33) because he (Resident 33) repeatedly called him (Resident 47) the N-word and he (Resident 47) felt insulted, so he threw the cup at him (Resident 33). During a review of Resident 47's CP for Physical Aggression, created 11/3/2024, the CP indicated Resident 47 will not have any negative outcomes related to altercation through next review date. The Care Plan indicated interventions to provide one-to-one (when one staff is assigned to monitor one resident at all times) monitoring by a CNA. During an interview with Licensed Vocational Nurse 3 (LVN 3) on 11/05/2024 at 8:23 a.m., LVN 3 stated she (LVN 3) went to the room of Resident 33 and Resident 47 on 11/3/2024 at approximately 7:00 a.m. at the start of the 7:00 a.m. to 3:00 p.m. shift. LVN 3 stated Resident 33 was bleeding continuously to the mid-forehead despite the application of a pressure dressing (a bandage that applies pressure to a wound to help it heal). LVN 3 stated Resident 47 was in the room and stated, he (Resident 33) kept calling me the N-word, so I hit him with a cup. LVN 3 stated 911 was called, the paramedics arrived and took Resident 33 to the GACH 1. LVN 3 stated Resident 47 was moved to a different room from Resident 33. LVN 3 stated Resident 33 returned from GACH 1 at approximately 2:30 p.m. with sutures in his forehead. LVN 3 stated this incident is being treated as physical abuse and that a CNA is monitoring Resident 47, at all times. During an interview with Resident 47 on 11/05/2024 at 11:20 a.m., Resident 47 stated he hit Resident 33 with a coffee cup because he (Resident 33) called him the N-word. Resident 47 stated police came to the facility and stated he (Resident 47) had every right to do what he did. During an interview with the Director of Nursing (DON) on 11/07/2024 at 9:19 a.m., the DON stated the physical abuse allegation was substantiated (to show something to be true, or to support a claim with facts) because Resident 47 stated he hit Resident 33 because he became offended when Resident 33 called him the N-word. The DON stated it is important to keep residents safe from abuse to protect the residents and keep them from injury. During an interview with the Administrator (ADM) on 11/07/2024 at 1:59 p.m., the ADM stated the abuse allegation was substantiated because Resident 47 acted willfully (done intentionally, or on purpose) when he threw the cup at Resident 33. During a review of the facility ' s policy and procedure (P&P) titled, Abuse Prevention and Prohibition Program, last reviewed on 10/29/2024, the P&P indicated the residents have the right to be free from mistreatment, neglect (fail to care for properly), abuse The policy and procedure indicated facility staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, misappropriation (unauthorized, improper, or unlawful use) of resident property, or deprivation of goods necessary to attain or maintain physical, mental, and psychosocial well-being.

Based on observation, interview, and record review, the facility failed to provide care in accordance with professional standards by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (fatty area beneath the skin) administration sites of insulin (a hormone that lowers blood sugar) for one (Resident 30) of five sampled residents investigated for unnecessary medications. This deficient practice had the potential for adverse effects (undesired harmful effect resulting from a medication) of same site subcutaneous administration of insulin such as lipodystrophy (when fat cells accumulate under the skin from repeated injections in the same place). Findings: During a review of Resident 30's Face Sheet (admission record), the Face Sheet indicated the facility admitted the resident on 9/11/2023 with diagnoses that included diabetes mellitus (high blood sugar). During a review of Resident 's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/12/2024, the MDS indicated Resident 30 was cognitively (the process of acquiring knowledge and understanding through thought, experience, and the senses) intact with skills required for daily decision making. The MDS indicated Resident 30 required setup help (helper sets us or cleans up; resident completes activity) with eating. The MDS indicated Resident 30 receives insulin injections. During a review of Resident 30's Care Plan (CP) for Diabetes Mellitus, the CP indicated a goal the resident will remain free from complications related to diabetes through the review date. The care plan indicated an intervention to rotate insulin injection sites. During a review of Resident 30's Physician's Orders, the documents indicated the following: - Insulin Glargine Subcutaneous Solution Pen-injector 100 units per milliliter (unit/ml, a unit of measure for insulin), inject 34 units subcutaneously at bedtime for diabetes mellitus; rotate sites, dated 7/16/2024. - Insulin Glargine Subcutaneous Solution Pen-injector 100 units/ml, inject 46 units subcutaneously one time a day for diabetes mellitus, give before breakfast, dated 7/16/2024. - Novolog FlexPen Subcutaneous Solution Pen-injector 100 unit/ml, inject as per sliding scale subcutaneously before meals and at bedtime for diabetes mellitus; rotate injection sites: -If 0 - 200 milligrams per deciliter (mg/dL, a unit of measure for blood sugar) give no units. - if BS is less than 70 mg/dL, give orange juice and call the physician - if 201 - 250 mg/dL, give 3 units. - if 251 - 300 mg/dL, give 4 units. - if 301 - 350 mg/dL, give 6 units. - if 351 - 400 mg/dL, give 9 units. - if 401 - 450 mg/dL, give 12 units - if blood sugar is greater than 401, notify the physician, dated 2/28/2024. - Novolog FlexPen Subcutaneous Solution Pen-injector 100 unit/ml, inject as per sliding scale subcutaneously before meals and at bedtime for diabetes mellitus; rotate injection sites: - if 0 - 200 milligrams per deciliter (mg/dL, a unit of measure for blood sugar) give no units. - if BS is less than 70 mg/dL, give orange juice and call the physician - if 201 - 250 mg/dL, give 4 units. - if 251 - 300 mg/dL, give 6 units. - if 301 - 350 mg/dL, give 8 units. - if 351 - 400 mg/dL, give 10 units. - if 401 - 450 mg/dL, give 12 units - if blood sugar is greater than 401, notify the physician, dated 10/07/2024. During a review of Resident 30's Location of Administration Record, dated 10/01/2024 to 10/31/2024, the Location of Administration Record indicated insulin administered on the following dates and sites: - On 10/01/2024 at 5:48 p.m., insulin was administered on the abdomen on the left upper quadrant (left upper part of the abdomen). - On 10/01/2024 at 9:25 p.m., insulin was administered on the abdomen on the left upper quadrant. - On 10/07/2024 at 5:41 a.m., Novolog FlexPen insulin was administered on the abdomen on the left upper quadrant. - On 10/07/2024 at 5:42 a.m., Glargine insulin was administered on the abdomen on the left upper quadrant. - On 10/08/2024 at 6:31 a.m., Glargine insulin was administered on the abdomen on the right upper quadrant. - On 10/08/2024 at 10:21 p.m., Glargine insulin was administered on the abdomen on the right upper quadrant. - On 10/15/2024 at 6:31 a.m., Glargine insulin was administered on the abdomen on the right upper quadrant. - On 10/15/2024 at 9:36 p.m., Glargine insulin was administered on the abdomen on the right upper quadrant. - On 10/24/2024 at 5:38 a.m., Glargine insulin was administered on the abdomen on the right lower quadrant. - On 10/24/2024 at 5:38 a.m., Novolog FlexPen insulin was administered on the abdomen on the right lower quadrant. - On 10/25/2024 at 11:50 a.m., Novolog insulin was administered on the abdomen on the left upper quadrant. - On 10/25/2024 at 5:53 p.m., Novolog insulin was administered on the abdomen on the left upper quadrant. - On 10/26/2024 at 4:25 p.m., Novolog insulin was administered on the abdomen on the right lower quadrant. - On 10/26/2024 at 9:26 p.m., Novolog insulin was administered on the abdomen on the right lower quadrant. - On 10/29/2024 at 5:32 p.m., Novolog insulin was administered on the abdomen on the right lower quadrant. - On 10/29/2024 at 9:40 p.m., Novolog insulin was administered on the abdomen on the right lower quadrant. - On 10/31/2024 at 6:16 a.m., Glargine insulin was administered on the abdomen on the right lower quadrant. - On 10/31/2024 at 6:16 a.m. Novolog insulin was administered on the abdomen on the right lower quadrant. During an observation and interview with Resident 30 on 11/04/2024 at 9:30 a.m., Resident 30 stated she receives insulin. When asked if staff rotate the insulin injection sites, she stated she gets the injections in her stomach but did not know that the injection sites need to be rotated. During an interview and observation with Licensed Vocational Nurse 2 (LVN 2) on 11/06/2024 at 1:49 p.m., observed the computer charting at a computer terminal at one of the medication carts for the MAR (also known as eMAR). LVN 2 demonstrated how to see the last three instances of where the insulin was given on a resident. The LVN 2 stated it is the practice of the facility to rotate insulin injection sites. During a concurrent record review and interview with LVN 5 on 11/07/2024 at 7:25 a.m., reviewed Resident 30's 10/2024 MAR. LVN 5 stated he gave insulin without rotating sites on 10/07/2024, 10/24/2024, and 10/31/2024. LVN 5 stated Resident 30 lifts their shirt and indicates the place to administer the insulin. LVN 5 stated he has not educated Resident 30 on the importance of rotating insulin injection sites. LVN 5 stated it is important to rotate insulin injection sites to not cause a fatty lump or irritate the skin. During a concurrent interview and record review with the Director of Nursing (DON) on 11/07/2024 at 1:22 p.m., reviewed Resident 30's 10/2024 MAR. The DON confirmed that the instances in which the insulin infection sites were not rotated. The DON stated it is the policy to rotate injection sites for residents who are prescribed insulin. The DON stated this is important to avoid causing lipodystrophy. A review of the facility's policy and procedure titled, Insulin Administration, last reviewed 10/29/2024, indicated insulin injection sites should be rotated to reduce the risk of damaging the skin tissue.

Based on interview and record review, the facility failed to ensure residents who receive apixaban (a medication that treats and helps prevents blood clots in the heart and blood vessels) were accurately monitored for side effects (an often harmful and unwanted effect) for one of six sampled residents (Resident 13). This deficient practice had the potential to result in Resident 13 experiencing adverse side effects (unwanted, uncomfortable, or dangerous effects that a drug may have) from the anticoagulant including unusual bruising (a mark on the skin that occurs when small, bleeding from the gums or nose, and having blood in the stool. Findings: During a review of Resident 13's Admission Record, the Admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to, epilepsy (a brain disorder that causes seizures [sudden, uncontrolled electrical disturbances in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]), acute kidney failure (when the kidneys suddenly cannot filter waste products from the blood), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and dementia (a progressive state of decline in mental abilities). During a review of Resident 13's History and Physical (H&P), dated 7/7/2024, the H&P indicated Resident 13 does not have the capacity to understand and make decisions. During a review of Resident 13's Minimum Data Set Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/13/2024, the MDS indicated the resident had severely impaired cognition (thought processes) and was dependent on staff for all activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 13's physician's orders, the orders indicated the following orders: 1. Apixaban 2.5 milligram (mg) tablet: give one tablet twice a day for atrial fibrillation, dated 9/8/2024. 2. Apixaban: monitor for signs and symptoms of bleeding (abnormal or unexplained bruising, petechiae, internal bleeding, nosebleeds, bleeding gums, abnormal bleeding), dated 9/8/2024. During a review of Resident 13's care plan (a document that summarizes a patient's health conditions, treatments, and care needs), titled The resident has high risk for bleeding, bruising, and/or skin discoloration related to anticoagulant therapy apixaban ., revised on 9/8/2024, the care plan indicated to monitor, document, and report to the doctor signs and symptoms of anti-coagulant complications including bruising. During a concurrent interview and record review on 11/6/2024 at 3:39 p.m. with Licensed Vocational Nurse (LVN) 4, Resident 13's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) dated 10/16/2024 and Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 10/1/2024-10/31/2024 were reviewed. The SBAR indicated Resident 13 had bruising to the right knee and right toes. The 10/2024 MAR did not indicate Resident 13 experienced any bruising in October 2024. LVN 4 stated bruising should be documented each shift in the MAR under the order to monitor for signs and symptoms of bleeding and bruising and she could not explain why there is bruising noted in Resident 13's SBAR but not in the MAR. LVN 4 stated if bruising is present but not properly documented it could affect the resident because apixaban can cause bruising as a side effect and they might need to notify the doctor and possibly hold the medication. During an interview on 11/6/2024 at 4:26 p.m. with the Director of Nursing (DON), the DON stated Resident 13's bruising should have been documented in the MAR. The DON stated they may not be able to accurately inform the physician of all side effects of the medication if the side effects are not all documented. During a concurrent interview and record review on 11/7/2024 at 3:01 p.m. with the DON, the manufacturer's guidelines for apixaban provided by the facility, dated December 2012, was reviewed. The DON stated they do not have a facility policy regarding anticoagulant side effect monitoring, but they do follow the manufacturer's guidelines. The manufacturer's guidelines indicated apixaban can cause bleeding and bruising and any unusual bleeding should be evaluated and reported to a physician.

Based on interview and record review, the facility failed to ensure a resident was free from unnecessary psychotropic drugs (any drug that affects behavior, mood, thoughts, or perception in excessive dose, excessive duration, without adequate monitoring) for one of six sampled residents (Residents 10) by failing to ensure Resident 10 received the correct dose of duloxetine (medication that is used to treat depression [a persistent feeling of sadness or a lack of interest in outside stimuli]) as ordered by the physician. This deficient practice resulted in an administration of excessive dose of duloxetine to Resident 10 and had the potential to place the resident at risk for significant adverse consequence (unwanted, uncomfortable, or dangerous effects that a drug may have) from the use of unnecessary psychotropic drug, which could result to impairment (being weakened) or decline (gradually become less) in the resident's mental, physical condition, functional, and psychosocial status. Findings: During a review of Resident 10's Admission Record, the Admission Record indicated the facility originally admitted the resident on 6/1/2020, and readmitted on [DATE], with diagnoses including major depressive disorder (characterized by a persistent feeling of sadness or a lack of interest in outside stimuli), difficulty in walking, and type two diabetes mellitus (a disorder characterized by difficulty in blood sugar control). During a review of Resident 10's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 8/20/2024, the MDS indicated the resident`s cognitive skills (the brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was moderately impaired (decisions poor, cues/supervision required). The MDS indicated that Resident 10 was feeling down, tired, was depressed, and experiencing low levels of energy. The MDS further indicated that Resident 10 was taking antidepressant medication (medication used to treat depression). During a review of Resident 10`s physician History and Physical (H&P) dated 2/5/2024, the H&P indicated that the resident had the capacity to understand and make decisions. During a review of Resident 10`s Physician Order dated 4/18/2024, the order indicated to administer duloxetine oral capsule 30 milligrams (mg-a unit of measure of mass) by mouth once a day for depression manifested by crying episodes. Further review of Resident 10`s physician orders indicated that the order for duloxetine 30 mg once a day was discontinued on 5/15/2024 and was changed to duloxetine 20 mg once a day with a start date of 5/16/2024. During a review of Resident 10`s Note to Attending Physician/Prescriber Form dated 5/15/2024, the note indicated that the facility`s consultant pharmacist (a healthcare specialist who provides expert advice on medications and pharmaceutical services, including patient safety) recommended a Gradual Dose Reduction (GDR- the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) for duloxetine 30 mg. The note further indicated that Resident 10`s Nurse Practitioner (NP- a nurse who has advanced clinical education and training in administering patient care) agreed with the GDR and then ordered duloxetine 20 mg to be administered by mouth once a day. During a review of Resident 10`s care plan, initiated on 4/18/2024, the care plan indicated that the resident is taking duloxetine 30 mg manifested by crying episodes. The care plan indicated that Resident 10 was at risk for adverse reactions of the medication. The care plan further indicated that a GDR was done, and Resident 10 is currently taking duloxetine 20 mg by mouth daily. The care plan goal for the resident was to not experience adverse side effect of this medication. The care plan interventions were to administer the medication as ordered by the physician, encourage verbalization of needs, fears, and concerns, encourage to join activities of interest to divert the attention (to turn the attention away) positively, and to monitor side effects of anti-depressant during every shift such as headache, dizziness, tremors (shaking in part of body), and dry mouth. During a review of Resident 10`s Medication Administration Record (MAR - a record of mediations administered to residents) for November 2024, indicated that the resident received duloxetine 20 mg from 11/1/2024 to 11/4/2024. During an observation of the medication administration for Resident 10 on 11/5/2024 at 9:06 a.m., Licensed Vocational Nurse 2 (LVN 2) checked duloxetine medication bubble pack (a card that packages doses of medication within small, clear, or light-resistant, plastic bubbles that is punched out to administer to a resident) against Resident 10`s MAR. LVN 2 stated, Resident 10 is required to receive duloxetine 20 mg per her physician`s order, however, the existing bubble pack for duloxetine was for 30 mg. LVN 2 stated that based on the available count of duloxetine in the bubble pack, it appears that Resident 10 was administered 30 mg of duloxetine instead of 20 mg as ordered by the physician. LVN 2 stated Resident 10 was medicated with a greater dose than ordered by her physician. LVN 2 stated she is not going to administer 30 mg of duloxetine and will contact the pharmacy to instead receive the 20 mg of duloxetine which is the correct dose. During a concurrent interview and record review on 11/5/2025 at 9:15 a.m., with the Director of Nursing (DON), Resident 10`s physician orders, MAR, facility`s pharmacy proof of delivery form for October 2024, and bubble pack for duloxetine were reviewed. The DON stated Resident 10`s duloxetine order was changed from 30 mg to 20 mg on 5/15/2024, because the facility`s pharmacy consultant recommended GDR. The DON stated Resident 10 has been receiving duloxetine 20 mg since 5/16/2024. The DON stated the pharmacy delivered duloxetine 30 mg for Resident 10 instead of the of 20 mg on 10/11/2024. The licensed nurses have been administering duloxetine 30 mg to Resident 10 instead of 20 mg for 21 days based on the count on the bubble pack. The DON stated licensed staff are required to check the dosage of medication against physician order to ensure the correct dose of medication is being administered. The DON stated the potential outcome of administering the incorrect dose of duloxetine is over medicating and exposing the resident to possible adverse reactions of the medication such as drowsiness (feeling of being sleepy), and dry mouth. During a review of the facility`s policy and procedure (P&P) titled Medication Administration-General Guidelines, reviewed on 10/29/2024, the P&P indicated that five rights-right resident, right drug, right dose, right route, and right time, are applied for each medication being administered. A triple check of these five rights is recommended at three steps in the process of preparation of a medication for administration, when the medication is selected, when the dose is removed from the container and finally just after the dose id prepared and the medication put away. Prior to administration, the medication and dosage schedule on the resident`s MAR and compared with the medication label. If the label and MAR are different and the container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions, the physician`s orders are checked for the correct dosage schedule. During a review of the facility`s policy and procedure titled Medication Errors, revised March 2024, the P&P indicated that the facility ensures that its residents are free from any significant medication errors, and that its medication error rates are not five percent or greater.

Based on observation, interview, and record review the facility failed to ensure a resident was free from significant medication error by failing to administer the correct dose of duloxetine (medication used to treat depression [a persistent feeling of sadness or a lack of interest in outside stimuli]) as ordered by the physician for one of three sample residents (Resident 10). This deficient practice resulted in an administration of excessive dose of duloxetine to Resident 10 and had the potential to place the resident at risk for significant adverse consequence (unwanted, uncomfortable, or dangerous effects that a drug may have) from the use of unnecessary psychotropic drug, which could result to impairment (being weakened) or decline (gradually become less) in the resident's mental, physical condition, functional, and psychosocial status. Cross reference F758 Findings: During a review of Resident 10's Admission Record, the Admission Record indicated the facility originally admitted the resident on 6/1/2020, and readmitted on [DATE], with diagnoses including major depressive disorder (characterized by a persistent feeling of sadness or a lack of interest in outside stimuli), difficulty in walking, and type two diabetes mellitus (a disorder characterized by difficulty in blood sugar control). During a review of Resident 10's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 8/20/2024, the MDS indicated the resident`s cognitive skills (the brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was moderately impaired (decisions poor, cues/supervision required). The MDS indicated that Resident 10 was feeling down, tired, was depressed, and experiencing low levels of energy. The MDS further indicated that Resident 10 was taking antidepressant medication (medication used to treat depression). During a review of Resident 10`s physician History and Physical (H&P) dated 2/5/2024, the H&P indicated that the resident had the capacity to understand and make decisions. During a review of Resident 10`s Physician Order dated 4/18/2024, the order indicated to administer duloxetine oral capsule 30 milligrams (mg-a unit of measure of mass) by mouth once a day for depression manifested by crying episodes. Further review of Resident 10`s physician orders indicated that the order for duloxetine 30 mg once a day was discontinued on 5/15/2024 and was changed to duloxetine 20 mg once a day with a start date of 5/16/2024. During a review of Resident 10`s Note to Attending Physician/Prescriber Form dated 5/15/2024, the note indicated that the facility`s consultant pharmacist (a healthcare specialist who provides expert advice on medications and pharmaceutical services, including patient safety) recommended a Gradual Dose Reduction (GDR- the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) for duloxetine 30 mg. The note further indicated that Resident 10`s Nurse Practitioner (NP- a nurse who has advanced clinical education and training in administering patient care) agreed with the GDR and then ordered duloxetine 20 mg to be administered by mouth once a day. During a review of Resident 10`s care plan initiated on 4/18/2024, indicated that the resident is taking duloxetine 30 mg manifested by crying episodes. The care plan indicated that Resident 10 was at risk for adverse reactions of the medication. The care plan further indicated that a GDR was done, and Resident 10 is currently taking duloxetine 20 mg by mouth daily. The care plan goal for the resident was to not experience adverse side effect of this medication. The care plan interventions were to administer the medication as ordered by the physician, encourage verbalization of needs, fears, and concerns, encourage to join activities of interest to divert the attention (to turn the attention away) positively, and to monitor side effects of anti-depressant during every shift such as headache, dizziness, tremors (shaking in part of body), and dry mouth. During a review of Resident 10`s Medication Administration Record (MAR - a record of mediations administered to residents) for November 2024, indicated that the resident received duloxetine 20 mg from 11/1/2024 to 11/4/2024. During an observation of the medication administration for Resident 10 on 11/5/2024 at 9:06 a.m., Licensed Vocational Nurse 2 (LVN 2) checked duloxetine medication bubble pack (a card that packages doses of medication within small, clear, or light-resistant, plastic bubbles that is punched out to administer to a resident) against Resident 10`s MAR. LVN 2 stated, Resident 10 is required to receive duloxetine 20 mg per her physician`s order, however, the existing bubble pack for duloxetine was for 30 mg. LVN 2 stated that based on the available count of duloxetine in the bubble pack, it appears that Resident 10 was administered 30 mg of duloxetine instead of 20 mg as ordered by the physician. LVN 2 stated Resident 10 was medicated with a greater dose than ordered by her physician. LVN 2 stated she is not going to administer 30 mg of duloxetine and will contact the pharmacy to instead receive the 20 mg of duloxetine which is the correct dose. During a concurrent interview and record review on 11/5/2025 at 9:15 a.m., with the Director of Nursing (DON), Resident 10`s physician orders, MAR, facility`s pharmacy proof of delivery form for October 2024, and bubble pack for duloxetine were reviewed. The DON stated Resident 10`s duloxetine order was changed from 30 mg to 20 mg on 5/15/2024, because the facility`s pharmacy consultant recommended GDR. The DON stated Resident 10 has been receiving duloxetine 20 mg since 5/16/2024. The DON stated the pharmacy delivered duloxetine 30 mg for Resident 10 instead of the of 20 mg on 10/11/2024. The licensed nurses have been administering duloxetine 30 mg to Resident 10 instead of 20 mg for 21 days based on the count on the bubble pack. The DON stated licensed staff are required to check the dosage of medication against physician order to ensure the correct dose of medication is being administered. The DON stated if a licensed nurse administers the incorrect dose of a medication, it is considered medication error. The DON stated medication error occurred when licensed nurses administered Resident 10 doluxetine 30 mg instead of duloxetine 20 mg. The DON stated the potential outcome of administering the incorrect dose of duloxetine is over medicating and exposing the resident to possible adverse reactions of the medication such as drowsiness (feeling of being sleepy), and dry mouth. During a review of the facility`s policy and procedure titled Medication Errors, revised March 2024, indicated that the facility ensures that its residents are free from any significant medication errors, and that its medication error rates are not five percent or greater. During a review of the facility`s policy and procedure (P&P) titled Medication Administration-General Guidelines, reviewed on 10/29/2024, the P&P indicated that five rights-right resident, right drug, right dose, right route, and right time, are applied for each medication being administered. A triple check of these five rights is recommended at three steps in the process of preparation of a medication for administration, when the medication is selected, when the dose is removed from the container and finally just after the dose id prepared and the medication put away. Prior to administration, the medication and dosage schedule on the resident`s MAR and compared with the medication label. If the label and MAR are different and the container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions, the physician`s orders are checked for the correct dosage schedule.

Based on observation, interview, and record review the facility failed to ensure a safe and sanitary environment and food storage practices in the kitchen when: 1. A single sausage patty was observed exposed and unwrapped on top of an open box containing an unsealed bag of the same sausage patties in Freezer 1. 2. An undated bottle of Gatorade belonging to a staff member was stored in Refrigerator 2. 3. Shelves intended to hold clean trays were observed stained, with crumbs and dust. 4. Two plastic bins holding clean utensils were observed with reddish food residue and crumbs and placed on dusty shelves. These deficient practices had the potential to place the facility residents at risk for foodborne illness (illness caused by food contaminated with bacteria, viruses, and other toxins) and to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another). Findings: During an initial kitchen tour on 11/4/2024 at 7:45 a.m., with [NAME] 1, observed an unwrapped sausage patty on top of an open box containing an unsealed bag of the same sausage patties in the Freezer 1. [NAME] 1 immediately discarded the exposed sausage patty and stated that the bag inside the box was not sealed, and all the sausages were exposed in Freezer 1. [NAME] 1 stated food stored in the freezer must be properly wrapped and sealed to prevent freezer burn (a condition of discoloration or other damage caused to frozen food by evaporation [liquid turns into a gas], typically due to inadequate packaging or storage conditions in the freezer]). [NAME] 1 removed the sausage patty box and disposed of it. During a concurrent observation and interview on 11/4/2024 at 7:45 a.m., in the facility`s kitchen with [NAME] 1, an undated bottle of Gatorade was observed in Refrigerator 2. [NAME] 1 stated the bottle that was left in the refrigerator belongs to one of the staff. [NAME] 1 stated that personal food or drinks are not allowed in the kitchen refrigerator. Observed [NAME] 1 discard the Gatorade bottle. During a concurrent observation and interview on 11/4/2024 at 8:00 a.m. with [NAME] 1, shelves intended to hold clean trays were observed stained, with crumbs and dust. Two plastic bins holding clean utensils were observed with reddish food residue and crumbs and placed on dusty shelves. [NAME] 1 stated the shelves and utensil bins are dirty and dusty. [NAME] 1 stated the potential outcome of dirty kitchen shelves and utensil bin is cross-contamination. During an interview on 11/4/2024 at 12:45 p.m., with Dietary Supervisor (DS), the DS stated food in the freezer must be properly wrapped and sealed to prevent freezer burn. The DS stated personal food or drinks are not permitted to be stored in the kitchen refrigerator or freezer. The DS stated the kitchen staff do not clean the kitchen over the weekend and he (DS) is the one cleaning the kitchen when he arrives to the facility on Mondays. The DS stated the potential outcome of an unclean and unsanitary kitchen environment is cross contamination and infection. During a review of the facility`s policy and procedure (P&P) titled Food Storage, revised on 9/1/2021, the P&P indicated that food items will be stored, thawed, and prepared in accordance with good sanitary practice. Foods to be frozen should be stored in their original containers if designed for freezing. Foods to be frozen should be store in airtight containers or wrapped in heavy-duty aluminum foil, special laminated papers, or plastics. During a review of the facility`s policy and procedure titled Cleaning Schedule, revised on 7/1/2016, the P&P indicated that the dietary staff would maintain a sanitary environment in the dietary department by complying with the routine cleaning schedule developed by Dietary Manager. The Dietary Manager will develop a cleaning schedule that includes the frequency of which equipment, and areas are to be cleaned. The Dietary Manager monitors the cleaning schedule to ensure compliance.

Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition, and current treatments) to meet the resident`s needs for one of five sampled residents (Resident 14) by failing to develop and implement a comprehensive person-centered care plan addressing Resident 14`s problem with communication. This deficient practice had the potential to result in Resident 14 not being able to communicate requests, needs or concerns which could lead to inadequate care of Resident 14. Findings: During a review of Resident 14's Admission Record, the Admission Record indicated the facility admitted the resident on 5/11/2023, with diagnoses including unspecified dementia (a progressive state of decline in mental abilities) , repeated falls, dysphagia (swallowing difficulties), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily activities of living). During a review of Resident 14's Minimum Data Set (MDS -a federally mandated resident assessment tool) dated 8/8/2024, the MDS indicated the resident`s cognitive skills (the brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated that Resident 14 was dependent on staff (helper does all of the effort) for oral hygiene, showering/bathing, upper and lower body dressing, toileting hygiene, and personal hygiene. The MDS indicated Resident 14`s preferred language was Armenian, and he would want or need an interpreter to communicate with a doctor or healthcare staff. During a review of Resident 14`s physician History and Physical (H&P) dated 6/25/2024, the H&P indicated that the resident did not have the capacity to understand and make decisions. During a review of Resident 14`s Psychosocial Assessment/Social History/Discharge Planning Form dated 8/8/2024, it indicated Resident 14`s primary language is Armenian, and Resident 14 is able to speak Armenian and some English. The Psychosocial Assessment/Social History/Discharge Planning Form indicated Resident 14 needed an interpreter to communicate with a doctor or a health care staff. During a review of Resident 14's Care Plan (CP-a document that outlines how a patient's health care needs will be met) on communication problem due to dementia, initiated on 2/24/2024, the CP indicated that the resident was at risk for decline (gradually become worse) in communication skills. The care plan goal for the resident was to be able to make his basic needs known on a daily basis. The care plan interventions were to anticipate and meet the resident`s needs, monitor the effectiveness of communication strategies and assistive devices, use communication techniques which enhance (increase) interaction and to use alternative communication tools as needed such as communication book/board, writing pad, gestures (a movement of the body that expresses an attitude), signs, and pictures. During a concurrent observation and interview on 11/4/2024 at 9:33 a.m., inside Resident 14's room, Resident 14 was not present. Certified Nursing Assistant 1 (CNA 1) who was inside Resident 14`s room stated that Resident 14 was in the activity room. CNA1 stated Resident 14 is confused and can be aggressive towards staff members, speaks Armenian. and is able to say couple of words in English. CNA1 stated that he (CNA 1) is unable to communicate with Resident 14 because Resident 14 does not seem to understand English. CNA1 stated a communication board with pictures and signs is required for residents who do not speak English. CNA1 started looking for a communication board/device at Resident 14`s bedside. However, he did not find one. During a concurrent observation and interview on 11/4/2024 at 9:55a.m. inside the activity room, Resident 14 was observed sitting on his wheelchair, drinking coffee. Resident 14 was able to answer simple questions in Armenian asked by the surveyor. Resident 14 did not have a communication board/device with him. During an observation on 11/5/2024 at 11:30 a.m., inside the activity room, Resident 14 was observed sitting on his wheelchair and an Armenian communication board/device was attached to the resident`s wheelchair. During a concurrent interview and record review on 11/6/2024 at 1:44 p.m., with MDS Coordinator (MDSC), Resident 14`s care plans were reviewed. The MDSC stated Resident 14 is Armenian speaking and he (Resident 14) is unable to speak English fluently. The MDSC stated that she (MDSC) is in charge of developing and updating residents` care plans in the facility. The MDSC stated Resident 14`s care plan for communication was not person centered for him (Resident 14) because the care plan did not indicate the specific language that he (Resident 14) speaks. The MDSC stated there is no care plan developed for Resident 14 indicating that he (Resident 14) speaks Armenian. The MDSC stated the Armenian communication board/device was placed on Resident 14`s wheelchair after the surveyor noticed that there was no communication board available for Resident 14 at his bedside or on his wheelchair. The MDSC stated he missed developing a person-centered care plan for Resident 14 `s inability to communicate. The MDSC stated the potential outcome of not developing a person-centered care plan for residents who have communication problems and English is not their primary language is the inability to address the appropriate care and services that they need. During a review of the facility's policy and procedure (P&P) titled, Develop-Implement comprehensive Care Plans, revised on 03/2023, the P&P indicated that the facility develops a person-centered comprehensive care plans that are culturally competent and trauma-informed, developed and implemented to meet his or her preferences and goals, and address the resident`s medical, physical, mental, and psychosocial needs. Care plans must be person-centered and reflect the resident`s goals for admission and desired outcomes, interventions that reflect the resident`s cultural preferences, values, and practices.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 14) was provided a communication device or board (a tool that includes pictures that help residents communicate their healthcare and every-day needs to facility staff) in his preferred language. This deficient practice had the potential to prevent the resident from communicating with the staff and receiving care in a timely manner. Cross reference F656 Findings: During a review of Resident 14's Admission Record, the Admission Record indicated the facility admitted the resident on 5/11/2023, with diagnoses including unspecified dementia (a progressive state of decline in mental abilities) , repeated falls, dysphagia (swallowing difficulties), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily activities of living). During a review of Resident 14's Minimum Data Set (MDS -a federally mandated resident assessment tool) dated 8/8/2024, the MDS indicated the resident`s cognitive skills (the brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated that Resident 14 was dependent on staff (helper does all of the effort) for oral hygiene, showering/bathing, upper and lower body dressing, toileting hygiene, and personal hygiene. The MDS indicated Resident 14`s preferred language was Armenian, and he would want or need an interpreter to communicate with a doctor or healthcare staff. During a review of Resident 14`s physician History and Physical (H&P) dated 6/25/2024, the H&P indicated that the resident did not have the capacity to understand and make decisions. During a review of Resident 14`s Psychosocial Assessment/Social History/Discharge Planning Form dated 8/8/2024, the form indicated Resident 14`s primary language is Armenian, and Resident 14 is able to speak Armenian and some English. The Psychosocial Assessment/Social History/Discharge Planning Form indicated Resident 14 needed an interpreter to communicate with a doctor or a health care staff. During a review of Resident 14's Care Plan (CP-a document that outlines how a patient's health care needs will be met) on initiated on 2/24/2024, the CP indicated that the resident had a communication problem due to dementia and was at risk for decline (gradually become worse) in communication skills. The care plan goal for the resident was to be able to make his basic needs known on a daily basis. The care plan interventions were to anticipate and meet the resident`s needs, monitor the effectiveness of communication strategies and assistive devices, use communication techniques which enhance (increase) interaction and to use alternative communication tools as needed such as communication book/board, writing pad, gestures (a movement of the body that expresses an attitude), signs, and pictures. During a concurrent observation and interview on 11/4/2024 at 9:33 a.m., inside Resident 14's room, Resident 14 was not present. Certified Nursing Assistant 1 (CNA 1) who was inside Resident 14`s room stated that Resident 14 was in the activity room. CNA1 stated Resident 14 is confused and can be aggressive towards staff members, speaks Armenian. and is able to say couple of words in English. CNA1 stated that he (CNA 1) is unable to communicate with Resident 14 because Resident 14 does not seem to understand English. CNA1 stated a communication board with pictures and signs is required for residents who do not speak English. CNA1 started looking for a communication board/device at Resident 14`s bedside. However, he did not find one. During a concurrent observation and interview on 11/4/2024 at 9:55a.m. inside the activity room, Resident 14 was observed sitting on his wheelchair, drinking coffee. Resident 14 was able to answer simple questions in Armenian asked by the surveyor. Resident 14 did not have a communication board/device with him. During an observation on 11/5/2024 at 11:30 a.m., inside the activity room, Resident 14 was observed sitting on his wheelchair and an Armenian communication board/device was attached to the resident`s wheelchair. During a concurrent interview and record review on 11/6/2024 at 1:44 p.m., with MDS Coordinator (MDSC), Resident 14`s care plans were reviewed. The MDSC stated Resident 14 is Armenian speaking and he (Resident 14) is unable to speak English fluently. The MDSC stated that she (MDSC) is in charge of developing and updating residents` care plans in the facility. The MDSC stated Resident 14`s care plan for communication was not person centered for him (Resident 14) because the care plan did not indicate the specific language that he (Resident 14) speaks. The MDSC stated there is no care plan developed for Resident 14 indicating that he (Resident 14) speaks Armenian. The MDSC stated the Armenian communication board/device was placed on Resident 14`s wheelchair after the surveyor noticed that there was no communication board available for Resident 14 at his bedside or on his wheelchair. The MDSC stated he missed developing a person-centered care plan for Resident 14 `s inability to communicate. The MDSC stated the potential outcome of not providing a communication board/device for a non-English speaking resident is inability to understand the resident and provide care for him. During an interview on 11/7/2024 at 11:16 a.m., with the Director of Nursing (DON), the DON stated staff are required to provide a communication board or device to the residents who do not speak English in the language that they speak. The DON stated Resident 14 was not provided a communication device/board in his primary language. The DON stated the potential outcome of not providing a communication board/device to the residents who do not speak English is the inability to communicate with the resident accurately and understand his needs.

Based on observation, interview, and record review, the facility failed to discard a medicated ointment belonging to Resident 8 from one of one inspected treatment carts after the resident had been discharged . This deficient practice resulted in the facility staff still being able to access a discharged resident's medication. Findings: During a review of Resident 8's Admission Record, the Admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and dementia (a progressive state of decline in mental abilities). The Admission Record indicated Resident 8 was discharged on [DATE]. During a review of Resident 8's History and Physical (H&P), dated 7/30/2024, the H&P indicated Resident 8 does not have the capacity to understand and make decisions. During a review of Resident 8's physician's orders, a discontinued order dated 6/27/2024 indicated to insert one application of Preparation H ointment rectally as needed up to four times a day for hemorrhoids. During an observation on 11/5/2024 at 11:06 a.m. with Treatment Nurse (TN) 1, Resident 8's Preparation H ointment was inside the treatment cart. During a concurrent observation and interview on 11/5/2024 at 2:20 p.m. with the Director of Nursing (DON), Resident 8's Preparation H ointment was in the discarded medications area. The DON stated when a resident is discharged a nurse should remove the medications from the medication and treatment carts and she will put them aside and discard them. During a concurrent interview and record review on 11/6/2024 at 4:26 p.m. with the Director of Nursing (DON), the DON stated Resident 8 was discharged so the Preparation H ointment should be discarded and not on the treatment cart. During a review of the facility's policy and procedure (P&P) titled, Disposal of Medications and Medication-Related Supplies, last reviewed on 10/29/2024, the P&P indicated unused, unwanted, and non-returnable medications should be removed from their storage area and secured until destroyed. The P&P also indicated medications left in the facility after a resident's discharge should be destroyed.

Based on observation, interview, and record review, the facility failed to meet the nutritional needs for one of three sampled residents (Resident 12) by failing to provide a fortified diet (a food that has extra nutrients [important substances you get from food that help your body survive and grow] added to it) as ordered by the physician. This deficient practice had the potential to result in Resident 12's decreased nutritional intake and weight loss. Findings: During a review of Resident 12's Admission Record, the Admission Record indicated that the facility originally admitted the resident on 8/25/2014, and readmitted on [DATE], with diagnoses including dysphasia (swallowing difficulties), anorexia (an eating disorder that causes people to weigh less than is considered healthy for their age and height), unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) . During a review of Resident 12's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 10/25/2024, the MDS indicated the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated Resident 12 was dependent to staff (helper does all of the effort) for eating, oral hygiene, showering/bathing, toileting hygiene, and personal hygiene. The MDS indicated Resident 12 did not have a weight loss of 5% or more within the last month nor did it indicate Resident 12 had a weight loss of 10% or more in the last six months. During a review of Resident 12's Physician Order dated 9/14/2024, the order indicated that the resident should be provided with a diet which includes a regular pureed textured (a smooth texture with no lumps), fortified, and large portioned meals with a moderately thick consistency fluid (fluids that are thicken than regular, still pourable but flows more slowly like honey). During a review of Resident 12`s Nutritional assessment dated [DATE], the assessment indicated that the resident`s current weight was normal within his Ideal Body Weight Range (IBWR-a target weight based on your height and gender). However, the assessment indicated that Resident 12 had a gradual weight loss of nine pounds (lbs.- a unit of weight) within the last year. The assessment further indicated that Resident 12 had a good appetite, and his food intake was 75% and higher. During a review of Resident12's Care Plan (written guide that organizes information about the resident's care) initiated on 9/14/2024, the care plan indicated that the resident had a regular diet, pureed texture, moderately thick consistency, fortified and large portion diet. The care plan goal was to adhere (follow) to the diet as ordered by the physician. The care plan interventions were to monitor the resident`s meal intake, provide a diet as ordered, and to provide the resident with his food preference so long as it does not conflict with his treatment plan. During a concurrent observation and interview on 11/5/2024 at 12:24 p.m., at Resident 12`s bedside with the Dietary Supervisor (DS), Resident 12 was observed lying on his bed. Resident 12's lunch food tray was observed placed on the resident`s side table. Resident 12`s lunch menu ticket indicated a pureed, fortified, and large portioned diet. Resident 12`s lunch tray included pureed vegetables, pureed cheese ravioli, and pureed bread. The DS stated that Resident 12`s lunch tray was not a fortified diet as ordered by the physician. The DS stated that residents who are ordered to have a fortified diet should have received mashed potatoes with gravy in addition to their regular diet today. The DS stated that Resident 12 did not receive mashed potatoes with gravy on his tray. The DS returned the lunch tray to the kitchen. During a concurrent observation and interview on 11/5/2024 at 12:29 p.m. in the kitchen, [NAME] 1 observed Resident 12`s lunch tray and lunch menu ticket. [NAME] 1 stated Resident 12's tray does not include mashed potatoes with gravy. [NAME] 1 stated that Resident 12 was required to receive fortified large portion pureed food. [NAME] 1 stated that a fortified diet was not provided to Resident 12. During an interview on 11/5/2024 at 12:33 p.m., with Registered Nurse 1 (RN 1), RN 1 stated that she checked the residents` food trays today against their physician orders prior to distributing them. RN1 stated Resident 12 has already received his fortified diet for lunch and consumed it (fortified diet lunch). RN 1 then walked inside Resident 12`s room with the DS and observed that there was no food tray at Resident 12`s bedside. The DS informed RN 1 that he returned Resident 12`s lunch tray to the kitchen because the meal was not fortified. RN1 stated she checked Resident 12`s lunch tray before distribution. However, she did not confirm that if it was a fortified meal. RN1 stated the physician ordered a fortified diet for Resident 12 because he is at risk for weight loss. RN 1 stated the potential outcome of not providing the ordered fortified diet is weight loss. During a concurrent interview and record review on 11/5/2024 at 2:10 p.m., with the facility`s Registered Dietician (RD-a health professional who has special training in diet and nutrition), Resident 12`s Nutritional Assessments, weights, and Physician Orders were reviewed. RD stated that Resident 12`s diet order is fortified large portion meals. The RD stated that the potential outcome of not providing fortified meals to a resident who is recovering from a weight loss is not following the physician`s order and possible additional weight loss. During an interview on 11/7/2024 at 1:30 p.m., with the Director of Nursing (DON), the DON stated that the facility is required to serve meals based on the residents` physician orders. The DON stated Resident 12 was not provided with a fortified diet as ordered by his physician. The DON further stated the potential outcome of not serving fortified diet to a resident as ordered by the physician is inability to meet the resident`s nutritional needs which could lead to weight loss. During a review of the facility's policy and procedure (P&P), titled Food and Nutritional Services, revised March 2023, the P&P indicated the facility provides each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. The facility has an ongoing communication and coordination among and between staff within all departments to ensure the resident assessment, care plan and food and nutrition services meet each resident`s daily nutritional and dietary needs and choices. During a review of the facility's policy and procedure titled Assisted Nutrition and Hydration, revised March 2023, the P&P indicated the purpose of this policy is to provide nutritional and hydration care and services to each resident, consistent with the resident`s comprehensive assessment. Provide a therapeutic diet that takes in to account the resident`s clinical condition, and preferences, when there is a nutritional indication. Therapeutic diet is ordered by the physician or other delegated provider that is part of treatment for a disease or clinical condition to eliminate, decrease or increase certain substances in the diet, or to provide mechanically altered food when indicated.

Based on observation, interview, and record review, the facility failed to maintain infection control practices when Licensed Vocational Nurse 1 (LVN 1) did not wash hands between administering medications via gastrostomy tube (also known as a G-Tube, is a flexible that is inserted through the abdominal wall and into the stomach to provide nutrition and fluids) and giving an insulin (a hormone that lowers the level of sugar in the body) injection to Resident 32. This deficient practice had the potential to cause Resident 32 to develop an infection. Findings: During a review of Resident 32's Admission Record, the Admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to, anemia (a condition where the body does not have enough healthy red blood cells), colon cancer, and vascular dementia (a progressive state of decline in mental abilities that occurs when the blood supply to the brain is disrupted). During a review of Resident 32's History and Physical (H&P), dated 10/5/2024, the H&P indicated Resident 32 does not have the capacity to understand and make decisions. During a concurrent observation and interview on 11/6/2024 at 9:54 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 did not wash his hands after giving Resident 32 medications via G-tube and before donning gloves to prepare to give Resident 32 an injection. LVN 1 went to give Resident 32 the insulin injection when the surveyor stopped him and inquired about hand hygiene practices. LVN 1 stated he should have washed his hands after giving the medications via the gastrostomy tube and before donning gloves to give the injection. LVN 1 stated he should wash his hands to maintain infection control. During a concurrent interview and record review on 11/6/2024 at 4:26 p.m. with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled Medication Administration-General Guidelines, last reviewed on 10/29/2024, indicated the person administering medications adheres to good hand hygiene, which includes washing hands thoroughly before and after coming into direct contact with a resident and administration of medications given via enteral tubes. The DON stated hands should be washed after giving medications via a gastrostomy tube for infection control purposes.

Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for two of five sampled residents (Resident 1 and Resident 2) when on 3/10/2024 Certified Nurse Assistant 2 (CNA 2) witnessed Resident 2 punch Resident 1 in the stomach area; and then Resident 1 punch Resident 2's right side of the face. This deficient practice resulted in Resident 1 and Resident 2 being subjected to physical abuse while under the care of the facility. Resident 2 sustained skin abrasions (when the surface layers of the skin have been broken) to the right side of the forehead (the part of the face above the eyes), the nose bridge (upper part of the nose) and right side of the nose crease (the part of the nose directly under the bridge) that needed first aid (initial assistance and care given to a resident who has been injured) and daily wound treatments. Findings: A review of Resident 1's Admission Record indicated the facility originally admitted Resident 1 on 4/4/2023 and readmitted the resident on 2/23/2024 with diagnoses that included schizoaffective disorder (a mental illness that can affect your thoughts, mood and behavior). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 2/29/2024 indicated Resident 1's cognition (ability to think and make decisions) was moderately impaired. The MDS further indicated that Resident 1 required supervision from staff with toileting hygiene, upper and lower body dressing, personal hygiene and with mobility (movement). A review of Resident 1's Change of Condition (COC - when there is a sudden change in a resident's health) Form dated 3/10/2024 timed at 7:05 a.m., indicated that on 3/10/2024 at 7:05 a.m., Resident 1 initiated physical aggression towards Resident 2 while in the hallway (in front of Resident 1's room). A review of Resident 1's Care Plan (untitled) dated 3/10/2024 indicated that Resident 1 was at risk for emotional distress due to Resident 1 being involved in a physical aggression with Resident 2. The goal was for Resident 1 not to have any negative outcome related to the altercation. A review of Resident 2's Admission Record indicated the facility admitted Resident 2 on 12/29/2023 with diagnoses that included bipolar disorder (a mental illness that causes unusual shifts in mood, ranging from extreme highs [mania or manic episode] to lows (depression or depressive episode]), schizophrenia (a mental disorder in which a person interpret reality abnormally), psychosis (collection of symptoms that affect the mind, where there has been some loss of contact with reality). A review of Resident 2's MDS dated [DATE] indicated Resident 2 had intact cognition and required supervision from staff with toileting hygiene, upper and lower body dressing, and moderate assistance from staff with mobility. A review of Resident 2's COC Form dated 3/10/2024 timed at 7:05 a.m., indicated that on 3/10/2024 at 7:05 a.m., Resident 2 received physical aggression from Resident 1. Resident 2 sustained abrasions on the right side of forehead and on the nose bridge. The COC Form further indicated Resident 2 complained of pain with a pain rating of three (3) out of 10 on a pain scale from 0 to10 (where 10 is the worst possible pain) to his lower back. A review of Resident 2's Wound Assessment Report dated 3/10/2024, timed at 10:30 a.m. indicated Resident 2 sustained the following injuries: 1. skin abrasion on the right side of forehead with a length of four (4) centimeters (cm - a unit of measurement) and a width of 0.2 cm 2. skin abrasion to the nose bridge with a length of 0.4 cm and a width of 0.4 cm 3. skin abrasion to the right side of nose crease with a length of 0.2 cm and a width of 0.2 cm. A review of Resident 2's Physician Order Summary dated 3/10/2024, indicated the following orders: 1. Right side of forehead skin abrasion: Cleanse with Normal Saline (NS - a liquid solution used to cleanse wounds) pat dry, then, apply Triple Antibiotic Ointment (a medication used to prevent and treat skin infections caused by cuts or scrapes) and leave it open to air daily for 14 days. 2. Nose bridge skin abrasion: Cleanse with NS, pat dry, then, apply Triple Antibiotic Ointment and leave it open to air daily for 14 days. 3. Right side of nose skin abrasion: Cleanse with NS, pat dry, then, apply Triple Antibiotic Ointment and leave it open to air daily for 14 days. A review of Resident 2's Care Plan (untitled) dated 3/10/2024 indicated that Resident 2 was at risk for emotional distress due to Resident 2 being involved in a physical aggression with Resident 1. The goal was for Resident 2 not to have any negative outcome related to the altercation. During an interview on 3/22/2024 at 12:03 p.m., with Resident 1, Resident 1 stated that he does not recall the date of the physical altercation but remembers a guy (referring to Resident 2) hitting him on his mouth. During an interview on 3/22/2024 at 12:20 p.m., with Resident 2, Resident 2 stated that about two weeks ago while in the facility hallway, Resident 1 punched Resident 2. During a concurrent interview and record review on 3/22/2024 at 1:04 p.m., with the Administrator (ADM) and the Director of Nursing (DON), the ADM and the DON reviewed the video feed of the facility's surveillance recording with a date and time stamped of 3/10/2024 at 6:57:39 a.m. through 3/10/2024 at 7:02:00 a.m. The video recording shows Resident 2 punching Resident 1 in the stomach area with a closed fist. The video then shows Resident 1 punching Resident 2 in the face multiple times. The video then shows two staff (identified by the ADM as CNA 2 and Licensed Vocational Nurse 1 [LVN 1]) run towards Resident 1 and Resident 2 and separating the residents. The ADM stated that physical contact occurred between Resident 1 and Resident 2. During an interview with CNA 2 on 3/22/2024 at 2:02 p.m., CNA 2 stated that on 3/10/2024, CNA 2 saw Resident 1 and Resident 2 punching each other. made a closed fist and started punching each other. CNA 2 further stated this was the first time he witnessed an actual physical abuse. During a follow-up interview on 3/22/2024 at 3:38 p.m. with the DON, the DON stated that the video recording regarding the altercation on 3/10/2024 between Resident 1 and Resident 2 confirmed that physical abuse occurred between Resident 1 and Resident 2. A review of the facility's policy and procedure (P&P) titled, Abuse- Resident to Resident Altercation last reviewed by the facility on 2/27/2024, indicated, each resident has the right to be free from abuse and neglect from resident-to-resident altercations

Based on observation, interview, and record review, the facility failed to ensure an accident was immediately reported to the supervisor and a physician for one out of 14 sample residents (Resident 1). Resident 1 fell and sustained an acute angulated (sharp obstructive angle) proximal left femur fracture (a broken thigh bone) that required a surgical repair. Resident 1 was not provided immediate intervention to minimize the risk of further injury to related to the fracture. Resident 1 also had a right hip fracture prior to his admission to the facility. This deficient practice resulted in delayed assessment of Resident 1 immediately following the fall, in order to identify a femur fracture, and provide prompt treatment and pain control for Resident 1. Findings: On June 7, 2016, at 2 p.m., Resident 1 was observed sitting up in his wheelchair and propelling himself in the hallways. A review of Resident 1's admission record, indicated the resident was originally admitted to the skilled nursing facility on December 4, 2014, and was readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS- a comprehensive assessment and screening tool) assessment dated [DATE], indicated Resident 1's cognitive skills for daily decision making were impaired, required limited assistance for transfer, dressing, personal hygiene, and toileting, and required extensive assistance for bathing. The care area assessment (CAA) dated December 15, 2015, indicated Resident 1 was at risk for fall secondary to gait and balance problem, poor safety awareness, and multiple medications. The resident was status [REDACTED]. A review of Resident 1's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated March 15, 2016, indicated Resident 1's functional status had a decline in his activities of daily living (ADLs): to requiring extensive assistance for transfer, ambulation, dressing, eating, personal hygiene, bathing, and toileting. Resident 1's plan of care initiated on December 4, 2014, and revised on December 4, 2015, indicated he was at risk for falls related to limited mobility, poor balance, motor deficit, and totally dependent with care. The goal was to demonstrate preventative measures to minimize injury. The interventions included to assist the resident in activity or the TV room, supervise TV room whenever residents are present. A review of Investigation Report dated February 8, 2016, indicated Resident 1 had left femur fracture. The resident had swelling on his left upper leg without skin discoloration. According to the investigation report, the resident had no memory of what happened and did not respond to the questions due to cognition impairment. A review of the conclusion of the investigation report regarding Resident 1, indicated the facility terminated Certified Nursing Assistant (CNA) 3 on February 24, 2016, because CNA 3 did not follow proper protocol and violated Policy Number 42. A review of the facility's undated Policy Number 42 violation indicated team member who observe, suspect, or otherwise have knowledge of possible resident abuse and/or neglect must immediately report the same to the supervisor, a member of management or the Executive Director/Administrator. On June 8, 2016, at 5 p.m., during an interview with CNA 2, she stated she witnessed Resident 1's fall on February 7, 2016. CNA 2 stated, it was about six o'clock p.m. when she saw Resident 1 lost his balance and fell down by the door of the TV room. CNA 3 was walking behind Resident 1. By the time CNA 2 ran to the scene to help CNA 3, Resident 1 was seated on a wheelchair by CNA 3. CNA 2 stated she did not report the fall to the supervisor. On June 9, 2016, at 9:40 a.m., during an interview with the Director of Nursing (DON), she stated that CNA 3 did not report Resident 1's fall incident to anyone. The facility found Resident 1 with swelling of the left upper thigh on the following day. A review of Resident 1's Nurses Notes dated February 8, 2016, at 2:15 a.m., (over eight hours after Resident 1 fell ), indicated the charge nurse on duty heard Resident 1 talking in Spanish. The charge nurse asked Resident 1 if he needed a diaper change and he replied Yes in Spanish. The charge nurse noticed Resident 1's left upper thigh was swollen while helping a certified nursing assistant change the resident's diaper. At that time the resident said dolor which means pain in Spanish. However, there was no evidence of documentation of full body assessment including range of motion and vital signs (VS- reflects essential body functions, including the heartbeat, breathing rate, temperature, and blood pressure) was performed to reflect Resident's medical condition after a fall on February 7, 2016 at 6 p.m. There was no documentation of pain assessment to include the use of a pain scale (measures a resident's pain intensity. Pain scales are based on self-report, observational /behavioral, or physiological data) and questions such as what precipitates pain and what relieves pain. A review of Resident 1's Nurses Notes dated February 8, 2016 at 2:15 a.m., indicated pain medication was offered to the resident however, the medication administration record (MAR) for February 7 and 8, 2016, indicated no pain medication was given even though Resident 1 stated he was having pain on February 8, 2016, at 2:15 a.m. after the resident fell . A review of a physician's orders [REDACTED]. On February 8, 2016, at 2:15 a.m., the charge nurse notified the physician and obtained radiology (X-Ray) orders for left upper arm, and both hips to rule out fractures. A review of the left hip radiology report dated February 8, 2016, at an unspecified time indicated Resident 1 had an acute angulated (sharp obstructive angle) proximal(nearer to the center of the body), left femur fracture. The resident's arm X-ray indicated he had no broken bone in his left arm. On February 8, 2016, at 9:15 a.m., the Nurses Note indicated, Resident 1 was transferred to General Acute Care Hospital (GACH) for further evaluation and treatment. The In-patient Physical Therapy Examination note dated February 10, 2016, indicated Resident 1 required surgical intervention of left hip intramedullary nailing (a metal rod insertion which allows ambulation within weeks) on February 9, 2016, while at the GACH. Resident 1 had a history of [REDACTED]. A review of the skilled nursing facility's physicians' orders indicated on March 14, 2015, Resident 1 had an order to administer Tylenol 500 milligram (mg) two tablets twice a day, for osteoarthritis (a type of joint disease that results from breakdown of joint cartilage and underlying bone. The most common symptoms are joint pain and stiffness) and Tylenol 325 mg two tablets every four hours as needed for mild pain. A review of Resident 1's Medication Administration Record for February 2016, indicated Tylenol 500 milligram (mg) was given at 9 a.m. and 5 p.m., on February 7, 2016. There was no indication of any pain medication administered after the resident fell and fractured his left femur as the resident had not yet been assessed for his injury. A review of Resident 1's Pain Assessment Record on February 7, 2016, during 3 p.m. to 11 p.m., shift indicated Nurses Non-Verbal Scale was two on a scale of (1-6, with one being no pain and six being excruciating pain), which represents mild pain. During 11 p.m. to 7 a.m. shift indicated Nurses Non-Verbal Scale was 1 which represents the resident had no pain which is contradictory to nurses notes. A review of the facility's policy titled, Fall Management and Investigation, dated October 30, 2001, indicated the DON is responsible for supervising the process of review, management and monitoring procedures. After a fall, a licensed nurse would evaluate the resident immediately when the fall has occurred. The resident must not to be moved until the review is completed, unless there is an immediate safety concern. An incident report must be completed when a resident falls within 24 hours of accident. All incidents will be reported to the appropriate agencies within the time frame as required by state.

Based on observation, interview and record review, the facility failed to ensure one of 16 sampled residents (Resident 6), who had a history of [REDACTED]. Fluid intake was not provided as ordered by the physician, specified in the nutritional assessment, and directed by the Interdisciplinary Team (IDT) plan of care to prevent dehydration (a condition caused by the excessive loss of water from the body). As a result Resident 6 was not provided fluids sufficient to: 1. Resolve a UTI that can lead to worsening of the infection and development of a serious medical [MEDICAL CONDITION] (a potentially life-threatening complication of an infection). 2. Resolve an elevated blood urea nitrogen (BUN) 32 milligrams per deciliter (mg/dL), indicating the resident was dehydrated that can lead to worsening and development of a serious medical condition, acute [MEDICAL CONDITION] (an abrupt decline in kidney function). Findings: On June 6, 2016 at 8:45 a.m., during the initial tour of the facility in the presence of Registered Nurse (RN 1), Resident 6 was observed lying in bed. The resident's facial skin was observed to be dry. There was a full liter size water pitcher at the resident's bedside table, toward foot of the bed. A review of Resident 6's admission record indicated the resident was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set (MDS) assessment (a comprehensive assessment tool), dated September 22, 2015, indicated that Resident 6's cognition was usually intact with the ability to make self understood and to understand others. The resident required limited assistance with activities of daily living (ADLs), such as eating, dressing and transferring. The MDS care area assessment (CAA) also triggered as a concern for UTI and dehydration. The MDS did not list [MEDICAL CONDITION] as a diagnoses. Review of the facility's Roster/Sample Matrix Resident 6 was triggered for UTI and hydration. A review of Resident 6's nurse's weekly summary charting dated February 2, 2016, indicated the resident's skin condition had a Braden's Score of fourteen (indicating the resident had a moderate risk for developing a pressure ulcer) and required the staff to implement preventative measures for the dry skin. The staff documented to keep the resident well hydrated. The Situation, Background, Assessment, Recommendation ( SBAR) dated February 1, 2016, indicated Resident 6 had developed a UTI and was to have fluids encouraged as tolerated. There was no indication of the total additional amount of fluid that Resident 6 would require in order to increase the chance of resolving his UTI. A review of the progress notes dated March 29, 2016, indicated Resident 6 was admitted to a general acute care hospital (GACH) with a chief complaint of agitation and combative behavior. According to the resident's history and physical (HP) examination record dated March 29, 2016, done at acute care hospital (GACH), the resident was diagnosed with [REDACTED]. 1. Elevated blood urea nitrogen (BUN) 32 mg/dL 2. Normal creatinine (CR) 1.1, mg/dL 3. Rule out urinary tract infection [MEDICAL CONDITION]. The laboratory studies indicated abnormal BUN and a normal CR (BUN/CR, ratio of greater than 20 indicates dehydration), and dehydration can lead to acute [MEDICAL CONDITION]. The physician in GACH ordered intravenous fluid and Nephrology (study of kidney) consult. A review of Resident 6's admission record indicated the resident was readmitted to the skilled nursing facility on April 2, 2016, with [DIAGNOSES REDACTED]. There was a physician's orders [REDACTED]. A review of Resident 6's IDT care plan dated April 2, 2016, indicated a concern for UTI and dehydration related to elevated BUN of 59 mg/dL. The goal was to ensure that the resident would have no signs and symptoms of dehydration by monitoring and recording intake/output as ordered, and encouraging fluids. There was no indication of the total amount of fluid that Resident 6 would require in order to resolve his elevated BUN. The physician's orders [REDACTED]. a. April 2, monitor I&O every shift for thirty days b. April 6, encourage fluids every shift for three days due to elevated BUN c. April 11, encourage fluids every shift for three days due to elevated BUN 59 and [DIAGNOSES REDACTED]. d. April 13, encourage fluids for 3 days due to elevated BUN. e. April 15, encourage fluids every shift for elevated BUN 59. A review of the Nutritional assessment dated [DATE], completed by the Registered Dietician (RD) indicated that the resident's daily fluid requirement was from 1500 -1800 milliliters (ml/cc's) of fluid per 24 hours. The RD also indicated that the facility staff give an extra four ounces of fluid with medication and post (after) medication. However, a review of Resident 6's fluid intake record totals for each shift, including snacks for April 2016, through June 2016, indicated that Resident 6 did not receive the volume of fluid as recommended by the RD for approximately fifteen days. For example: 1. On April 16, 2016, Resident 6 received a total of 820 cubic centimeters (cc). This was 680 cc to 980 cc less than the required daily fluid requirement. 2. On April 17 - 19, 2016, Resident 6 received a total of 720 cc. This was 690 cc to 990 cc less than the daily fluid requirement. 3. On May 1, 2016, Resident 6 received a total of 1320 cc. This was 200 cc to 300 cc less than the daily fluid requirement. 4. On May 2, 2016, Resident 6 received a total of only 960 cc. This was 540 cc to 840 cc less than the daily fluid requirement. 5. On May 3, 2016, Resident 6 received a total of only 1200 cc. This was 300 cc to 600 cc less than the daily fluid requirement. 6. On May 5, 2016, Resident 6 received a total of only 240 cc. This was 1200 cc to 1580 cc less than the daily fluid requirement. 7. On June 2, 2016, Resident 6 received zero fluid. This was 1500 cc to 1800 cc less than the daily fluid requirement. 8. On June 6, 2016, Resident 6 received a total of 1440 cc. This was 90 cc to 360 cc less than the daily fluid requirement. 9. On June 7, 2016, Resident 6 received a total of 1320 cc. This was 180 cc to 480 cc less than the daily fluid requirement. 10. On June 8, 2016, Resident 6 received a total of 1540 cc. This was 260 cc less than the daily fluid requirement. A review of Resident 6's I&O record for the above dates did not indicate the provision of extra fluids as directed by the physician, nor was there measurement of urine output done to determine if Resident 6 had sufficient fluid intake. A review of the laboratory test results dated May 5, 2016, indicated the following: 1. Sodium of 135 milliequivalent /liter (mEq reference range 135- mEq/L). 2. BUN, 30 milligram (mg)/per deciliter (mg/dl, reference range less than 23 mEq/dl). 3. Cr, 1.0 mg/per deciliter (mg/dl, range less than 1.4 mg/dl). The BUN/Cr ratio was 30 which indicated Resident 6 was dehydrated. An elevated sodium level is an indicator for dehydration. A BUN/Cr ration ranging from 20:1 to 24:1 is an indicator for impending dehydration and a BUN/Cr ratio of 25:1 or more is an indicator for dehydration (American Journal of Nursing June 2006, Vol. 106 No. 6 Pages 40-49). Dehydration is a condition in which the total body's fluid (intra and extra vascular) volume is reduced or depleted due to several causes that include insufficient fluid consumption (American Journal of Nursing May 1999 Vol. 99- issue 5 Pages 66-69). A review of the physician's orders [REDACTED]. 1. February 1, 2016, [MEDICATION NAME] 350 mg 1.4 milliliters (ml) intramuscularly every twelve hours for ten days for UTI. (This treatment was initiated based on a urine culture and sensitivity test (C&S) result that indicated Extended Spectrum Beta Lactamases (bacteria in urine) (ESBL) in urine greater than 100,000 cfu/ml, a unit of measure). 2. April 2, 2016, Cranberry extract capsule 425 mg one capsule by mouth twice a day to prevent UTI. 3. April 15, 2016, Encourage fluid every shift. 4. May 23, 2016, [MEDICATION NAME] 5 mg tablets by mouth every day for [MEDICAL CONDITION]. Monitor resident for side effects every shift. ([MEDICATION NAME] is used to treat [MEDICAL CONDITION] (a severe mental disorder). The resident must be monitor for dry skin, dry mouth/nose, and [MEDICAL CONDITION] or difficulty.) 5. April 2, 2016, monitor I & O time thirty days Resident 6 was not observed offered water, water with breakfast and on one day was not offered water or breakfast. The resident was observed lying in bed, with the water pitcher full of water on the beside table, but at times, the water was not within the resident's reach as follows: 1. June 6, 2016 from 8:45 a.m. to 10:45 a.m. 2. June 7, 2016 from 8:45 a.m. to 10:45 a.m. 3. June 8, 2016 from 7 a.m. to 11 a.m. no water or breakfast offered. On June 7, 2016, at 8 a.m., during an interview with Resident 6, when asked does the staff offer her water, Resident 6 stated, when she asks the staff for water, the staff gives water to her, but the staff does not offer her water. On June 7, 2016 at 2 p.m., Registered Nurse 1 (RN 1), in an interview was asked for Resident 6's I&O record, used to monitor fluid intake as ordered by physician, recommended by Registered Dietician (RD) and IDT care plan. RN 1 stated the facility does not keep an I&O record, and does I&O only from admission up to thirty days. RN 1 provided the survey team with I &O records for Resident 6 after her admission for the month of April 2016, however, the I&O was discontinued on April 7, 2016, without a physician's orders [REDACTED]. output and I & O was not done after April 7, 2016. On June 7, 2016 at 2:10 p.m., during an interview the director of nurses (DON) was asked about Resident 6's I&O record being discontinued before thirty days without a physician's orders [REDACTED]. The DON stated that she kept Resident 6's I&O record in the Medication Administration Record [REDACTED]. On June 8, 2016, at 10:50 a.m., during an interview, Certified Nurse Attendance (CNA) 4 who was assigned to care for Resident 6, was asked about the resident's dry skin and water not being offered to Resident 6. CNA 4 stated that she offers the resident juices but not water because the resident knows what to do. CNA 4 was asked did she offer the resident any water or juice on June 8, 2016, from 7 a.m. to 11:45 a.m., or whether another CNA offered water or breakfast to her assigned resident. CNA 4 stated, No, that she did not offer the resident water, or see the resident eating her breakfast. When passing the breakfast trays out CNA 4 stated, the trays have to be passed out very fast. When CNA 4 was asked to describe the resident's skin, CNA 4 stated the resident has dry skin. CNA 4 stated that is why she put A/D ointment on the resident's body. CNA 4 also stated fluids should be given every two hours. On June 8, 2016 at 10:55 a.m., during an interview with the DON about Resident 6 being diagnosed with [REDACTED]. The DON agreed that the resident's dry skin could be from dehydration. The DON agreed that the resident did not receive fluids or breakfast on June 8, 2016, from 7 a.m. to 11:00 a.m. but it was an isolated incident due to the individualized method of passing trays based on time intervals. The breakfast schedule indicated that Resident 6 was supposed to receive her breakfast tray at 7:30 a.m. The DON agreed if the resident was in bed, and the water pitcher was on the bedside night stand, then the water would not be within reach for the resident. The DON provided I&O records after the survey exit. According to the facility's revised policy Hydration/Fluid Management, dated January 5, 2011, residents will be provided with fluid daily. Fluids will be offered to each resident during and between meals. I&O measurements will be done with physician's orders [REDACTED].>Cross refer to F 315 - The facility failed to prevent urinary tract infection [MEDICAL CONDITION] by failing to provide adequate hydration to prevent recurrent UTIs.