Every finding on record at The Cove at la Jolla

Based on observation, interview, and record review, the facility failed to ensure fall mats were placed appropriately for one of 14 sampled residents (40), and ensure loose flooring was identified for three of three hallways. These failures placed residents at increased risk of injury. Findings: 1. Per the facility's Admission Record, Resident 40 was admitted to the facility on [DATE] with diagnosis of difficulty walking. Per the facility's undated Care Plan Report, Resident 40 was at risk for falls related to impaired mobility, weakness, and a history of falls. The Care Plan Report had an intervention to add floor mats to both sides of Resident 40's bed to prevent injury due to a previous fall on 4/30/25. On 5/15/25 at 2:59 P.M., an observation of Resident 40 and interview was conducted with Licensed Nurse (LN) 5. There was a floor mat one side of Resident 40's bed, and the floor mat on the other side of his bed was stood up against the wall. LN 5 stated, staff moved the floor mat out of the way while transferring Resident 40, but it looked like they forgot to put the fall mat back down after the transfer. LN 5 further stated, the floor mat would not have been effective while placed up against the wall instead of being on the floor. On 5/16/25 at 10 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated, Resident 40's floor mat should have been returned to the floor next to his bed. Per the facility's policy titled, Fall Management System, revised June 2018, It is the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls. 43518 2. On 5/15/25 at 11:14 A.M., a concurrent observation of facility flooring and interview with the Director of Environmental Services (DES) was conducted. The DES confirmed flooring was loose . The DES stated that the flooring was water damaged and bubbling up in many of the hallways. The following areas had water damage with loose flooring: 1. The beginning of the center hallway; four areas with three inch diameter bubbles extended upward from the floor, directly under the hand railing, 2. Near room [ROOM NUMBER], beneath the handrail, three areas of one inch bubbles extended upward from the floor, adjacent to a recently repaired area, 3. Near room [ROOM NUMBER] in the hallway, two areas with one inch bubbles extended upward from the floor 4. Near room [ROOM NUMBER] one area with a three inch bubble, the floor was separated at the seam creating a two-inch-high area where flooring was warping upward, beneath the hand railing. The DES stated that the loose flooring could have been a tripping hazard for residents, staff, and visitors. On 5/16/25 at 10 A.M. an interview was conducted with the Administrator (ADM). The ADM stated that the expectation was that hallways should have been free from any tripping hazards. The ADM stated that the importance of a safe environment was for the comfort and safety of the residents, staff, and the visitors of the facility. Review of the facility policy titled PHYSICAL ENVIRONMENT, undated, indicated .It is the policy of this facility that the facility must provide a safe, functional, sanitary, comfortable, and home-like environment for residents, staff and public through monthly environmental rounds .The following should be included in Monthly Environmental Rounds .8. Hallways free of potential environmental hazards .

Based on observation, interview, and record review the facility failed to ensure that palatable food was served to fifteen of fifty-one sampled residents. This failure had the potential to prevent residents from eating their meals and not receiving their daily nutrition. Cross reference F550 Findings: On 5/13/25 from 7:30 A.M. to 4:30 P.M., resident interviews were conducted during the initial tour of the facility. The following represents residents' statements about food during the initial tour: Resident 8 stated I received cereal with no milk .the combinations are ridiculous like yesterday I got cold sausage with brussels sprouts .food is usually lukewarm, not enough food .I had two meals that I couldn't figure out what it was, it looked like fried mush, and I didn't' t eat it . the orange juice is terrible, doesn't taste like orange . Resident 159 stated .The food is always cold, dry eggs, scrambled, and hard . Resident 15 stated .Food barely adequate, not very good, always cold .Canned vegetables, lettuce not fresh. Portions too big to finish . Resident 31 stated .Food not good, lunch and dinner are not up to expectations, always cold, not cooked very well, chicken is tough . I only eat breakfast .They don't season and tastes just plain . Resident 17 stated .Food cold, unhealthy, bad flavor . Resident 16 stated .Concerned with not sending requested sandwich for dialysis appointments . Resident 10 stated .Food was terrible, no flavor, bad presentation .meal ticket it did not specify what he was receiving . Resident 209 stated .Food content not good .seemed like food from prior day . Resident 210 stated .Food was unidentifiable . Resident 6 stated .The food was often cold .she did not always get what was on the menu .she was looking forward to getting sauerkraut, but they gave her carrots instead. She was tired of carrots because she got them every day .she was brought green beans, but could not have green beans because she was allergic . Resident 24 stated .The food was terrible, it was cold, and had no flavor . On 5/14/25 at 10:02 A.M., a Resident Council Meeting was held with eight residents. Five of eight anonymous residents had food complaints. The complaints were as follows: .Pancakes like rubber . .Food was bad . .Sometimes good, sometimes not . .She had lost weight . .People do not like to eat same food for days . .Have been trying to get menu for weeks . .Did not know what to expect. At times did not know what they will receive . .Menu was posted in hallway .Menu was tiny and pale .postings were too tall, difficult to read . On 5/14/25 between 12 P.M. and 1:25 P.M. an observation of the tray line was conducted. The last tray was completed and sent out of the kitchen at 1:24 P.M. The last tray served to the last resident of the last unit was completed at 1:30 P.M. On 5/14/25 At 1:30 P.M., a concurrent sampling of a test tray was conducted with the Dietary Manager (DM) and Registered Dietician (RD), on 5/14/25 at 1:30 P.M. Temperatures and palatability were as follows: Milk-43 F, Juice 46 F- not tasted Pureed tray: Pureed Meatloaf-127 F, warm, bland,needed seasoning Mashed Potatoes- 140 F, warm, bland, needed seasoning Pureed Spinach Au Gratin, 126 F, warm, bland, needed seasoning, no cheese flavor Regular tray: Meatloaf 135 F, warm, bland, needed seasoning Spinach Au gratin, 126 F, warm, bland, needed seasoning, no cheese flavor The RD stated that the facility standard for hot food was to be at least 120 F, and for beverages to be lower than 45 F. On 5/16/25 at 10 A.M., an interview with the RD was conducted. The RD stated that the expectation for assessing residents' preferences and dislikes was to review the monthly menu with each resident, document resident's dislikes, and provide alternatives for foods that they disliked. The RD stated the importance of providing palatable food to residents was to provide adequate nutrition for nourishment of the residents during their stay and to promote healing. Record review of the facility policy titled FOOD PREFERENCE, dated 2023 indicated .Resident's food preferences will be adhered to within reason. Substitutes for dislike will be given from appropriate food groups. Condiments such as salt, pepper, and sugar are available at each meal unless contraindicated by the diet order .

Based on observation, interview and record review the facility failed to ensure that one kitchen staff wore a beard restraint during breakfast tray line. This failure had the potential to contaminate all residents' food with staff's facial hair and promote foodborne illness. Findings: On 5/13/25 at 7:45 A.M., an observation of the breakfast tray line and an interview with the Dietary Supervisor (DS) was conducted. The DS was observed with an uncovered beard and mustache plating breakfast food. The DS stated that the policy was that he could serve food without a beard restraint if the beard and mustache were trimmed and groomed. The Registered Dietician(RD) was asked to review policy for facial hair for kitchen staff. Record review of the facility policy titled DRESS CODE, dated 2023, indicated that .8. If applicable, beards and mustaches (any facial hair) must wear beard restraint . On 5/16/25 at 10 A.M., an interview with the Registered Dietician (RD) was conducted. The RD stated that the expectation was for any staff with facial hair needed to cover it with beard restraint. The RD stated that the importance of covering facial hair was to prevent contamination of residents' food from staff facial hair.

Based on observation, interview and record review, the facility failed to honor two (Resident 1, 16) of 14 sampled residents reviewed for resident rights when: 1. The facility did not honor Resident 1's request not to have eggs for breakfast; 2. The facility did not honor Resident 16's request to have a sandwich during dialysis appointments. These failures resulted in not allowing residents to make a choice regarding their care. Findings: 1. Resident 1 was admitted to the facility on [DATE] with diagnoses including hemiplegia (total or partial paralysis of one side of the body) and hemiparesis (muscle weakness on one side of the body) involving unspecified cerebrovascular disease (a condition affecting blood flow and blood vessels in the brain) according to the facility's Admission Record. During an observation and interview on 5/13/25 at 8:43 A.M. with Resident 1, Resident 1 stated she disliked eggs but received eggs for breakfast. Resident 1 showed an omelette on the breakfast tray and a meal ticket which indicated dislikes: eggs, plain yogurt, sausage and cooked spinach. An interview on 5/16/25 at 7:56 A.M. was conducted with Certified Nurse Assistant (CNA) 1. CNA 1 stated when meal trays arrived, the Licensed Nurse (LN) checked the meals for the correct diet and residents' food likes and dislikes against a diet list. An interview on 5/16/25 at 9 A.M. was conducted with LN 1. LN 1 stated residents' meals were checked against a diet order list with the meal ticket from the kitchen then the food on the plate. LN 1 stated the meals were checked for texture, liquid consistency and the resident's food preferences. During an interview and concurrent record review on 5/16/25 at 9:30 A.M. with the Registered Dietician (RD), the RD stated the Dietary Manager interviewed residents for food preferences. The RD reviewed Resident 1's meal ticket which indicated dislikes for plain yogurt, sausage, eggs and cooked spinach. The RD stated it was important to know residents' food dislikes so they will not get it. An interview on 5/16/25 at 10 A.M. with the Director of Nursing (DON) was conducted. The DON stated residents' meal trays were checked in the kitchen, then the LN compared residents' meal slips with the meal tray that was served to the resident. The DON stated it was important to check for the correct diet, texture and to ensure residents' preferences were honored. During a review of the facility's undated admission document titled, ATTACHMENT F, the document indicated, Patients shall have the right .to be encouraged and assisted throughout the period of stay to exercise rights as a patient .the right to .reside and receive services in the facility with reasonable accommodation of your needs and preferences. A review of the facility's policy and procedure (P&P) titled, Resident allergies, Preferences and Substitutes, dated 10/2024 was conducted. The P&P indicated, It is the policy of this facility to ensure resident allergies, preferences and substitutes will be adhered to .Resident food trays will be checked by the Dietary department and verified by Nursing to ensure accuracy, prior to delivery. 2. Resident 16 was admitted to the facility on [DATE] with diagnoses including protein-calorie malnutrition (inadequate intake of nutrients to meet the body's needs) according to the facility's Admission Record. An interview on 5/13/25 at 8:18 A.M. was conducted with Resident 16. Resident 16 stated he had dialysis (procedure done by a trained professional to remove wastes and excess fluids from the body) appointments three times a week and the facility gave him three cups of puree food to take to dialysis. Resident 16 stated he had requested from multiple staff including the dietician to give him a sandwich, Nepro (a protein supplement) and three napkins. Resident 16 stated nobody had listened to his requests. An interview on 5/14/25 at 3:03 P.M. was conducted with the Registered Dietician (RD). The RD stated Resident 16 requested last week a sandwich to take to Resident 16's dialysis appointments. The RD stated she did not document Resident 16's request. The RD stated she referred Resident 16's request to the Speech Therapist who recommended to continue with puree consistency. The RD stated Resident 16's request had not been discussed with the interdisciplinary team (IDT- team members with various areas of expertise who work together toward the goals of their residents). The RD further stated Resident 16 had the right to choose what diet texture he preferred. During an interview on 5/15/25 at 10:20 A.M. with Resident 16, Resident 16 stated he received three cups of puree food again to take to dialysis yesterday, 5/14/25. Resident 16 stated he threw them away and only had the Nepro for lunch at dialysis. An interview with the Director of Nursing (DON) was conducted on 5/16/25 at 8:34 A.M. The DON stated Resident 16's request should have been addressed as soon as possible. The DON stated she would have felt frustrated if she had a request that was not addressed right away. During a review of the facility's undated admission document titled, ATTACHMENT F, the document indicated, Patients shall have the right .to be encouraged and assisted throughout the period of stay to exercise rights as a patient .the right to .reside and receive services in the facility with reasonable accommodation of your needs and preferences.

Based on observation, interview, and record review, the facility failed to develop and/or implement a patient centered care plan for one of 14 residents reviewed for care plan. (Resident 209) Cross reference F695 This failure had the potential for Resident 209 to not receive appropriate care, treatment, and interventions for the use of a continuous positive airway pressure machine (CPAP-a machine that delivers mild air pressure through the nose to keep breathing airways open while asleep). Findings: Resident 209 was admitted to the facility on [DATE] with diagnoses including obstructive sleep apnea (OSA- a problem in which breathing pauses during sleep due to blocked airways) according to the facility's Admission Record. An observation and interview was conducted on 5/13/25 at 11:42 A.M. with Resident 209. Resident 209 had a white machine on the bedside drawer. Resident 209 stated the machine was a BIPAP [Bilevel positive airway pressure machine used as breathing support and administered through a face mask or nasal mask] machine. Resident 209 stated she cleaned the machine and added water to the machine when needed. An interview and joint record review was conducted on 5/14/25 at 8:57 A.M. with Licensed Nurse (LN) 2. LN 2 reviewed Resident 209's electronic medical record (EMR). LN 2 stated there was no care plan for a BIPAP or CPAP machine. During an interview and joint record review on 5/15/25 at 3:27 P.M. with the Minimum Data Set Nurse (MDSN- a nurse who assessed and evaluated the quality of care being given to residents), the MDSN stated the hospital history and physical, dated 5/10/25 indicated Resident 209 used a CPAP machine. The MDSN stated there was no care plan for the CPAP machine until 5/14/25. An interview on 5/16/25 at 8:26 A.M. with the Director of Nursing (DON) was conducted. The DON stated there should have been a care plan for the CPAP machine to ensure that Resident 209's condition was treated, education was provided to Resident 209 and for staff to know how to clean the machine for infection control. A review of the facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning, dated 10/2024 was conducted. The P&P indicated, .the interdisciplinary team (IDT)[team members with various areas of expertise who work together toward the goals of their residents] shall develop a comprehensive person-centered care plan for each resident .to meet a resident's medical, nursing, mental and psychological need.

Based on observation, interview and record review, the facility failed to provide respiratory care services for one of one resident who used a continuous positive airway pressure machine (CPAP-a machine that delivers mild air pressure through the nose to keep breathing airways open while asleep) when Resident 209 used a CPAP machine but did not have a physician's order. In addition, Licensed nurses did not know how to clean the CPAP machine. This failure had the potential for Resident 209 to receive inappropriate care and treatment to address Resident 209's respiratory problems. Cross reference F656 Findings: Resident 209 was admitted to the facility on [DATE] with diagnoses including obstructive sleep apnea (OSA- a problem in which breathing pauses during sleep due to blocked airways) according to the facility's Admission Record. An observation and interview was conducted on 5/13/25 at 11:42 A.M. with Resident 209. Resident 209 had a white machine on the bedside drawer. Resident 209 stated the machine was a BIPAP [Bilevel positive airway pressure machine used as breathing support and administered through a face mask or nasal mask] machine. Resident 209 stated she cleaned the machine and added water to the machine when needed. An interview and joint record review was conducted on 5/14/25 at 8:57 A.M. with Licensed Nurse (LN) 2. LN 2 reviewed Resident 209's electronic medical record (EMR). LN 2 stated there was no physician's order for a BIPAP or a CPAP machine. During an interview on 5/15/25 at 2:03 P.M. with LN 4, LN 4 stated she was aware that Resident 209 had a CPAP machine. LN 4 stated she needed to check with the Director of Nursing (DON) regarding the facility's policy for CPAP machine cleaning. During an interview on 5/15/25 at 2:23 P.M. with LN 3, LN 3 stated she did not know how to clean a CPAP machine. During an interview and joint record review on 5/15/25 at 3:27 P.M. with the Minimum Data Set Nurse (MDSN- a nurse who assessed and evaluated the quality of care being given to residents), the MDSN stated the hospital history and physical, dated 5/10/25 indicated Resident 209 used a CPAP machine. The MDSN stated there was no physician's order for the CPAP machine until 5/14/25. An interview on 5/16/25 at 8:26 A.M. with the Director of Nursing (DON) was conducted. The DON stated there should have been a physician's order for the CPAP machine to ensure that Resident 209's condition was treated, education was provided to Resident 209 and for staff to know how to clean the machine for infection control. A review of the facility's undated policy and procedure (P&P) titled, CPAP/BIPAP Monitoring and Management was conducted. The P&P indicated, It is the policy of this facility that: 1. BIPAP/CPAP devices be administered as ordered by the physician for conditions such as .Sleep Apnea .Interventions are implemented to minimize risks associated with BIPAP/CPAP.

Based on observation, interview, and record review, the facility failed to provide residents with a diet free of food they were allergic to for one of 14 sampled residents (6). This failure placed Resident 6 at an increased risk of allergic reaction. Findings: Per the facility's Admission Record, Resident 6 was admitted to the facility on [DATE]. Per the facility's Allergy Report, dated 5/15/25, Resident 6 had an allergy to Broccoli, documented on 1/19/25. On 5/15/25 AT 9:40 A.M., an interview was conducted with Resident 6. Resident 6 stated, a Certified Nursing Assistant (CNA) brought her broccoli on 5/14/25 at dinnertime. On 5/15/25 at 1:38 P.M., an interview was conducted with CNA 4. CNA 4 stated, when she brought the dinner meal tray to Resident 6 on 5/14/25, Resident 6 complained to her that there was Broccoli on her plate. CNA 4 further stated, she was supposed to check the meal tray to see if it matched her diet, but she missed that one. On 5/15/25 at 1:52 P.M., an interview was conducted with Licensed Nurse (LN) 5. LN 5 stated, she checked the meal trays for accuracy before the CNAs delivered them to the residents. LN 5 further stated, she checked Resident 6's dinner tray on 5/14/25, but she did not remember seeing broccoli on her tray. On 5/16/25 at 9:59 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated, there should have been three staff checking to ensure Resident 6's diet was followed. The DON further stated, the broccoli should have been identified by the kitchen staff, the LN who checked the tray, and the CNA who delivered the tray. Per the facility's policy, titled Food Preferences, dated 2023, .Resident's food preferences will be adhered to within reason . Per the facility's policy titled, Resident allergies, Preferences and Substitutes, reviewed 10/24, Resident food trays will be checked by the Dietary department and verified by Nursing, to ensure accuracy, prior to delivery.

Based on observation, interview, and record review, the facility failed to accurately assess and code the Minimum Data Set (MDS-a clinical assessment tool) for three of four residents (1, 5, 103) reviewed for wander guards (a wrist band worn by residents that alarms and alerts staff when the resident get near or exit a specific area). As a result, the Centers for Medicare and Medicaid Services (CMS) was unaware of Resident 1, 5, and 103's current health status and wandering behavior. Findings: a. Resident 1 was admitted to the facility on [DATE], with diagnoses which included encephalopathy (a disease of the brain which affects daily function), per the facility's Admission Record. On 6/5/24, Resident 1's clinical record was reviewed: According to the physician's order, dated 2/21/24, .WanderGuard wrist band to LEFT Wrist . According to the quarterly Elopement/Wandering Evaluation, dated 4/2/24, Resident 1 was categorized as a high risk for elopement. The care plan titled At Risk for Elopement, undated, listed interventions such as: Monitor Wander guard placement (left wrist). According to the nurses' notes, dated 10/8/23 at 3:16 P.M., the family approved of the use of a wander guard. The quarterly MDS, dated [DATE], Section P-Restraints and Alarms was coded 0, indicating a Wander/elopement alarm was not in use. b. Resident 5 was admitted to the facility on [DATE], with diagnoses which included dementia (progressive memory loss), per the facility's Admission Record. On 6/5/24, Resident 5's clinical record was reviewed: According to the physician's order, dated 9/15/23, .WanderGuard wrist band to LEFT Wrist . According to the quarterly Elopement/Wandering Evaluation, dated 5/2/24, Resident 5 was categorized as a high risk for elopement. The care plan titled At Risk for Elopement/wandering related to Dementia, dated 7/8/23, listed interventions such as: Monitor Wander guard placement (left wrist). According to the nurses' notes, dated 7/8/23 at 9:18 P.M., the family approved of the wander guard placement. The quarterly MDS, dated [DATE], Section P-Restraints and Alarms was coded 0, indicating a Wander/elopement alarm was not in use. c. Resident 103 was admitted to facility on 5/15/24, with diagnoses which included encephalopathy (a disease of the brain which affects daily function), per the facility's Admission Record. According to the physician's order, dated 5/17/24, .WanderGuard wrist band to (L. Wrist) . According to the admission Elopement/Wandering Evaluation, dated 5/17/24, Resident 103 was categorized as a high risk for elopement. The care plan, titled Wander guard to L. wrist related to intermittent confusion, undated, listed interventions such as: Monitor Wander guard placement (left wrist). According to the nurses' notes, dated 5/17/24 at 10:56 A.M., Resident and emergency contact agree with wanderguard plan. The admission MDS, dated [DATE], Section P-Restraints and Alarms was coded 0, indicating a Wander/elopement alarm was not in use. On 6/5/24 at 9:36 A.M., an interview and record review was conducted with the Minimum Data Set Nurse (MDSN). The MDSN stated when preparing quarterly or annual MDS evaluations, she reviewed the physician orders, nurses' notes, and visually checked the resident. The MDSN reviewed Resident 1, physician orders and verified the wander guard orders and then checked the MDS Section P-Restraints and Alarms coding. The MDSN stated I missed it. The MDSN stated because the MDS was not coded accurately, CMS was unaware of the resident's current status. The MDSN reviewed Resident 5 and 103 physician's order and coding for MDS Section P-Restraints and Alarms coding. The MDSN stated my assistant missed Resident 5's and Resident 103's coding. The MDSN stated she would need to correct these immediately, so CMS was aware of the residents' wandering behavior. On 6/05/24 at 10:44 A.M., an interview was conducted with the DON. The DON stated elopement and wandering behavior was a safety issue and needed to be monitored. The DON stated she expected the MDS to identify the residents at risk for elopement and what efforts were put in place to prevent the risk. The DON stated she expected all residents to be assessed and coded properly, so CMS was aware of the residents' current status. According to the Resident Assessment Instrument Tool 3.0 Manual, dated October 2019, Section P: Restraints and Alarms, P0200: Alarms, . Identify all alarms that were used at any time (day or night) during the 7-day look-back period. Code the frequency of use: .Code 0, Not used .Code 2, used daily .

Based on observation, interview, and record review, the facility failed to follow professional standards for food safety when: 1. Dishware was not properly stored; and 2. Date on powdered thickener did not indicate open, discard, or preparation date; and 3. Gloves were not changed and hand hygiene was not conducted during food service. This failure had the potential to cause food-borne illness to all residents in the facility. Findings: 1. On 6/3/24 at 8:15 A.M., during an initial tour of the kitchen with the Certified Dietary Manager (CDM), an observation of [NAME] 1 (CK 1) was conducted. CK 1 was observed removing wet dishware from the dish machine and immediately stacking them on a nearby metal rack, without allowing them to air dry first. The CDM stated, Dishes shouldn't be stored wet, because there's a risk of bacterial growth that could effect everyone who eats food from our kitchen. A review of the facility policy titled Dish Washing dated 2018, .Dishes are to be air dried in racks before stacking and storing . 2. On 6/3/24 at 8:24 A.M., during an initial tour of the dry storage room with the CDM, tubs of powdered thickener were observed in two clear, plastic bins, located on a storage rack. The two clear bins were labeled on the outside with, 5/28/24. The CDM stated the thickener label did not indicate what the date referred to. The CDM stated, It's probably the received date, but no one would know. There should be three dates: received, opened, and use by. 3. On 6/04/24 at 12:12 P.M., an observation and interview was conducted with the CDM during lunch trayline. CK 1 was observed wearing gloves while plating food for lunch. CK 1 held food scoops with his gloved hand then placed his left thumb on the food surface of numerous plates. CK 1 wore the same gloves and made a sandwich, cut the sandwich and was touching other surfaces without removing his gloves, or performing hand hygiene. The CDM stated, That is a cross-contamination risk. Gloves should be changed between activities and hand hygiene performed. A review of the facility policy titled Sanitation, dated 2018 indicated, .Dishes are to be handled on the rim of plates . hands must not contact the food surface . On 6/6/24 at 11 A.M., an interview was conducted with the RD. The RD stated the dishes should always be air dried. The RD stated best practice should be to include three dates. One date was the date received, one date would be the date the product was opened, the the third date would be the date to use the item by. The RD stated touching food surfaces caused contamination.

Based on interview and record review, the facility failed to make a good faith attempt to address root cause issues brought forth by the resident council meeting in their Quality Assurance Performance Improvement (QAPI) committee meetings, related to timely call light responses. (Cross Reference F-558) This failure had the potential to affect the care provided to residents. Findings: An interview was conducted with the ADM on 6/6/24 at 10:25 A.M. The ADM stated call light responses were added to their QAPI plan in March 2024, after the March Resident Council identified the issue during their monthly meeting. The ADM stated call light responses were identified again as an issue in the April and May 2024, Resident Council meetings. The ADM stated the staff were immediately in-serviced on call light responses and call light responses were included as a question during the morning Angel Rounds (when department heads are assigned to a specific rooms, to meet with resident every morning in order to identify concerns). The ADM stated the Angel Round responses were not documented, but were verbally brought to the team every morning during their stand-up (department heads meet to discuss issues that occurred during the night or morning). The ADM stated call light response audits had previous been started in January 2024, via their computerized call light response system, which tracks the length of time a call light is on, before answered and deactivated. The ADM stated the QAPI compliance goal was divided into three sections: under 5 minute, over 5 minutes, and 30 minute responses. The ADM stated sometimes they reached the compliance goal and other times they did not. The ADM stated the staff in-services did not include leaving the call lights on, until the resident's needs were met. The ADM stated during the call light audit, she had not divided and analyzed into staff shifts (days, evenings, and night shifts) or nursing units, but bunched all the time responses together to get the current data. The ADM stated they were aware the delayed call light responses were still a problem and they were not getting to the root of the problem, based on their ongoing audits and Angel Rounds. According to the facility's policy titled Quality Assurance and Performance Improvement, dated January 2022, The facility will establish and implement a Quality Assessment and Assurance committee .and implement Performance Improvement Projects (PIPs) through a data driven and proactive approach .6.The facility may utilize the following established Performance Improvement tools/Processes: A. Plan-Do-Study-Act (PDSA cycles). B. The Five Why's to identify root cause .

Based on interview and record review, the facility failed to ensure call lights were answered in a timely manner for six of 56 residents (Residents 10, 4, 24,15,19,7) reviewed for call lights response. This failure had the potential for resident needs to go unmet and at risk for safety. Findings. On 6/3/24 a review of the past three Resident Council (when residents meet once a month to discuss facility concerns) meeting minutes was reviewed. Resident Council minutes dated 3/5/24, 4/2/24, and 5/14/24 indicated slow call light responses. The ADM response to the concerns was documented as, Noted. 1. A review of Resident 10's Admission Record indicated, Resident 10 was admitted to the facility on [DATE] with diagnoses that included acute (sudden) cystitis (an infection of the bladder). An interview on 6/3/24 at 10:30 A.M., with Resident 10 was conducted. Resident 10 stated he knew the facility was understaffed, due to call lights not being answered timely and it would take more than 20 minutes or more to get a response. During State run Resident Council meeting on 6/4/24 at 10 A.M., Resident 10 stated call light responses were worse after meals when staff were on break. Resident 10 stated he was incontinent (no control) of both bowel and bladder and had to wait for twenty minutes or more for staff to changed him. Resident 10 stated night shift was worst because they had less staff working. A record review of Resident 10's Minimum Data Set (MDS- a clinical assessment tool), dated 3/18/24, indicated Resident 10 had a Brief Interview for Mental Status (BIMS-a cognitive score) score of 14, which indicated cognition was intact. 2. Resident 4 was admitted to the facility on [DATE], with diagnoses which included congestive heart failure (when the heart pumps ineffectively), per the Admission Record. An interview on 6/3/24 at 11:00 A.M., with Resident 4 was conducted. Resident 4 stated, response to call lights was dependent on the time of day, which was usually on nights and weekends. Resident 4 stated the CNAs answered call lights in 15 or 20 minutes. Resident 4 stated she required assistance in going to bed and used of the bathroom before bedtime and in the middle of the night. A record review on 6/5/24 of Resident 4's MDS dated [DATE], listed a BIMS score of 13, indicating cognition was intact. 3. Resident 24 was admitted to the facility on [DATE], with diagnoses which included cellulitis of right lower limb (infection of the soft tissue in the leg), per the facility's Admission Record. An interview on 6/3/24 at 11:15 A.M., with Resident 24 was conducted. Resident 24 stated the facility was short of staff on weekends and it took time for the call lights to get answered. A record review on 6/5/24 of Resident 24's MDS listed a BIMS score, dated 4/10/2024 of 15, indicating cognition was intact. 3. Resident 15 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease, (ineffective gas exchange in the lungs), per the facility's Admission Record. An interview on 6/3/24 at 3:07 P.M., with Resident 15 was conducted. Resident 15 stated he does not have any issues or concerns with the facility, except the call lights. Resident 15 stated the call lights was worst at nighttime, and it took a while for staff to respond which was around 30 minutes or even more. A record review on 6/5/24 of Resident 15's MDS dated [DATE], listed Resident 15's BIMS score was 15, indicating cognition was intact. 4. Resident 19 was admitted to the facility on [DATE], with diagnoses which included acute (sudden) respiratory failure, per the facility's Admission Record. An interview on 6/4/24 at 11:30 A.M., with Resident 19 was conducted. Resident 19 stated he had a stroke three times and was on a heart monitor. Resident 19 stated he needed bathroom assistance at times, so he would use his call light. Resident 19 stated it would take a while for his call light to get answered. Resident 19 stated the facility was short of help on the evenings, night shifts, and on the weekends. A record review on 6/5/24 of Resident 19's MDS listed a BIMS score was 14, indicating cognition was intact. 5. Resident 7 was admitted on [DATE], with diagnoses which included hemiplegia (stroke, weakness on one side of the body) affecting the right dominant side, per the facility's Admission Record. An interview on 6/5/24 at 12:08 P.M., with Resident 7 was conducted. Resident 7 stated when he used the call light, sometimes it took 30 minutes for staff to respond. Resident 7 stated, the staff were busy, and he thought less people were working, especially in the evening and at night. A record review on 6/5/24 of Resident 7's MDS dated [DATE], listed a BIMS score of 9, indicating cognition was moderately impaired. An interview on 6/5/24 at 3:36 P.M., with CNA 1 was conducted. CNA 1 stated residents call lights needed to be answered as soon as possible to meet residents needs and ensure residents safety. CNA 1 stated call lights should be answered in less than five minutes and not any longer. An interview on 6/5/24 3:48 P.M., with CNA 2 was conducted. CNA 2 stated, call lights needed to be answered within five to ten minutes to meet resident needs and to ensure residents were safe. An interview on 6/5/24 at 3:50 P.M., with CNA 3 was conducted. CNA 3 stated call lights should be answered in five minutes, not ten minutes. CNA 3 stated they should answer to call lights promptly to ensure resident needs were met and ensure their safety. An interview on 6/5/24 at 4 P.M., with LN 1 was conducted. LN 1 stated call lights were important to be answered promptly within at least five minutes to meet residents needs and ensure resident safety. An interview on 6/5/24 at 4:16 P.M., with the DON was conducted. DON stated call lights were important to get answered in a timely manner, at least within five minutes, to make sure the resident needs are met promptly and ensure safety. A review of the facility's Policy & Procedure - entitled Nursing Clinical Subject: Call light / Bell undated, .Procedures: 1. Answer the light/ bell within a reasonable time .3. Listen to the resident's request /need .

Based on interview and record review, the facility failed to create a person centered care plan related to pain management involving non-pharmacological interventions for one of five residents (Resident 2), reviewed for pain management. This outcome had the potential for Resident 2's pain to be managed only through pharmacological interventions. Findings: Resident 2 was admitted to the facility on [DATE], with diagnoses that included displaced oblique fracture of shaft of left femur (an angled break in the long bone of the thigh) and fracture of the lower end of the left femur (a break in the long bone of the thigh near the knee), per the Admission Record. On 6/3/24 at 3:14 P.M., an interview was conducted with Resident 2 who stated her, Hip pain can get very bad. Resident 2 stated her pain was managed by the facility only with medication and repositioning. On 6/5/24 at 9:15 A.M., a record review of Resident 2's was conducted. According to the physician orders, dated 5/31/24, methadone 12.5 milligrams (a synthetic pain reliever similar to morphine) every eight hours for pain management and non-pharmacological interventions for pain 1 = repositioning, 2 = dim light/ quiet environment, 3 = relaxation 4 = distraction, 5 = music, 6 = massage. A review of care plan titled Pain, undated, listed only one intervention which was repositioning. According to the Medication administration Record (MAR) for May 2024, the MAR only listed repositioning as an attempted non-pharmacological intervention. On 6/05/24 at 9:50 A.M., an interview was conducted with Resident 2. Resident 2 stated no staff have offered any other pain management interventions other than repositioning. On 6/05/24 at 9:53 A.M. an interview and concurrent record review was conducted with the DON. The DON stated, I don't see any non-pharmacological suggestions in the care plan except repositioning. (Resident 2's) preferences for interventions are not reflected in the care plan and they should be. A review of the facility policy entitled Comprehensive Person-Centered Care Planning, undated, It is the policy of this facility that the interdisciplinary team (IDT-when department heads meet to discuss resident care) shall develop a comprehensive person-centered care plan for each resident .

Based on observation, interview, and record review, the facility failed to accurately calculate the fluid intake and urinary output (measurement of urine daily), for one of one resident (Resident 106), reviewed for accurate documentation. As a result, Resident 106's clinical record was not correct, which had the potential to affect his care for fluid balance. Findings: Resident 103 was admitted to the facility on [DATE], with diagnoses which included urinary tract infection (an infection in part of the urinary system), per the facility's Admission Record. On 6/3/24 at 9:01 A.M., an observation was conducted of Resident 103, as he laid in bed. A urinary catheter (a flexible tube inserted into the bladder, in order to drain urine to an external collection bag) bag was attached to the left lower bed frame, which was covered in a blue dignity bag (a bag that covers the urine collection bag to protect a person's dignity). The urine in the tubing was dark yellow and cloudy looking. An interview was conducted with CNA 11 on 6/5/24 at 1:13 P.M. CNA 11 stated urinary catheter bags needed to be emptied at least once a shift. CNA 11 stated if input/output measurements were ordered by the physician, the urine was measured in a cylinder measuring container, after the catheter bag was emptied. CNA 11 stated she would write down the amount of urine removed and then inform the licensed nurse, so the amount could be documented and calculated on a 24-hour basis. An interview was conducted with LN 12 on 6/5/24 at 1:17 P.M. LN 12 stated the CNAs measured the urine when removed from a urinary collection bag and reported the amount to the licensed nurses. LN 12 stated input/output orders were important for physicians and staff, to ensure adequate fluid balance were occurring and residents were not fluid overloaded or dehydrated. On 6/5/24, Resident 106's clinical record was reviewed: According to the physician's order, dated 5/29/24, .Indwelling catheter #16 F (size) .Monitor intake and output every shift .Calculate total 24 hours intake and output every evening shift . Resident 106's Medication Administration Record (MAR) was reviewed from 5/29/24 through 6/4/24. The intake (oral fluid intake) and output (catheter urine output) for the day shift (7 A.M.-3:30 P.M.), evening shift (3 P.M.-11:30 P.M.) and night shift (11 P.M.-7:30 A.M.) on 5/31/24 was documented as: Day shift: (in) 800 milliliters (ml) , (out) x 2 Evening: (in) 450 ml, (out) 350 ml Night: (in) 200 ml, (out) 500 ml The calculated total for 24-hour input and output on 5/31/24 was documented as: Total in: 1050 ml Correct calculation for input was 1450 ml Total out: 1650 ml Correct calculation for output was 850 ml The documented input and output for 6/1/24 was documented as: Day shift: (in) 500 ml, (out) x 2 Evening : (in) 480 ml, (out) 350 ml Night: (in) 120 ml, (out) 600 ml The calculated total for 24-hour input and output on 6/1/24 was documented as: Total in: 1180 ml Correct calculation for input was 1100 ml Total out: 1200 ml Correct calculation for output was 950 ml The documented input and output for 6/2/24 was documented as: Day shift: (in) 700 ml, (out) x 2 Evening : (in) 480 ml, (out) 500 ml Night: (in) 200 ml, (out) 450 ml The calculated total for 24-hour input and output on 6/2/24 was documented as: Total in: 1300 ml Correct calculation for input was 1380 ml Total out: 2000 ml Correct calculation for output was 950 ml The documented input and output for 6/4/24 was documented as: Day shift: (in) 660 ml, (out) 400 ml Evening : (in) 240 ml, (out) 300 ml Night: (in) 240 ml, (out) 300 ml The calculated total for 24-hour input and output on 6/4/24 was documented as: Total in: 1240 ml Correct calculation for input was 1140 ml Total out: x 5 Correct calculation for output was 1000 ml According to the care plan, titled Indwelling Catheter, undated, listed interventions such as: Monitor and document intake and output as per facility policy. On 6/5/24 at 1:39 P.M., an interview and record review was conducted with LN 11 of Resident 106's MAR. LN 11 stated monitoring I&Os (input and output) was important for early detection of fluid imbalances or potential problems. LN 11 stated the CNAs were expected to measure the urine output from a urinary catheter and report the amount to the licensed nurse for documentation. LN 11 reviewed Resident 106's MAR, listing the output as x 2 and x 5. LN 11 stated there should not be any x 2 or x 5 listed on the output, because a measurable numerical number was expected, especially with a urinary catheter. LN 11 stated the totals for the end of the 24-hour period should be an accurately balanced, because the physicians and nurses were analyzing the data. LN 11 stated if the input and output was not accurately documented, you could not tell if the resident's fluid status was safe or not. On 6/5/24 at 10:44 A.M., an interview and record review was conducted with the DON of Resident 106's MAR. The DON stated Resident 106's MAR was inaccurate, because x 2 and x 5 were not numerical numbers. The DON stated the 24-hour totals did not match with the shift totals for input and output. The DON stated accurate documentation was required in order to provide quality of care. The DON stated the I&O numerical values did not balance out, so everyone was unaware of what Resident 106's true fluid balance was on a daily basis. According to the facility's policy titled Charting and Documentation, undated, The resident's clinical record is a concise account of treatment, care, response to care, signs, symptoms and progress of the resident's treatment .Importance and Use of the Records: .3. To the physician, it guides him in his treatment, use and effects of drugs and plan for care .

Based on interview and record review, the facility failed to notify the physician of a laboratory (lab) test not being completed due to an expired specimen container for one of two sampled residents (1). As a result, there was an increased risk of Resident 1 not receiving the appropriate care and services they needed. Findings: Per the facility ' s Admission Record, Resident 1 was admitted to the facility on [DATE] with diagnoses to include malnutrition. Per the facility ' s Lab Results Patient Report, dated [DATE], the results read, .Test nor performed. Specimen submitted in expired/outdated collection device .expire date [DATE] . The form had a space to indicate who reviewed the form, but the space was blank. On [DATE] at 12:23 P.M., a telephone interview was conducted with the Director of Nursing (DON). The DON stated, if a specimen container had an expiration date then the nurse should have checked it. The DON further stated, when Resident 1 ' s lab results arrived on [DATE] and indicated that the test was not completed, the nurse should have notified the physician, but the DON was unable to find documentation that anyone notified the physician. The facility did not have a policy which required staff to notify the practitioner of lab results.

Based on observation, interview and record review, the facility failed to follow and implement policies and procedures for an allegation of abuse when: the alleged perpetrator returned to work and continued to enter the alleged victim's (Resident 5) room. This failure had the potential for Resident 5 to be vulnerable and exposed to the alleged perpetrator. Findings: Resident 5 was admitted to the facility on [DATE] with diagnoses including aphasia (language disorder affecting how to communicate) following other cerebrovascular disease (group of conditions affecting blood flow and blood vessels in the brain) and need for assistance with personal care according to the facility's Admission Record. An interview was conducted on 9/25/23, at 10:24 A.M. with Resident 5. Resident 5 was sitting in a wheelchair in her room and nodded when asked if she had any concerns with the facility staff. Resident 5 frowned and stated in a loud voice, A man, terrible person, grabbed . Resident 5 had difficulty completing sentences but kept repeating he was a terrible person. Resident 5 stated she screamed and yelled when she saw the man. During a review of Resident 5's clinical record titled Progress Notes (PN) dated 9/18/23, the PN indicated a licensed nurse (LN) documented Resident 5 complained about a nurse who stood in between Resident 5's bed and her roommate (Resident 1) on 9/17/23. The PN indicated, Resident told the nurse to move away and leave the room .resident explained sticking her left arm out towards nurse to move away and the resident claims the nurse hit her left arm 2 separate times. An interview was conducted with LN 2 on 9/25/23, at 4:31 P.M. LN 2 stated he did not work 9/18/23 and 9/19/23. LN 2 stated he returned to work on 9/20/23 and was assigned to Resident 5's roommate in bed B (Resident 1). On 9/20/23 evening shift, LN 2 stated Resident 5 and Resident 1 was heard yelling at each other. LN 2 stated he went into the room to ask Resident 1 what happened, then LN 2 and another CNA separated the beds further away. LN 2 further stated Resident 5 saw him at the other room and told him to go away. An interview was conducted with the Administrator (Admin) on 9/26/23, at 11:07 A.M. The Admin stated she was not aware of LN 2 being assigned in Resident 5's room. The Admin stated she would not have assigned LN 2 in Resident 5's room because this would upset Resident 5. During a review of the facility's Investigative Summary, dated 9/22/23, the Investigative Summary indicated LN 2 as the suspected abuser and was suspended pending investigation was returned to work on 9/20/23. A review of the facility's undated policy and procedure (P&P) titled, Resident Rights Abuse: Prevention of and Prohibition Against was conducted. The P&P indicated, .G. Protection 1. If an allegation of abuse . is reported, discovered or suspected, the Facility will take the following steps to protect all residents from physical and psychosocial harm during and after the investigation .Make room or staffing changes . to protect the resident (s) from the alleged perpetrator .

Based on observation, interview, and record review, the facility failed to develop patient centered care plans regarding a new diagnosis of urinary tract infection (UTI-an infection affecting the kidneys, bladder or urethra) for 2 residents (Resident 6 and 8) reviewed for care plans. This failure had the potential for residents to not receive the care needed to meet their needs and prevent UTI related complications. Findings: Resident 6 was readmitted to the facility on [DATE] with diagnoses which included UTI according to the facility's Admission Record. Resident 8 was admitted to the facility on [DATE] with the diagnoses which included Parkinson's Disease (brain disorder that causes uncontrollable movements and difficulty with balance and coordination) according to the facility's Admission Record. A review of Resident 6's physician's order was conducted. Resident 6's Order Summary Report, dated 8/14/23 indicated {Brand Name} 100mg (milligram) .Give 1 capsule by mouth two times a day for UTI for 5 days. The physician's order further indicated to change {Brand Name} on 8/16/23 to, {Brand Name} (a different antibiotic) Oral (by mouth) Tablet 500-125 MG .Give 1 tablet by mouth two times a day for UTI for 5 Days. During an interview and concurrent record review on 8/29/23, at 1:15 P.M., with Licensed Nurse 2 (LN), LN 2 stated Resident 6 had a UTI, but the resident already completed the antibiotic. Upon review of Resident 6's progress notes dated 8/14/23, LN 2 stated the urinalysis (urine test) result was sent to the physician and an antibiotic was prescribed for UTI. LN 2 reviewed Resident 6's care plans and did not find a plan of care for the diagnosis of UTI. LN 2 stated there should be a care plan because it was a change of condition. LN 2 further stated a care plan was a source of information for Licensed Nurses to identify resident problems and to update the interventions as needed. On 8/29/23 at 1:43 P.M., the Director of Nursing (DON) was interviewed. The DON stated it was important to have a care plan in order for staff to know how to monitor the resident and know the interventions for the UTI. During an interview and concurrent record review on 8/29/23, at 2:13 P.M., with the DON, the DON stated Resident 8 had a physician's order for {Brand Name} (an antibiotic) 500mg three times a day for UTI. Upon review of Resident 8's progress notes, the DON stated Resident 8 was sent to the hospital for Foley (brand name for a urinary catheter) re-insertion. The DON stated Resident 8 returned to the facility with a new order for an antibiotic for UTI. During a review of Resident 8's care plans, the DON stated there was no care plan completed to address Resident 8's diagnosis of UTI. The DON further stated there should have been a care plan developed. A review of the facility's policy and procedure (P&P) titled, Significant Change in Condition, Monitoring for, dated 6/2019, the P&P indicated, .It is the policy of this facility to ensure each resident receives quality of care and services .in accordance with the interdisciplinary comprehensive assessment and plan of care .The IDT shall collaborate with the Attending Physician, Resident, and/or Resident Representative to review risk indicators and the plan of care .

Based on observation, interview, and record review, the facility failed to implement the plan of care for 1 of 3 sampled residents (1) when: 1a. Licensed Nurses (LNs) did not follow physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] 1b. Licensed Nurses did not document wound care had been completed as ordered. As a result, there was the potential for Resident 1 ' s skin breakdown to increase in severity, and negatively impact Resident 1 ' s quality of life. Findings: 1a. Resident 1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/26/22, Resident 1 ' s EHR was reviewed. On 12/24/21, the physician ordered: TX: LEFT GREAT TOE NECROTIC AREAS: CLEAN WITH [MEDICATION(S)] DAILY AND LEAVE OTA [open to air]. every day shift On 12/24/21, the order was entered into Resident 1 ' s electronic Treatment Administration Record (eTAR). On 12/24/21, a care plan was created outlining interventions for wound care indicated Administer treatments as ordered and monitor for effectiveness. On 7/15/22 at 4 P.M., LN 4 was interviewed via telephone. LN 4 stated, during her shift on 3/16/22, Resident 1 asked LN 4 to check his toes due to discomfort. LN 4 observed a dressing covering the left toes. LN 4 stated when she removed the dressing, the wounds presented with a foul smell and an increase in drainage from previously noted. LN 4 stated Resident 1 ' s toes should have been left uncovered, and open to the air. LN 4 stated the dressing wasn ' t supposed to be there. On 8/3/22 at 3:50 P.M., the DON was interviewed. The DON stated the expectation was for LNs to follow the physicians ' orders as written. The facility ' s policy, Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 1b. Resident 1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/26/22, Resident 1 ' s EHR was reviewed. On 12/24/21, the physician ordered: TX: LEFT GREAT TOE NECROTIC AREAS: CLEAN WITH [MEDICATION(S)] DAILY AND LEAVE OTA. every day shift TX: RIGHT GREAT TOE NECROTIC AREAS: CLEAN WITH [MEDICATION(S)] DAILY AND LEAVE OTA. every day shift TX: LEFT GREAT TOE NECROTIC AREAS: MONITOR FOR S/S [signs and symptoms] OF INFECTION OR SKIN BREAKDOWN every shift TX: RIGHT GREAT TOE NECROTIC AREAS: MONITOR FOR S/S OF INFECTION OR SKIN BREAKDOWN every shift On 12/24/21, the orders were entered into Resident 1 ' s electronic Treatment Administration Record (eTAR). On 12/24/21, a care plan was created outlining interventions for wound care indicated Administer treatments as ordered and monitor for effectiveness. There was no documentation the treatment had been done on the following shifts or the reasons the treatment had not been done in the Nursing Progress Notes: 3/15/21 Day shift (typically 7 A.M. to 3 P.M.). 3/16/21 Day shift. There was no documentation the wounds had been monitored on the following shifts or the reasons the order to monitor the wounds had not been followed in the Nursing Progress Notes: 3/15/21 Evening shift (typically 3 P.M. to 11 P.M.). 3/15/21 Night shift (typically 11 P.M. to 7 A.M.). 3/16/21 Day shift. On 8/3/22 at 3:50 P.M., the DON was interviewed by telephone. The DON stated the expectation was for the LNs to sign off that they had completed the treatment on their shift. The DON stated documentation was essential to ensure orders were being followed. The DON stated the LNs responsible for completing the treatment on the days noted were not available for interview. According to the facility ' s policy, Charting and Documentation, revised 5/07, The resident ' s clinical record is a concise account of treatment

Based on observation, interview, and record review, the facility failed to implement the plan of care for 1 of 2 sampled residents (1) when LNs did not document wound care had been completed as ordered. As a result, there was the potential for Resident 1's skin breakdown to increase is severity, and negatively impact Resident 1's quality of life. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/7/22, Resident 1's electronic health record (EHR) was reviewed. On 12/18/20, the physician ordered: TX: Coccyx blanchable redness [reddened skin that turns white when pressed with the fingers and returns to red when the fingers are removed]: Cleanse with H2O, pat dry, apply [MEDICATION(S)] Q [every] shift and PRN as needed. The order was entered into Resident 1's electronic Treatment Administration Record (eTAR). On 1/8/21, the order was renewed for 14 days. On 12/18/20, a care plan was created outlining interventions for wound care and indicated Administer treatments as ordered and monitor for effectiveness. There was no documentation the treatment had been done on the following shifts or the reasons the treatment had not been done in the Nursing Progress Notes: 12/23/20 Day shift (typically 7 A.M. to 3 P.M.). 12/24/20 Day shift. 12/24/20 Night shift (typically 11 P.M. to 7 A.M.). 12/28/20 Day shift. 12/29/20 Day shift. 1/4/21 Day shift. On 8/3/22 at 3:50 P.M., the Director of Nurses (DON) was interviewed by telephone. The DON stated the expectation was for the licensed nurse (LN) to sign off that they had completed the treatment on their shift. The DON stated documentation was essential to ensure orders were being followed. The DON stated the LNs responsible for completing the treatment on the days noted were not available for interview. According to the facility's policy, Charting and Documentation, revised 5/07, The resident's clinical record is a concise account of treatment

Based on interview and record review, the facility failed to accurately complete a transfer assessment for one of two residents (1) upon transfer to the hospital. As a result, there was the potential information related to Resident 1's care and comfort would be missed by the receiving facility. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/7/22, Resident 1's electronic health record (EHR) was reviewed. On 12/18/20, Resident 1 was noted with blanchable redness [reddened skin that turns white when pressed with the fingers and returns to red when the fingers are removed] to the coccyx. On 1/8/21, the area was reassessed as superficial excoriation with measurable parameters of 1 centimeter (cm) by 1 cm. On 1/12/21, Resident 1 was transferred to the local emergency room due to a critical change in condition. The facility's Nursing Home to Hospital Transfer Form, additional information page, dated 1/12/21, did not include information about Resident 1's skin condition or wound care. On 8/3/22 at 3:50 P.M., the Director of Nurses (DON) was interviewed. The DON stated Resident 1's transfer form should have been completed. The DON stated the transfer form provided a clinical picture of Resident 1, so staff taking over could provide appropriate care. The DON stated the expectation was for all areas on the form to have correct and current information. According to the facility's policy, Discharge or Transfer, revised 10/20, It is the policy of tis facility to provide the Resident with a safe organized structured transfer 1. C. Complete transfer/discharge form

Based on observation, interview, and record review, the facility failed to ensure the call light was within reach for one of 16 sampled residents (4). This failure had the potential for Resident 4's needs to go unmet. Findings: Resident 4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/9/22, Resident 4 ' s clinical record was reviewed. Per the Minimum Data Set (MDS- an assessment tool), Section G, Functional Status, dated 4/25/22, Resident 4 required extensive assistance to complete activities of daily living. On 5/9/22 at 2:30 P.M., Resident 4 was observed alone in their room, lying in bed, leaning toward the right side with their head close to the bed rail. Resident 4's stated they were not comfortable and needed a position change. Resident 4 was unable to find the call light. Resident 4 ' s stated they would have to wait for someone to come in. On 5/9/22 at 2:35 P.M., a concurrent observation and interview was conducted with CNA 1. CNA 1 found Resident 4 ' s call light wrapped around the arm of a wheelchair behind the privacy curtains. CNA 1 stated Resident 4 would not have been able to reach the call light where it had been left. CNA 1 stated it was important to have the call light within the resident ' s reach because that was how the resident contacted the staff if they needed help. On 5/9/22 at 2:45 P.M., LN 1 was interviewed. LN 1 stated ensuring Resident 4 had the call light within reach was part of the nursing assessment. LN 1 stated she did not take notice and was unsure if Resident 4 had the call light before she left the room. On 5/9/22 at 2:54 P.M., OT 1 was interviewed. OT 1 stated she was unsure if Resident 4 had the call light after she applied the hand splints and left the room. On 5/9/22 at 3 P.M., Resident 4 was observed lying in bed with the call light within reach of their dominant left hand. Resident 4 was observed to be able to depress the call button to activate the call system. On 5/9/22 at 3:10P.M., the DON was interviewed. The DON stated the expectation was that all residents should have their call lights within their reach whenever they are in bed or in their room. Per the facility's policy, titled Call Light/Bell, revised 10/17, . 5 Place the call device within resident's reach before leaving the room