Every finding on record at The Orchard - Post Acute Care

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from significant medication errors in accordance with the facility's policy and procedures titled, Medication Administration-General Guidelines and Medication Errors and Adverse Reactions. The facility failed to ensure: 1. Nurse Practitioner (NP) 1 completed the medication reconciliation process (the process of comparing current medication orders to all of the medications the resident has actually been taking) and reviewed Resident 1's home medication list upon admission from the hospital on 7/26/2026 to prevent a delay in restarting Resident 1's levothyroxine (a medicine that replaces thyroid hormone [a natural chemical the body makes to control energy, metabolism, and how fast the body works]). NP 1 did not prescribe, and Resident 1 did not receive the levothyroxine for 10 days after admission to the facility. 2. admission Registered Nurse (RN) 1 provided to NP 1 and thoroughly reviewed Resident 1's General Acute Care Hospital (GACH) 1's discharge medications, including home medications, during the medication reconciliation process. These deficient practices resulted in significant medication errors in which Resident 1's blood level had abnormally high TSH (thyroid-stimulating hormone increases when the thyroid gland is underactive and not making enough thyroid hormone, a condition called hypothyroidism) that put the resident at risk for fatigue, low heart rate, decreased energy, and overall clinical decline. 3. Licensed Vocational Nurse (LVN) 1 discharge Resident 1 to home on 8/14/26 with Verapamil (a medicine that can lower blood pressure [how hard the blood pushes against the blood vessel walls when the heart beats] and slow the heart rate (how fast the heart beats each minute)], which was not prescribed to the resident. This deficient practice had the potential for Resident 1 to be at risk for having dangerously low blood pressure, low heart rate that could lead to decreased blood flow to major body organs that could lead to hospitalization and death. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included toxic encephalopathy (a condition where toxins cause the brain to not work normally), hypothyroidism (when the thyroid gland is underactive and makes too little hormone), and type 2 diabetes mellitus (a condition where the body has trouble using insulin, causing high blood sugar). During a review of Resident 1' GACH 1's Discharge Medication Orders (DMO), dated 7/26/2026, the DMO indicated Resident 1's home medications included levothyroxine 112 mcg (microgram, unit of weight) oral tablet, to give 1 tablet orally (by mouth) once a day. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment), dated 7/28/2026, the MDS indicated Resident 1's cognition was moderately impaired, and Resident required supervision or touching assistance with oral and personal hygiene. During a review of Resident 1's admission Drug Regimen Review (ADRR), dated 7/27/2026, the ADRR indicated that RN 1 documented no issues with Resident 1's medication list and marked no in response to the question, one or more medical conditions/active diagnoses do not have a prescribed medication therapy. During a review of Resident 1's Lab Results Report (LRR), dated 7/31/2026, the LRR indicated Resident 1's TSH (thyroid-stimulating hormone, a chemical from the pituitary gland that tells the thyroid how much hormone to make) level was abnormally high at 103.68 while the reference range is 0.45-5.33. During a review of Resident 1's Order Summary Report (OSR), the OSR indicated a physician order on 8/3/2026 for levothyroxine sodium oral tablet 50 mcg to give 1 tablet by mouth in the morning for thyroid starting on 8/4/2026. The OSR indicated, there was no physician order for Verapamil. During a review of Resident 1's Progress notes (PN), dated 8/14/2026, the PN indicated Resident 1 was discharged at 3:30 PM on 8/14/2026 and all medications, discharge instructions, and paperwork were given to the resident. During a review of the facility's Investigation Summary (IS), dated 8/27/2026, the IS indicated LVN 1 reported that while gathering the discharge medications and paperwork for placement into the discharge bag, LVN 1 may have inadvertently included Verapamil bubble pack, which was not ordered for Resident 1. The IS indicated Verapamil was sent home with Resident 1 in error during the discharge process. During a phone interview on 8/26/2026 at 4:45 PM with NP 1, NP 1 stated that when Resident 1 was admitted on [DATE], the facility only sent her an admission Record and did not include GACH 1's discharge records that listed Resident 1's home medications. NP 1 stated she did not request GACH records of Resident 1 to review from the facility. NP 1 stated when she conducted a physical assessment of Resident 1 on 7/31/2026, FAM 1 shared a concern that Resident 1 has not been receiving her thyroid medication. NP 1 stated she ordered lab tests that included the blood TSH level and restarted levothyroxine on 8/4/2026. NP 1 stated that she and RN 1 should have reviewed all medications in the discharge packet from GACH 1 and reported all home medications to NP 1 upon admission to prevent any medications from being missed. NP 1 stated that a delay in restarting levothyroxine could contribute to an abnormal TSH level, and an abnormal TSH level indicates the body is not getting the hormone it needs, which could potentially cause harm to the resident. During a concurrent interview and observation on 8/26/2026 at 5 PM with LVN 1, LVN 1 stated she discharged Resident 1 on 8/14/2026 and provided Resident 1 and her family with all discharge medications and instructions. LVN 1 stated she obtained the discharge medications from the resident's assigned slot in the medication cart which LVN 1 demonstrated by pointing to the medication name, dosage, and instructions on a medication bubble pack. When asked why she did not verify the resident's name on the medication bubble pack before giving it to Resident 1, LVN 1 did not provide a response. During a concurrent interview and record review on 8/27/2026 at 3:58 PM with the Director of Nursing (DON), Resident 1's GACH 1's DMO, dated 7/26/2026, Resident 1's ADRR, dated 7/27/2026, and Resident 1's LRR, dated 7/31/2026, were reviewed. The DON stated RN 1 did not thoroughly review Resident 1's discharge packet from GACH 1. The DON stated she expected RN 1 to verify all medications, including the resident's home medications, and review them with NP 1 to prevent any medications from being missed. The DON further stated that LVN 1 should review each medication bubble pack one by one, including checking the resident's name, to make sure the correct medications are given to the correct patient. The DON stated that failing to verify medications can lead to serious medication errors, such as a resident not receiving an important medication or being given the wrong medication, which could cause problems like low blood pressure, dizziness, confusion, or worsening medical conditions. During a review of the facility's policies and procedures (P&P) titled, Physician visits, dated 2015, the P&P indicated during the initial visit, the physician shall complete a thorough assessment, develop a plan of care and writes or verifies admitting orders for the resident. During a review of the facility's P&P titled, Medication Administration-General Guidelines, updated 2021, the P&P indicated: Medications are administered in accordance with written orders of the attending physician. Medications supplied for one resident are never administered to another resident. During a review of the facility's P&P titled, Six Rights of Medication Administration, revised 2023, the P&P indicated the six rights of medication administration are as follows in order to ensure safety and accuracy of administration: right resident, right time, right medication, right dose, right route, and right documentation. During a review of the facility's P&P titled, Medication Errors and Adverse Reactions, revised 2025, the P&P indicated: significant medication error means one which causes the resident discomfort or jeopardizes his or her health and safety. The medical director, director of nursing services and consultant pharmacist must be informed of all medication errors and adverse reactions. Medication errors and adverse reactions, with or without adverse clinical consequences, are reported or referred to the QAPI/QAA committee.

Based on observation, interview, and record review, the facility failed to ensure medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier for one of three sampled resident (Resident 2) by failing to ensure: 1.Resident 2's prescribed Verapamil (a medication used to lower high blood pressure and certain heart conditions by relaxing blood vessels and helping control heart rate) bubble packs (pre-sorted packaging method that organizes pills and capsules into individual, sealed plastic compartments labeled by resident's name and the specific day and time they need to be taken) which had been delivered by the pharmacy on 8/13/2026, was stored in the wrong slot in the medication cart and mistakenly sent the bubble pack home with another resident. 2.Resident 2's prescribed Mirtazapine (medications used to treat depression [a mood disorder manifested by severe sadness and hopelessness]) bubble pack was found stored in another resident's slot in the medication cart rather than in Resident 2's designated slot on 8/27/2026. These deficient practices had the potential to result in medication errors, including missed doses, delayed administration, or incorrect medication being given to residents, which could lead to adverse health outcomes.During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hyperlipidemia (high levels of fat, such as cholesterol, in the blood), essential hypertension (high blood pressure), and depression (a medical condition that affects mood, energy, and daily functioning). During a review of Resident 2's [NAME] Data Set (MDS, a resident assessment tool), dated 6/22/2026, the MDS indicated Resident 2's cognition (the ability to think, learn, and remember) was moderately impaired and the resident required supervision or touching assistance in eating and oral hygiene. During a review of Resident 2's Order Summary Report (OSR), the OSR indicated that on 6/17/2026, Resident 2 had physician orders for Verapamil HCL 120 mg (milligrams, unit of weight), to give one tablet by mouth twice daily for hypertension, and Mirtazapine 7.5 mg, to give one tablet by mouth at bedtime for depression manifested by poor intake. During an interview on 8/26/2026 at 1:45 PM with Resident 2, Resident 2 stated she was not sure if she had missed any doses of Verapamil or Mirtazapine. During a concurrent interview and record review on 8/27/2026 at 11:20 AM with Registered Nurse (RN) 2, the pharmacy packing slip dated 8/13/2026 was reviewed. The packing slip indicated that two bubble packs of Verapamil were delivered to the facility on 8/13/2026. RN 2 stated that Resident 2 was prescribed Verapamil twice daily, and therefore the two medication bubble packs would be labeled AM and PM. During a concurrent interview and observation on 8/27/2026 at 11:35 AM with Licensed Vocational Nurse (LVN) 2, one Verapamil bubble pack labeled AM was found, and LVN 2 stated he could not locate the corresponding PM Verapamil bubble pack that should have been available for the PM shift. During a concurrent interview and observation of medication storage on 8/27/2026 at 11:40 AM with LVN 2, LVN 2 identified Resident 2's Mirtazapine packet in another resident's medication cart slot. LVN 2 stated the packet's label displayed Resident 2's previous room number, which may have led staff to place it in the slot corresponding to that former room. LVN 2 stated that whoever placed the bubble pack in the medication cart should have verified the resident's name, not just the room number, because relying solely on room number could lead to medication errors due to incorrect patient medication storage. During an interview on 8/27/2026 at 3:58 PM with the Director of Nursing (DON), the DON stated that one medication bubble pack of Resident 2's prescribed Verapamil was missing because LVN 1 had mistakenly sent the bubble pack home with another resident. The DON explained that all medications must be properly labeled and stored in the resident's designated medication cart slot to ensure correct identification, prevent misplacement, and avoid medication errors. The DON further stated that sending a medication bubble pack home with the wrong resident, storing medications in the incorrect slot, or failing to verify the resident's name on the label is a federal violations and unsafe medication storage practice that placed residents at risk for receiving the wrong medications or missing required doses. During a review of the facility's policies and procedures (P&P) titled, Storage of Medications, updated 2019, the P&P indicated medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. During a review of the facility's P&P titled, Medication Administration-General Guidelines, updated 2021, the P&P indicated: Medications are administered in accordance with written orders of the attending physician. Medications supplied for one resident are never administered to another resident.

Based on interviews and record review, the facility failed to maintain accurate and complete medical documentation for one of three sampled residents (Resident 1) in accordance with the facility's policy and procedure titled, Nursing Administration - Documentation. The facility failed to: 1. The IDT meeting (Interdisciplinary Team, a group of staff from different departments who work together to plan and review a resident's care) on 7/30/2026 documented that Resident 1's physician was present during the IDT meeting, however, there was no evidence that the physician attended the meeting. 2.The IDT notes regarding the meeting held on 7/30/2026 did not include Family Member (FM) 1 who attended and expressed concerns about missing medications. 3. Nurse Practitioner (NP) 1 did not have documented evidence of the availability of the history and physical (H&P) in Resident 1's medical record during the stay from 7/26/2026 to 8/14/2026, following the assessment conducted on 7/31/2026. 4. Resident 1's diagnoses were not updated in the medical record until the resident was discharged home on 8/14/2026, rather than on the admission date of 7/26/2026. These deficiencies had the potential to negatively affect the accuracy and reliability of Resident 1's medical information that could affect the quality and continuity of care of the resident.Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included toxic encephalopathy (a condition where toxins cause the brain to not work normally), hypothyroidism (when the thyroid gland is underactive and makes too little hormone), and type 2 diabetes mellitus (a condition where the body has trouble using insulin, causing high blood sugar). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment), dated 7/28/2026, the MDS indicated Resident 1's cognition was moderately impaired, and Resident 1 required supervision or touching assistance with oral and personal hygiene. During a review of Resident 1's IDT Care Plan Review dated 7/30/2026, the IDT indicated that the team members participating in the review included Resident 1's physician. The IDT also indicated there was no family member participating in the care plan review. During an interview on 8/25/2026 at 4:40 PM with Resident 1's, FM 1stated she participated in Resident 1's IDT meeting on 7/30/2026. FM 1 stated, she explained Resident 1's complex diagnoses and expressed concerns to Case Manager (CM 1) about the resident missing her home medications. FM 1 also stated that no physician was present during the meeting. During a concurrent interview and record review on 8/26/2026 at 3 PM with CM 1, Resident 1's IDT Care Plan Review, dated 7/30/2026, was reviewed. CM 1 stated the physician was listed on the care plan review but did not participate and attended in the IDT. CM 1 stated she included the physician's name only to identify which physician was responsible for the resident. CM 1 further stated that Resident 1's family member participated in the care plan review and voiced concerns about the resident's home medications; however, CM 1 did not document these concerns in the record. During a concurrent interview and record review on 8/26/2026 at 4:15 PM with Director of Health Information Management (DHIM), Resident 1's medical record from 7/26/2026 to 8/26/2026 was reviewed. The DHIM stated he could not find Resident 1's H&P in the resident's medical record as of 8/26/2026. During the same interview and record review on 8/26/2026 at 4:15 PM with the DHIM, Resident 1's physical and electronic health record (EHR, a digital version of a resident's medical chart that stores their health information-such as assessments, diagnoses, medications, and progress notes-in an organized, easily accessible format) from 7/26/2026 to 8/14/2026, were reviewed. The DHIM stated that he updated Resident 1's diagnoses on 8/17/2026, after the resident was discharged from the facility. The DHIM stated that the MDS Nurse typically reviews the resident's record and provides a list of current medical diagnoses within three days of admission, which he then uploads into the EHR. The DHIM stated the facility should have ensured Resident 1's complete diagnoses were available in the medical record during the resident's stay to reflect the most current and accurate clinical status, especially since the resident's H&P was not available. During a phone interview on 8/26/2026 at 4:45 PM, NP 1 stated she assessed Resident 1 in person on 7/31/2026. NP 1 stated she did not ensure the history and physical (H&P) was placed in the resident's medical record to be readily available for review. NP 1 stated the H&P should have been available in the resident's health record immediately after her visit on 7/31/2026. During an interview on 8/27/2026 at 3:58 PM with the Director of Nursing (DON), the DON stated staff must ensure that residents' medical records are kept up to date and accurate to support continuity of care and appropriate clinical decision-making. During a review of the facility's policy and procedure (P&P) titled, Nursing Administration - Documentation, revised 2023, the P&P indicated documentation to ensure comprehensive, timely, and documentation pf nursing care and resident-related events. It is the responsibility of the Licensed Nurses to document the pertinent information in resident medical record of nursing care rendered. During a review of the facility's P&P titled, Physician visits, dated 2015, the P&P indicated during the initial visit, the physician shall complete a thorough assessment, develops a plan of care and writes or verifies admitting orders for the resident.

Based on interview and record review, the facility failed to ensure two of thirteen sampled resident (Resident 5 and Resident 48), or their representative were assisted to formulate an Advance Directives (AD-a written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) upon admission to the facility and ensure their Acknowledgement of Advance Directive (AAD, a document where a person confirms they have received information about their right to create an advance directive and understand their options for future medical decisions) form was completed accurately and timely. These deficient practices had the potential to cause conflict with Resident 5 and 48's wishes regarding health care treatment, especially in an event of emergency Findings: 1. During a review of Resident 48's admission Record, the record indicated Resident 48 was admitted to the facility on [DATE] with diagnoses including osteomyelitis (inflammation of bone or bone marrow, usually due to infection) of the left ankle and foot, hypertension (HTN- high blood pressure), and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). The record also indicated Resident 48's primary language was Spanish. During a review of Resident 48's History and Physical (H&P) dated 7/6/2026, the H&P did not indicate if Resident 48 executed an advanced directive (a legal document indicating resident preference on end-of-life treatment decisions) or if Resident 48 was given information on advanced directives. During a review of Resident 48's Minimum Data Set (MDS- a resident assessment tool) dated 7/11/2026, the MDS indicated Resident 48 had moderate cognitive impairment (moderate issues with memory, orientation, or attention) and required maximal assistance (helper does more than half the effort) for cares such as toileting hygiene, shower/bathing, lower body dressing, and putting on/taking off footwear. During a review of Resident 48's Acknowledgement of Advance Directive Form dated 7/6/2026, the form indicated Resident 48 had not executed an advanced directive. The form did not indicate if Resident 48 declined to execute an advanced directive or wished to execute an advanced directive. During an interview on 7/30/2026 at 3:27 PM with the Social Services Director (SSD), the SSD stated that, upon admission, the facility staff was supposed to provide residents with information on advanced directives in the admission packet and have the resident or their responsible party fill out the Advanced Directive Acknowledgement form. The SSD further stated that if the resident had not executed an advanced directive, the staff was supposed to ask the resident if they wanted to execute an advanced directive and if they would like more information on the procedures for executing one. During the same concurrent interview and record review with the SSD on 7/30/2026 at 3:27 PM, Resident 48's Acknowledgement of Advance Directive Form was reviewed. The SSD stated that the form had been completed by the receptionist at the time of Resident 48's admission; however, it was not filled out correctly. The SSD stated that the form should have indicated whether Resident 48 wished to execute an advance directive, but this section was left incomplete. The SSD stated Resident 48 was not provided the opportunity to initiate an advanced directive if Resident 48 wanted to. The SSD further explained that it was essential to provide this information to the resident or their responsible party so they can make informed decisions and clearly communicate their wishes. During an interview with the Admissions Coordinator Assistant (ACA) on 7/31/2026 at 8:35 AM, the ACA stated that the admissions staff went over the Advanced Directive Acknowledgement Form with new residents upon admission to the facility. The ACA stated that the admissions staff only asked the residents if they had a power of attorney (a legal document that authorizes a chosen agent to act on behalf of the principal in specified legal, financial, or healthcare matters) but never educated residents on Advanced Directives since the advanced directives was completed by social services. During the same concurrent interview and record review with the ACA on 7/31/2026 at 8:35 AM, Resident 48's Acknowledgement of Advance Directive Form was reviewed. The ACA stated that Resident 48's Acknowledgement of Advanced Directive Form was not completed correctly because the receptionist who completed the form was new to the facility and was just provided training on how to properly assess residents for Advanced Directives. During a concurrent interview and record review with Resident 48 on 7/31/2026 at 10:37 AM, Resident 48's Advanced Directive Acknowledgement Form was reviewed. Resident 48 requested a Spanish interpreter for the interview. Resident 48 stated that the Receptionist provided Resident 48 with a lot of information in English and Resident 48 remembered signing the paperwork but could not remember what the information was about. Resident 48 also stated that the facility usually spoke to Family Member (FM 2) about Resident 48's care. Resident 48 stated he wanted more information on advanced directives. During an interview with FM 2 on 7/31/2026 at 10:52 AM, FM 2 stated that she was Resident 48's responsible party and managed his care. FM 2 stated that she was not present when Resident 48 was admitted to the facility and she did not receive any information on advanced directives after Resident 48 was admitted to the facility. FM 2 further stated she and Resident 48 would like information on advanced directives so that she can have directions when Resident 48 could not make decisions for himself. During a review of the facility's Policy and Procedure (P&P) titled, Advanced Directives and Associated Documentation and dated 4/2025, the P&P indicated: Prior to, upon, or immediately after admission, a facility staff member shall provide the resident/family or responsible agent written information, in a manner easily understood by the resident or resident representative, regarding the right to accept or refuse medical or surgical treatment and the right to formulate Advanced Directives. The P&P also indicated that when an Advanced Directive was not completed, staff should refer the resident / resident representative or decision maker to their physician to define or clarify medical issues or respond to questions regarding medical or surgical treatments. 2, During a review of Resident 5's Face Sheet (FS), the FS indicated Resident 5 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dysphagia (trouble swallowing), hemiplegia (a medical condition causing total or severe impairment on one side of the body) and hemiparesis (weakness affecting one entire side of the body). During a review of Resident 5's Minimum Data Set (MDS, a resident assessment tool), dated 5/25/2026, the MDS indicated Resident 5 had severely impaired cognition (ability to think and reason) and memory. The MDS indicated Resident 5 required setup or clean-up assistance with eating, supervision or touching assistance with oral hygiene, partial/moderate assistance with personal hygiene, substantial/maximal assistance with toileting hygiene, and was dependent with shower/bathe self and chair/bed-to-chair transfer. During a concurrent interview and record review on 7/29/2026 at 4 PM with the Social Services Director (SSD), Resident 5's Acknowledgement of Advance Directive, dated 5/21/2025, was reviewed. The SSD stated AAD indicated Resident 5 had AD, but she verified with the Responsible Party (RP) later that Resident 5 did not have an AD. The SSD stated she was not the staff who completed the AAD form on 5/21/2025 and she does not know if the staff verified the AD with the resident and the RP, or if the staff provided information regarding the AD process. The SSD stated she did not check if Resident 5's AAD was completed accurately. During a concurrent interview and record review on 7/29/2026 at 4:14 PM with the Receptionist, Resident 5's Acknowledgement of Advance Directive, dated 5/21/2025, was reviewed. The Receptionist stated she provided the AAD form to the RP to sign during Resident 5's readmission on [DATE]. The Receptionist stated she just gave the AAD form to the RP without providing information of the AD because she thought the RP would know what AD was and how to make one since this was a readmission process. The receptionist stated the RP marked Resident 3 have executed an AD on the AAD form, but she did not verify with the RP if Resident 3 had an AD or not and she did not follow up with the AD. During an interview on 7/29/2026 at 4:16 PM with the SSD, the SSD stated the staff should have explained and verified if the residents had an AD. The SSD stated if the resident had an AD, the staff needed to obtain a copy of AD and keep it in the resident's medical record. The SSD stated If the resident did not an AD, the staff needed to check if the resident and the RP were interested in formulating an AD and provide the AD information to them. The SSD stated it is important to explain and provide information on AD to the resident and the RP, and document AAD correctly to ensure the resident's right and his or her wish for care was respected. During a review of the facility's policy and procedure (P&P) titled, Advance Directives and Associated Documentation, revised 4/2025, the P&P indicated a resident's choice about advance directives will be recognized and respected, to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. The facility recognizes and respects the resident's right to choose their treatment and make decisions about care to be received at the end of their life.

Based on observation, interview, and record review, the facility failed to ensure that one of three sample residents (Resident 141), who was at risk for constipation (a common digestive issue where aa person has fewer than three bowel movements a week, or passes hard, dry, and lumpy stools that are painful or hard to push out) received treatment and care in accordance with professional standards of practice, the comprehensive person centered care plan and physician's order for effective bowel management by failing to: 1. Assess and monitor the resident's bowel status according to the resident's care plan, physician's order and facility's policy and procedure. The care plan's interventions included monitoring side effects of constipation and monitoring/documenting/reporting to the physician complications related to constipation such as agitation, small loose stools, abdomen tenderness, guarding, or rigidity. 2. Implement and intervene when Resident 141 exhibited signs of symptoms of constipation such as small loose stools, agitation, and abdominal tenderness despite ongoing complaints of abdominal pain. 3. Assess and evaluate for risk factors for constipation such as decrease mobility and medication side effects of pain Hydrocodone-Acetaminophen (Norco, a pain medication combination of Hydrocodone [opioid] and Acetaminophen [Tylenol] and Ferrous Sulfate (iron supplement with side effect of constipation). 4. Administer the as needed (PRN) medications for constipation that included Milk of Magnesia suspension (MoM, liquid stool softener that helps relieve occasional constipation), Dulcolax (also known as Bisacodyl- stool softener) suppository (rectal medication), and fleet enema (liquid medication squeezed into the rectum) from 6/1/2026 to 7/30/2026. This failure resulted in Resident 141 continuing to experience unresolved pain, constipation, and abdominal discomfort and may result in failure to identify and treatment fecal impaction (a solid, dry mass of stool stuck in the lower intestine or rectum) which may lead to bowel obstruction (physical blockage in the small or large intestine) and ileus (temporary slowdown or stoppage of the intestinal muscles). Cross Reference F690 and F697 Findings: During a review of Resident 141's AR, the AR indicated that Resident 141 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included abnormal gait and mobility and spinal stenosis (a chronic condition of having abnormal narrowing of the spinal cord which puts pressure on the spinal cord or spinal nerves, most often in the lower back or neck resulting in pain). During a review of Resident 141's Order Summary Report, a physician order, dated 2/4/2026, indicated that Resident 141 had a physician order for Bisacodyl Enteric Coated (stimulant laxative, medication used to trigger the muscles of the intestine to move stool through) Delayed Release 5 milligrams (mg) with instructions to give 1 tablet by mouth one time a day for bowel management and to hold medication for loose stools. During a review of Resident 141's Order Summary Report, dated 5/1/2024 update on 6/29/2026, the physician order indicated to give Milk of Magnesia suspension (MoM), 30 milliliter (ml) every 24-hours as needed (PRN) for constipation if there was no bowel movement for 3 days. During a review of Resident 141's Order Summary Report, dated 5/1/2024 update on 6/29/2026 the physician order indicated to give Dulcolax 10 mg suppository rectally every 24 hours PRN for constipation if the MoM was not ineffective. During a review of Resident 141's Order Summary Report, dated 5/1/2024 updated on update on 6/29/2026, the physician order indicated to give one unit of fleet enema 7-19 grams (g) with instructions 1 unit rectally (given into the anus) every 24-hours PRN for constipation if the Dulcolax supplement was ineffective. During a review of Resident 141's Order Summary Report, dated 5/1/2024, updated indicated that Resident 141 had a physician order for Ferrous Sulfate tablet 325 mg with instructions to give 1 tablet by mouth twice a day with meals. During a review of Resident 141's care plan, initiated on 7/16/2024 and revised on 10/27/2025, the care plan indicated that Resident 141 was at risk for constipation related to decrease mobility and medication side effects of pain. The care plan's interventions included monitoring side effects of constipation and monitoring/documenting/reporting to the physician complications related to constipation such as agitation, small loose stools, abdomen tenderness, guarding, or rigidity. During a review of Resident 141's Order Summary Report, a physician order, dated 9/12/2025, update on 6/29/2026, indicated to administer Norco 10-325 mg one tablet by mouth every 6 hours PRN for severe pain (8-10/10 on the numerical pain scale). During a review of Resident 141's Order Summary Report, a physician order, dated 1/6/2026, indicated to administer Norco 5-325 mg with instructions to give 1 tablet by mouth every 6 hours PRN for moderate pain (4-7/10 on the numerical pain scale). During a review of Resident 141's Medication Administration Record (MAR) for June 2026, Resident 141 received Norco 10-325 mg 19 times for a pain intensity of 8-9/10 on the numerical pain scale from 6/1/2026 to 6/30/2026 (15 days total). During a review of Resident 141's MAR for July 2026, Resident 141 received Norco 10-325 mg 6 times for a pain intensity of 8/10 on the numerical pain scale from 7/1/2026 to 7/31/2026 (6 days total) and Norco 5-325 mg 38 times for a pain intensity of 5-8/10 on the numerical pain scale from 7/1/2026 to 7/31/2026 (20 days total). During a review of Resident 141's electronic MAR Medication Administration Note record in the progress notes, from 7/1/2026 to 7/31/2026, the records indicated that Resident 141 received Norco 5-325 mg for abdominal pain on 7/16/2026, 7/17/2026, 7/19/2026, and 7/30/2026 (total 5 times for a total of 4 days). During a review of Resident 141's MDS, dated [DATE], the MDS indicated that Resident 141's cognition (ability to process information) was moderately impaired. The MDS indicated Resident 141 needed supervision when performing toileting hygiene, repositioning self in bed, and transferring from the chair/bed to the chair or commode (a portable toilet, built like a chair with a bucket hidden under the seat). The MDS indicated that Resident 141 received a pain medication regimen and as needed pain medication. The MDS indicated that Resident 141 experienced frequent incontinence (loss of bladder or bowel control), and there was no documented evidence that Resident 141 was on a bowel toileting program. The MDS indicated that Resident 141 received opioid (Hydrocodone, a strong prescription pain medication with a side effect to cause constipation) for pain. During a review of Resident 141's Order Summary Report, dated 7/7/2026, indicated to administer Senna (stimulant laxative) oral (given by mouth) tablet with instructions to give one tablet by mouth one time a day for bowel management. During a review of Resident 141's Documentation Survey Report, for June and July 2026, the reports indicated that Resident 141 had no stool for 17 days in from 6/1/2026 to 6/30/2026 (total 23 days) in 7/1/2026 to 7/29/2026 (total 29 days). During a review of Resident 141's Medication Administration Report, for June and July 2026, the MAR indicated that Resident 141 did not receive any PRN MoM, Dulcolax suppository, or fleet enema for constipation. During a concurrent observation and interview on 7/28/2026 at 11:49 AM in Resident 141's room, Resident 141 was observed lying in bed with the occasional facial grimacing and pointed to her lower abdominal area. Resident 141 stated that she has had stomach pain all night because she has to poop. Resident 141 stated that her pain was 8/10 and [Resident 141] feels full. Resident 141 stated that her pain was in her stomach and described the location as a smile and pointed to her lower abdominal and the bilateral sides of her abdomen. Resident 141 stated her stomach pain was always present, but the intensity of the pain fluctuated with the highest intensity as an 8/10. During another concurrent observation and interview on 7/30/2026 at 3:25 PM in Resident 141's room, Resident 141 was observed lying sideways in bed with the occasional facial grimacing. Resident 141 stated she had a hard stool and it was in pieces. Resident 141 stated, my stomach hurts so bad that I would rather go to Heaven than deal with what I am dealing with right now! During a concurrent interview and record review on 7/30/2026 at 3:30 PM with Licensed Vocational Nurse (LVN) 3, LVN 3 was asked when the last time Resident 141 had a bowel movement. LVN 3 stated he did not know when the resident had bowel movement before giving the medications in the morning for constipation. Then, LVN 3 reviewed Resident 141's Certified Nurse Assistant (CNA) Tasks for Bowel Movement/continence, dated for July 2026 and replied, Resident 141 had a bowel movement was on 7/28/2026 (2 days ago.) LVN 3 stated he was aware that Resident 141 frequently complained of constipation. LVN 3 stated he did not administer and no documented evidence Resident 141 received any PRN bowel management medications in July 2026. During a concurrent interview and record review on 7/31/2026 at 12:10 PM with the Minimal Data Set Nurse (MDSN), Resident 141's Order Summary Report was reviewed. The MDSN stated that Resident 141's physician orders included Norco 5-325 mg and Norco 10-325mg. The MDSN stated there was no order to monitor for side effects of Norco such as constipation, and the MDSN stated that constipation was a side effect and complication of Norco. The MDSN stated that Resident 141's physician order included an iron supplement, and one of the side effects of an Iron supplement was constipation which had been monitored. During the same interview and record reviewed on 7/31/2026 at 12:13 PM with the MDSN, Resident 141's MAR for June to July 2026 was reviewed. The MDSN stated that Resident 141 had 3 routine stool softeners, but the facility did not administer any PRN bowel management medication to Resident 141. During a concurrent observation and interview on 7/31/2026 at 12:30 PM in Resident 141's room with the MDSN nurse, Resident 141 was observed lying in bed while the MDSN performed an abdominal palpation (a physical exam where a clinical provider presses gently or deeply on a resident's abdomen with their hands to check for pain, tenderness, and abnormal masses). Resident 141's had facial grimacing during MDSN abdominal assessment and palpation. Resident 141 stated that she felt better today because she had a bowel movement last night (7/30/2026). During an interview on 7/31/2026 at 1:45 PM with the Director of Nursing (DON), the DON stated Resident 141's stool pattern was not consistently monitored, and her current bowel management was not effective, leading to Resident 141's continued complaints of abdominal pain and discomfort due to constipation. During a review of the facility's policy and procedure (P&P) titled Pain Recognition and Management, dated 4/2025, the P&P indicated that the care plan will include preventative or care interventions (pharmacological and non-pharmacological) to management and or/prevent pain and consider the resident's needs, preferences, and goals. During a review of the facility's P&P titled Pain Recognition and Management, dated 4/2025, the P&P indicated to monitor for effectiveness of interventions and/or adverse consequences (e.g. constipation, sedations. The P&P indicated that the the interdisciplinary care plan will reflect the location and type of pain, pharmacological, and non-pharmacological interventions, with evaluation and revision as indicated.

The facility failed to ensure one of two sample residents (Resident 81), who had a history of psychoactive substance dependence (a state in which the body or mind relies on a mood- or mind-altering drug to function normally) and chronic opiate use (problematic pattern of using prescription or illegal opioids [drugs that carry extreme risks, including respiratory depression and addiction, they must only be used under strict medical supervision] that causes distress or harm) and overdose, was supervised and monitored to prevent drug overdose by failing to: 1.Ensure Registered Nurse Supervisor (RNS) 6 addressed and monitored Resident 81's known diagnosis of Psychoactive substance dependence upon admission on [DATE]. 2.Ensure the Director of Staff Development (DSD) thoroughly investigated to identify a possible source of medications when Resident 81 was found with a bag of Xanax (a type of benzodiazepine [[NAME]- a class of medications that depress the nervous system commonly used to treat anxiety, inability to sleep, seizures, and muscle spasms]), Soma (Carisoprodol- a muscle relaxant that helps relieve muscle pain by blocking pain signals to the nerves and brain) and Norco (a type of opiate [a pain-relieving drug that slows the brain and body to relieve pain]) on 7/27/2026 at the bedside to prevent unauthorized access to prescription medications. 3. Ensure RNS 5 evaluated, assessed and implemented appropriate interventions to ensure Resident 81's safety after Resident 81's Family Member (FM) 1 informed RNS 5 that Resident 81 had a history of drug addiction on 7/27/2026. 4. Ensure IDT meeting on 7/28/2026 addressed and acted upon a known safety concern that Resident 81 was at risk of overdose and medication interactions related to unauthorized access to prescriptions medications on 7/27/2026. As a result, on 7/30/2026, Resident 81 was found lethargic, moving and responding slowly, drowsy, and unable to follow commands after ingesting an unknown amount of unprescribed narcotics (drugs that can reduce pain, cause sleepiness, and sometimes create a sense of euphoria). An unlabeled pill bottle containing three different types of unidentified pills was found at the bedside. Emergency medical services were contacted, and Resident 81 was transported by 911 paramedics (emergency medical professionals that provide advanced medical care before and during transport to a General Acute Care Hospital [GACH]) to GACH 1 Emergency Department (ED) for evaluation and treatment of a suspected drug overdose. Findings: During a review of Resident 81's GACH 1 History and Physical (H&P), dated 6/12/2026, prior to facility admission, the H&P indicated Resident 81 had a history of chronic opiate use and polysubstance abuse (the use of more than one drug at the same time or over the same period) presented to the ED complaining of right knee pain and requested for pain medicine specifically. The H&P indicated that Resident 81 changed his story several times of how he injured his right knee and requested narcotics every hour. The H&P indicated Resident 81's urine drug screen (UDS- a urine test that checks for the presence of specific drugs) was positive for benzodiazepine, fentanyl (a potent, man-made pain medication that can easily cause overdose), opiates, and cannabinoids (chemicals found in the cannabis plan that attach to receptors in the body that affect mood, thinking, movements, and how the body handles pain and inflammation). The H&P indicated that Resident 81 was given pills by his friends that he ingested, and Resident 81 required Narcan (a fast-acting, easy-to-use nasal spray that reverses an opioid overdose by quickly relieving dangerous breathing and consciousness problems) upon discharge. The H&P indicated Resident 81 needed a social work consultation for polysubstance use. During a review of Resident 81's admission Record (AR), the AR indicated Resident 81 was admitted to the facility from GACH 1 on 6/19/2026 with diagnoses including long term (current) use of opiates, psychoactive substance dependence, and surgical after care of the right knee. During a review of Resident 81's Inventory of Personal Items (IPI), dated 6/19/2026, the IPI indicated Resident 81 did not have any type of medications brought in from home or from GACH 1. During a review of Resident 81's History and Physical (H&P), dated 6/22/2026, the H&P indicated Resident 81 was admitted to the facility from GACH 1 for further management of right knee pain and swelling secondary to a fall and for rehabilitation. The H&P further indicated Resident 81 had chronic opiate use, opioid dependence, and polysubstance abuse. During a review of Resident 81's Minimum Data Set (MDS- a resident assessment tool), dated 6/24/2026, the MDS indicated Resident 81 had mild cognitive impairment (mild issues with memory, orientation and processing information) and was dependent (helper does all of the effort) on cares such as lower body dressing, putting on/taking off footwear, and toileting hygiene. During a review of the facility's Visitor Sign-In Sheet (VSIS) dated 7/19/2026 to 7/31/2026, the VSIS did not indicate that Resident 81 had a visitor sign in between 7/19/2026 and 7/30/2026. The VSIS included the date, a space for the visitor's name, the room number of the resident being visited, and the visitor's time in and time out. The VSIS indicated multiple blank entries where visitors did not record the resident's room number or their time of entry or exit. During a review of Resident 81's Progress Notes (PN), dated 7/27/2026 timed at 1:09 PM, documented by Registered Nurse Supervisor (RNS) 4, the PN indicated that Certified Nursing Assistant (CNA) 5 notified RNS 5 and the Director of Staff Development (DSD) that Resident 81 had a bag of medications including Xanax and Norco at his bedside. The PN indicated Resident 81 was upset that his medications were confiscated and was educated on the risks of unprescribed (not ordered by the physician) drug interactions and the potential for drug overdose. The PN did not indicate that the DSD conducted a thorough investigation of the incident or attempted to identify a possible source of the medications to prevent Resident 81 from further unauthorized access to prescription drugs. During a review of Resident 81's PN, dated 7/27/2026 timed at 1:10 PM, documented by RNS 5, the PN indicated that Soma was also in the bag of medications that was found at Resident 81's bedside. The PN indicated that Resident 81 was educated that all medications needed to be verified and confirmed with the MD prior to administration. During a review of Resident 81's PN, dated 7/27/2026 timed at 1:15 PM, documented by RNS 5, the PN indicated RNS 5 spoke to Resident 81's Family Member (FM 1), who stated that Resident 81 had a history of drug addiction. During a review of Resident 81's Skilled Weekly Review (SWR), dated 7/28/2026, the SWR indicated an IDT meeting was held with the ADM, DON, MDS Nurse, Social Services, and therapy staff present. There was no documented evidence that the IDT discussed or addressed Resident 81's unauthorized drug possession on 7/27/2026 or identified interventions to monitor the resident, prevent access to unauthorized prescription medications, and reduce the risk of a potential overdose. During a review of Resident 81's PN, dated 7/30/2026 timed at 12:30 PM, documented by RNS 4, the PN indicated that CNA 3 paged RNS 4 to assess Resident 81 at 11:45 AM. Resident 81 was assessed to be visibly lethargic and, when asked if he took any medications outside of what was prescribed to him, Resident 81 stated he took medications from a pill bottle that was not from the facility, but could not identify what pills he had taken. The PN indicated Resident 81's blood pressure (BP- the pressure of blood against the artery walls; normal around 120/80 mmHg [millimeters of mercury- unit used to measure medical pressures]) was low at 98/86 mmHg and heart rate 122 beats per minute (bpm, normal result of 60-100 bpm). The PN indicated paramedics were called due to Resident 81's condition, and RNS 4 notified them that the resident had taken an unknown amount of medication from a pill bottle and was very lethargic. Resident 81 was then taken to GACH 1's ED. During a review of Resident 81's PN, dated 7/30/2026 timed at 1 PM, documented by RNS 3, the PN indicated that RNS 4 notified RNS 3 that Resident 81 had altered level of consciousness (ALOC - awareness and alertness were not normal) and was slow to respond. RNS 3 assessed and found that Resident 81 was unable to follow commands and did not respond to questions. The PN further indicated Resident 81 had low BP, a high HR, and was difficult to wake up. The PN indicated RNS 4 reported that a pill bottle with unidentified pills was found on Resident 81's bed and it was not known how or when Resident 81 obtained the pills. Paramedics were called and arrived to transfer Resident 81 to GACH 1 ED at 12:20 PM. During a review of Resident 81's GACH 1's ED Note, dated 7/30/2026 at 3:24 PM, GACH 1's ED Note indicated Resident 81 arrived at the GACH 1 ED on 7/30/2026 at 12:31 PM from the facility for ALOC due to medication overdose. GACH 1's ED Note indicated Resident 81 was found with an unlabeled bottle of various pills with different shapes and colors, including Xanax and other medications, and Resident 81 stated he did not know exactly what he had taken. GACH 1's ED Note indicated Resident 81 required administration of four doses of 0.2 mg (milligram- a unit of measurement) of Narcan over five hours to reverse his overdose, with notable improvement to his mentation. The note indicated Resident 81 was started on a Narcan intravenous drip (IV drip- to give continuously through the veins) due to his recurrence of apnea (when breathing stops), and improvement with Narcan. GACH 1's ED Note further indicated critical care (advanced medical treatment in a hospital unit for people with life-threatening injuries or illness, involving 24-hour monitoring and support for vital body functions) was provided to prevent the possibility of imminent life-threatening deterioration during Resident 81's ED care. GACH 1's ED Note indicated Resident 81 was diagnosed with opiate overdose and polysubstance use and required admission to the intensive care unit (ICU- a specialty unit in a hospital that provides critical care). During a review of Resident 81's GACH 1's Critical Care Consult (CCC), dated 7/30/2026 at 8:51 PM, GACH 1's CCC indicated Resident 81 was admitted to the ICU for multiple drug overdose, possible opioid and Xanax overdose, and hypercapnia (elevated carbon dioxide [CO2- a gas produced by the body during normal breathing] levels in the body that can be caused by breathing too slowly or too shallowly), compensated respiratory acidosis (when the body has too much CO2 in the blood but the kidneys adjust by keeping extra bicarbonate (bicarb- a natural chemical in the blood that neutralizes acids) to keep the blood acidity near normal) and to monitor Resident 81's neurological status and respiratory status while on a Narcan IV drip. During another review of Resident 81's GACH 1's Pain Management Consult (PMC), dated 8/3/2026 at 1:32 PM, GACH 1's PMC indicated Resident 81's UDS was positive for opiates and benzodiazepines, and was seen for evaluation for pain management. GACH 1's PMC indicated Resident 81 had track marks (visible scars or bruises along veins-most often on the arms or hands-caused by repeated injections of drugs using the same spots) on both his arms and legs and stated they were from his prolonged history of opiate use, including IV heroin (a strong, illegal opioid drug that produces a quick feeling of euphoria and pain relief but is highly addictive and dangerous). GACH 1's PMC indicated Resident 81 started obtaining opioids and benzodiazepine from the street, including oxycodone (a type of opioid), Norco, Xanax, and Ativan (another benzodiazepine drug) and was self-medicating with medications delivered to the facility by a friend from the streets. The GACH 1 records indicated Resident 81 admitted abusing all of the medications as a cross dependence (when one drug can prevent withdrawal symptoms [a set of physical and emotional symptoms like anxiety, nausea, shaking, or sleep problems that occur when someone stops or cuts back on a drug that they have become physically or mentally dependent on] from another drug in the same class) from his previous heroin use. During an interview with RNS 4 on 7/31/2026 at 12:05 PM, RNS 4 stated that he was the charge nurse on 7/30/2026 and, at around 8:30 AM, Resident 81 did not ask for his pain medication, which was unusual because Resident 81 always asked for pain medication as soon as he could get them. RNS 4 stated that around 11:45 AM, CNA 3 paged him into Resident 81's room because the resident was lethargic with altered mental status (AMS- a sudden change in a person's normal mental function). RNS 4 stated, upon assessment, Resident 81 appeared diaphoretic (sweaty), hot to touch, and could only stay awake for five to ten seconds before closing his eyes again. RNS 4 stated Resident 81 was unable to assist with his transfer, requiring three staff members to move him into bed. RNS 4 stated staff then checked Resident 81's vital signs and noted his BP was low and HR was122 bpm, so paramedics were called. RNS 4 stated when the paramedics arrived, staff found an unlabeled bottle of pills of different shapes and sizes in Resident 81's bed that was one quarter full. RNS 4 stated the paramedics commented on how Resident 81 was snoring while talking to them and needed to be woken up frequently to answer the paramedics' questions. RN 4 stated, the unlabeled pill bottle was given to the paramedics upon Resident 81's transfer to GACH 1 ED. During a concurrent interview and record review on 7/31/2026 at 12:10 PM with RN 4, Resident 81's medical diagnoses were reviewed. RNS 4 stated he was not aware of Resident 81's psychoactive drug dependence. RNS 4 stated that if he knew about it, he would have been monitoring for signs that Resident 81 was seeking narcotics. RNS 4 stated Resident 81 needed to be educated multiple times throughout his admission about using narcotics that were not prescribed by the facility's MD. During an interview on 7/31/2026 at 12:28 PM with Resident 69 (Resident 81's roommate), Resident 69 stated that he observed Resident 81 had visitors deliver food and pills to the room at night. Resident 69 further stated that there was one night (could not recall date or time) when a visitor came to see Resident 81 and he saw pills on the floor. Resident 69 could not recall what the pills looked like or how many there were, but when he asked the visitor and Resident 81, What are those pills? Resident 81 and the visitor did not reply. During an interview with RNS 5 on 7/31/2026 at 1:20 PM, RNS 5 stated that he was the RNS working when Resident 81 was taken to the GACH 1 ED on 7/30/2026. RNS 5 stated that he was called to Resident 81's room on 7/30/2026 and found Resident 81 very drowsy and unable to keep his eyes open, Resident 81 had low BP with rapid HR over 100 bpm. During a concurrent interview and record review on 7/31/26 at 1:25 PM with RNS 5, Resident 81's GACH 1's discharge records, dated 6/19/2026, were reviewed. RNS 5 stated the discharge records indicated Resident 81 had a history of polysubstance use and the facility's staff knew about it when he was admitted to the facility on [DATE]. During a concurrent interview and record review on 7/31/26 at 1:27 PM with RNS 5, Resident 81's care plan since admission on [DATE], was reviewed. RNS 5 stated there was no care plan with measurable interventions to address and monitor Resident 81's polysubstance use or psychoactive substance dependence, such as checking Resident 81's belongings, or assessing and monitoring for polysubstance use and psychoactive substance dependence while in the facility. RNS 5 stated there should have been a care plan with interventions addressing Resident 81's polysubstance use and psychoactive substance dependence so that all of his needs would be met related to that diagnosis. RNS 5 stated that safety was a priority for Resident 81 and the care plan was a communication tool for the multidisciplinary team to know what interventions were needed for the resident. Without the care plan, the staff would not know what interventions to implement for Resident 81. During the same interview with RNS 5 and concurrent record review on 7/31/26 at 1:29 PM, Resident 81's progress notes and CICs were reviewed. RNS 5 stated he was not aware that Resident 81 had unprescribed narcotics on 7/27/2026 and stated a CIC should have been created that day to communicate Resident 81's behaviors of receiving and hiding narcotics at the bedside. RNS 5 also stated that the CIC would have initiated monitoring related to Resident 81's new behavior and would have created interventions to prevent more incidences of sneaking in medication from outside of the facility and overdosing from happening again. RNS 5 stated Resident 81 was not monitored or supervised for behaviors of receiving and hiding narcotics after the resident was found with a bag of narcotics at the bedside on 7/27/026. During an interview with the Director of Registered Nursing (DON) and concurrent record review on 7/31/2026 at 1:45 PM, Resident 81's CICs and progress notes were reviewed. The DON stated she did not think a CIC needed to be created on 7/27/2026 when Resident 81 was found with unprescribed narcotics in his belongings because Resident 81 did not have a change in his condition. The DON stated that Resident 81 had not been leaving the facility to be out on pass, and therefore if he was not leaving the facility, then visitors were bringing in the narcotics. The DON later said that a CIC should have been created for a change in Resident 81's behavior of sneaking narcotics into the facility to initiate monitoring and supervision of this behavior. The DON also stated a formal IDT meeting was not held to address Resident 81's behavior of sneaking unprescribed narcotics into the facility. During the same interview with the Director of Nursing (DON) and concurrent record review on 7/31/2026 at 1:45 PM, Resident 81's Care Plan and diagnoses list were reviewed. The DON stated there was no care plan addressing Resident 81's addiction and psychoactive drug dependence but there should have been one to emphasize that problem area. The DON explained that the nursing staff were not made aware of the resident's drug use and no specific interventions were in place to address it. During a telephone interview on 7/31/2026 at 2:45 PM with Resident 81, Resident 81 stated he had a friend come by to deliver the medications on 7/30/2026 and he took a few pills of Xanax and Oxycodone which caused him to become hospitalized . During an interview on 7/31/2026 at 3:07 PM with the receptionist, the receptionist stated that she was working on 7/30/2026 but could not recall if Resident 81 had any visitors. The receptionist stated that when visitors came in, they were asked to fill out the sign-in sheet and to include the full name of the residents they were visiting. The receptionist stated that if a visitor falsified their name in the sign-in sheet, the facility would not know. The sign in sheet was the only record the facility had to monitor who came in and out of the facility. During a review of the facility's Policy and Procedure (P&P) titled, Comprehensive Person-Centered Care Planning and dated 4/2025, the P&P indicated, It is the policy of this facility that the interdisciplinary team (IDR) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. During a review of the facility's P&P titled, Change in Condition and dated 4/2025, the P&P indicated the following: a. If, at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware. Examples would be. change in behavior or increased problems that may cause injuries or incidents to self or others b. The nurse will perform and document an assessment of the resident and identify need for additional interventions, considering implementation of existing orders or nursing interventions considering implementation of existing orders or nursing interventions or through communication with the resident's provider using SBAR or similar process to obtain new orders or interventions. c. The resident will then be placed on the 24-Hour Report and Nursing will provide no less than three days of observation, documentation, and response to any interventions. An attempt to identify the cause for decline, when it occurs, needed assist and resident behavior / acceptance of increased need of assistance will be monitored. d. The nurse will communicate the change to other departments as appropriate and updated communications will be available during morning report. e. The interdisciplinary team shall collaborate with the attending physician, resident, and / or resident representative to review risk indicators and the plan of care. The IDT will document this collaboration in the EMR in the next scheduled Comprehensive Care Plan Meeting or sooner if deemed necessary by the IDT. During a review of the facility's P&P titled, Controlled Substances and dated 11/2021, the P&P indicated, The Director of Nursing and the consultant pharmacist maintain the facility's compliance with federal and state laws and regulations in the handling of controlled medications. Only authorized licensed nursing and pharmacy personnel have access to controlled medications.

Based on interview and record review, the facility failed to ensure Medical Doctor (MD) 1 completed and documented the resident's history and physical (H&P- a comprehensive, clinician-documented assessment completed at the time of admission or start of care that combines resident history and physical exam findings to establish a baseline for clinical care and guide ongoing treatment) for three of three residents (Residents 81, 76, and 168) in accordance with the facility's policy and procedure titled, Physician Visits. This deficient practice had the potential to result in incomplete or inaccurate clinical assessments which could delay in identifying medical conditions, and inadequate development of appropriate treatment plans due to the absence of an MD completed H&P. Findings: 1. During a review of Resident 81's admission Record, the record indicated Resident 81 was admitted to the facility on [DATE] with diagnoses including long term (current) use of opiate analgesic, psychoactive substance dependence, and surgical after care of the right knee. The admission record also indicated Resident 81's primary provider was MD 1 and secondary provider was Nurse Practitioner (NP) 1. During a review of Resident 81's History and Physical (H&P) dated 6/22/2026, the H&P indicated Resident 81 was admitted to the facility from the general acute care hospital (GACH) due to right knee pain and swelling secondary to a fall for further management and rehab. The H&P was signed by NP 1 and not by MD 1. During a review of Resident 81's Minimum Data Set (MDS- a resident assessment tool) dated 6/24/2026, the MDS indicated Resident 81 had mild cognitive impairment (mild issues with memory, orientation, or attention) and was dependent (helper does all of the effort) on cares such as lower body dressing, putting on/taking off footwear, and toileting hygiene. 2. During a review of Resident 76's admission Record, the record indicated Resident 76 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including sepsis (a life-threatening blood infection) and diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). The record also indicated Resident 76's primary provider was MD 1 and secondary provider was Nurse Practitioner (NP) 1 and not by MD 1. During a review of Resident 76's H&P dated 6/24/2026, the H&P indicated Resident 76 was admitted to the facility for further management and rehab. The H&P was signed by NP 1 and not by MD 1. During a review of Resident 76's MDS dated [DATE], the MDS indicated Resident 76 was cognitively intact (no issues with memory, orientation, or attention) and required maximal assistance (helper does more than half the effort) for cares such as toileting, shower/bathing, lower body dressing, and putting on/taking off footwear. 3. During a review of Resident 168's admission Record, the record indicated Resident 168 was admitted to the facility on [DATE] with diagnoses including radiculopathy (when a nerve root exiting the spine gets pinched or damaged, causing symptoms like sharp pain, numbness, tingling, or weakness in the area the nerve serves, often in the arms or legs) and abnormalities with walking and mobility. The record also indicated Resident 168's primary provider was MD 1 and secondary provider was Nurse Practitioner (NP) 1 and not by MD 1. During a review of Resident 168's H&P dated 7/23/2026, the H&P indicated Resident 168 was admitted to the facility for further management and rehab. The H&P was signed by NP 1 and not by MD 1. During a review of Resident 168's MDS dated [DATE], the MDS indicated Resident 168 had mild cognitive impairment (mild issues with memory, orientation, or attention) and was dependent (helper does all of the effort) for cares such as toileting hygiene, showering/bathing, lower body dressing, and putting on/taking off footwear. During an interview with Resident 81 on 7/28/2026 at 11:06 AM, Resident 81 stated that MD 1 was his primary physician in the facility, but MD 1 had never come to assess Resident 81 since his admission on [DATE]. Resident 81 stated that he had only been seen by NP 1 and the nursing staff in the facility which concerned him because he felt like his right knee was not getting better. Resident 81 further stated that when he asked to speak to MD 1 about his care, the nursing staff would simply say, okay, we'll try to get ahold of him but would leave after their shift was over without following through with his request to speak to MD 1. Resident 81 stated he felt frustrated and like he was being disregarded by the staff and MD 1. During an interview with the Director of Registered Nursing (DON) on 7/30/2026 at 1:37 PM, the DON stated that the residents' H&P could be done either by the NPs or MDs in the facility. During the same interview with the DON and concurrent record review on 7/30/2026 at 1:37 PM, the facility's policy and procedure (P&P) titled Physician Visits and revised on 6/2015 was reviewed. The DON stated that, based on their policy, the MD needed to do the initial comprehensive assessment (known as the H&P) then can delegate follow up visits to the NP. The DON stated that it was important for the primary MDs to complete the H&P for each resident to set a baseline assessment and plan of care for the resident. During a telephone interview with NP 1 on 7/30/2026 at 2:13 PM, NP 1 stated that she always completed the H&Ps for MD 1 in the facility. NP 1 stated her process was that the facility would notify NP 1 or MD 1 that there was a new admission, and NP 1 would then complete the H&P for that resident. NP 1 stated that she was aware MD 1 should be the one to complete the H&P for newly admitted residents, but when she was hired to work with MD 1 in the facility, she was instructed to complete the H&P for MD 1. NP 1 stated that she would usually complete the assessment by herself. NP 1 further stated that it was important for the primary MD to complete each residents' H&P to set the bar for their assessment and direct the plan of care for the residents. During an interview with 168's Family Member (FM 3) on 7/30/2026 at 2:41 PM, FM 3 stated that he had been visiting Resident 168 in the facility every day since her admission to the facility on 7/20/2026. FM 3 stated he was not familiar with MD 1 but remembered NP 1 coming to visit and assess Resident 168 in the facility and not by MD 1. During an interview with Resident 76 on 7/30/2026 at 2:57 PM, Resident 76 stated that NP 1 had been the provider seeing her during her time in the facility. Resident 76 further stated that NP 1 was the provider who saw her when she first admitted into the facility on 6/21/2026 and again on 7/29/2026 and not by MD 1. During a review of the facility's Policy and Procedure (P&P) titled, Physician Visits and revised 6/2015, the P&P indicated the following: a. Physician visits shall be made within the first 30 days, and then at 30 day intervals up until 90 days after the admission date. b. The initial comprehensive shall be made no later than 30 days after a resident's admission into the SNF (Skilled Nursing Facility) c. During the initial visit, the physician shall complete a thorough assessment, develops a plan of care and write or verifies admitting orders for the resident. d. After the initial physician visit, the physician may delegate alternate visits to a non-physician practitioner (NPP) such as an NP. e. These alternate visits, as well as medically necessary visits, may be performed and signed by the NPP.

Based on observation, interviews, and record review, the facility failed to ensure that two of two sample residents (Resident 124 and Resident 108) were monitored and re-assessed for pain and re-evaluated for the continued need for around-the-clock administration of Norco (is a prescription pain medication containing hydrocodone and acetaminophen, which is used to manage moderate to severe pain) when pain was documented as zero (no pain reported) for more than four months. These failures increased the risk of putting Resident 124, Resident 108, and other residents to unnecessary medication, which could result in adverse effects such as medication side effects, dependency, or decreased quality of life.Findings:1. During a review of Resident 124's admission Record, the admission Record indicated Resident 124 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included, Fracture of part of neck of left femur (break in the upper part of the thigh bone near the hip), subsequent encounter for closed fracture with routine healing (follow-up visit for a bone break that did not break the skin and is healing normally) with an onset date of 1/11/2022 and Orthopedic aftercare (treatment and follow-up for bone, joint, or muscle injuries), with an onset date of 1/11/2022. During a review of Resident 124's History and Physical (H&P) dated 4/16/2026, the H&P indicated Resident 124 has fluctuating capacity to understand and make decisions. During a review of Resident 124's Minimal Data Set (MDS, a standardized assessment tool), dated 7/16/2026, the MDS indicated Resident 124's cognition (ability to think, remember, and reason) was moderately impaired. During a review of Resident 124's General Acute Care Hospital (GACH) clinical records for hospital stay between 4/14/2026 through 4/16/2026 included a medication order for Norco (hydrocodone 5 milligrams [mg] and acetaminophen 325 mg) 5-325 mg indicated to administer one tablet by mouth four times a day as needed (PRN) for moderate to severe pain (scale 4 to 10, means pain is noticeable and affects daily activities, ranging from moderate discomfort to very severe pain). Additional Instructions: Hold for sedation or hypotension. Last Administered 4/16/2026 at 12:31 AM. The Medication Administration History, between 4/14/2026 through 4/16/2026 documented the administration of one dose of Norco 5-325 to Resident 124 over a three day stay. During a review of Resident 124's Order Summary Report dated 7/30/2026, the OSR indicated a physician's order for Norco 5-325, to give one tablet by mouth four times a day for pain management. Not to exceed (NTE) three (3) grams (gm, unit of measure by weight) per day from all sources of Acetaminophen (APAP), order date 7/31/2024. During a review of Resident 124's Care Plans indicated, Resident 124 has pain related to DX (diagnosis), S/P (status post, meaning after), Fall (after a fall), S/P Left hip OIF (Open Internal Fixation, a type of hip repair surgery), care plan date initiated 1/12/2022, and revised 4/27/2026. Resident 124's care plan indicated, Evaluate the effectiveness of pain interventions. Monitor/ record pain characteristics: Quality (e.g. Severity (1 to 10 scale [1 means very mild pain, 5 is moderate pain, and 10 is the worst pain imaginable]). continuous, intermittent); Aggravating factors; Relieving factors Monitor/ report to Nurse resident complaints of pain or requests for pain treatment. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain.Pain assessment every shift. During a review of Resident 124's Medication Administration Record (MAR, a document used to record medications administered to residents, when, and by whom) for the Months of April 2026 through July 2026, the MARs indicated by licensed nurses initials the resident was administered Norco 5-325 mg four times a day as follow, for: July 1, 2026, through July 28, 2026, a total of 112 doses were administered to Resident 124, with a pain level of zero (0) documented across all three shifts (Day, Evening, and Night Shifts) for the Month of July 2026. June 1, 2026, through June 30, 2026, a total of 120 doses were administered to Resident 124, with a pain level of zero (0) documented across all three shifts for the Month of June 2026. May 1, 2026, through May 31, 2026, a total of 124 doses were administered to Resident 124, with a pain level of zero (0) documented across all three shifts for the Month of May 2026. April 1, 2026, through April 30, 2026, a total of 120 doses were administered to Resident 124, with a pain level of zero (0) documented across all three shifts for the Month of April 2026. During a concurrent medication administration (pass) observation and interview on 7/28/2026 between 10:16 AM to 10:40 AM, with Licensed Vocational Nurse (LVN) 1, LVN 1 asked Resident 124 if she had any pain and the resident stated she had no pain. LVN 1 asked Resident 124 if she wanted her Norco and the resident stated yes. LVN 1 prepared Resident 124's morning medications that included Norco 5-325 mg, one tablet and administered the medications to the resident. LVN 1 acknowledged that there was no pain level indicated for the use of Norco 5-325 for Resident 124. During a concurrent interview and record review on 7/28/2026 at 4:24 PM with the Director of Nursing (DON), Resident 124's physician orders, nursing progress notes and MARs were reviewed for the Months of April 2026 through July 28, 2026, for the use of the pain medication Norco 5-325. The DON stated for Resident 124, Norco 5-325 mg was prescribed for pain, but pain levels and locations were not documented in the resident's MARs, and the resident's pain assessments showed zero pain each shift. The DON stated that Resident 124's physician order did not specify a pain scale, and there was no documentation of evaluating the resident's pain interventions for effectiveness. Resident 124 has received Norco four times daily since July 2024 and should have been re-evaluated, especially when reporting and documenting no pain. 2. During a review of Resident 108's admission Record, the admission Record indicated Resident 108 was admitted to the facility on [DATE] with diagnoses that included, Fracture of part of neck of right femur, subsequent encounter for closed fracture with routine healing with an onset date of 1/11/2025 and history of falling with an onset date of 1/11/2025. During a review of Resident 108's H&P dated 1/6/2026, the H&P indicated Resident 108 does not have the capacity to understand and make decisions. During a review of Resident 108's MDS, dated [DATE], the MDS indicated Resident 108's cognition was severely impaired. During a review of Resident 108's Physician Order dated 7/17/2025, the Physician Order indicated a telephone order for Norco 10-325, give one tablet by mouth one time a day for pain management related to fracture of unspecified part of neck of right femur, subsequent encounter for closed facture with routine healing. Not to exceed (NTE) three (3) grams/day from all sources of Acetaminophen (APAP). During a review of Resident 108's Care Plans, the care plans indicated, Resident 108 has acute/chronic pain related to diagnosis of mechanical fall sustaining right hip fracture, and bilateral hip replacement care plan date initiated 1/12/2025, and revised 6/18/2026. Resident 108's care plan indicated, Warning: Addiction, abuse, and misuse. Because the use of hydrocodone/acetaminophen (Norco) exposes patients and other users to the risk of opioid addiction, abuse, and misuse, which can lead to overdose and death, assess each patient's risk prior to prescribing and reassess all patients regularly for the development of these behaviors and conditions. Follow pain scale to medicate as ordered.Identify, record and treat resident's existing conditions which may increase pain or discomfort.Monitor/ document for probable cause of each pain episode.Monitor/ record pain characteristics: Quality (e.g. sharp, burning); Severity (1 to 10); Anatomical location; Onset; Duration (e.g., continuous, intermittent); Aggravating factors; Relieving factors. Pain assessment every shift. During a review of Resident 108's MARs for the Months of April 2026 through July 2026, the MARs indicated by licensed nurses initials the resident was administered Norco 10-325 mg once a day as follow, for: July 1, 2026, through July 28, 2026, a total of 28 out of 28 doses were administered to Resident 108, with a pain assessment of zero (0) documented across all three shifts (Day, Evening, and Night Shifts) for the Month of July 2026. June 1, 2026, through June 30, 2026, a total of 30 out of 30 doses were administered to Resident 108 with a pain assessment of zero (0) documented each shift for the entire Month of June 2026. May 1, 2026, through May 31, 2026, a total of 31 out of 31 doses were administered to Resident 108, with a pain assessment of zero (0) documented each shift for the entire Month of May 2026. April 1, 2026, through April 30, 2026, a total of 30 out of 30 doses were administered to Resident 108, with a pain assessment of zero (0) documented each shift for the entire Month of April 2026. During a concurrent medication storage inspection and interview on 7/28/2026 at 3:43 PM, with LVN 6 on Station 4 at Medication Cart B, Resident 108's controlled Medication Administration Record (MAR), nursing progress notes, and physician order was reviewed. LVN 6 stated Resident 108 was administered Norco 10-325 mg, one tablet today at 9:02 AM. LVN 6 was asked Resident 108's pain level at the time of administration. LVN 6 stated no level was documented or indicated in Resident 108's MAR or nursing progress notes, and there was no documentation of a follow-up to determine effectiveness of the treatment on 7/28/2026 administration of Norco 10-325 mg. LVN 6 stated licensed nurses should document Resident 108's pain level and the location of pain in the resident's progress notes. During a concurrent interview and record review on 7/28/2026 at 3:48 PM with the Registered Nurse Supervisor (RNS) 2, Resident 108's physician order for Norco 10-325, nursing progress notes, and MARs were reviewed. RNS 2 stated license nurses are not required to ask the resident for pain level or pain location for routine pain management medication. RNS 2 stated Resident 108 was receiving Norco for pain from a right femur fracture that happened in January 2025, with the medication started on 7/17/2025. RNS 2 reviewed Resident 108's July 2026 MAR which showed pain assessments recorded as zero throughout the month. The RNS 2 stated that the physician should have been notified when Resident 108 was no longer experiencing pain. During a concurrent interview and record review on 7/28/2026 at 5:00 PM with the DON, Resident 108's physician orders, nursing progress notes, and MARs were reviewed, between April 2026 through July 28, 2026, regarding the use of Norco 10-325 for pain management. The DON stated that Resident 108 has been prescribed Norco 10-325 mg since July 2025 due to a fracture sustained a year prior. The DON stated that documentation of pain assessments for each shift on Resident 108's MARs from April through July 2026 consistently indicated zero (0) pain. During a concurrent interview and record review on 7/28/2026 at 5:16 PM with the DON, Resident 124 and Resident 108, clinical records were reviewed that included, but was not limited to a review of the physician orders, nursing progress notes and MARs. The DON stated that Resident 108 and Resident 124 should have been reassessed and monitored for their ongoing use of Norco pain medication. The DON stated the pain management should have been reviewed during the monthly summary, the pharmacist's monthly regimen review, and daily by charge nurses when administering medications. The DON stated that residents' pain levels and the need for continued use of controlled medications should be evaluated at these times. The DON stated the physician should have been notified when the residents (Resident 124 and Resident 108) were no longer experiencing pain, so the physician could decide whether to decrease the dose, change the medication to an as-needed order, prescribe a different medication, or discontinue. The DON confirmed there was no documentation showing that the physician(s) had been informed that Resident 124 and Resident 108 were no longer documented to be experiencing pain, yet were still receiving routine controlled pain medications. During a review of the facility's Policy and Procedures (P&P), titled, Medication Administration - General Guidelines dated 11/2021, the P&P indicated, If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnoses or condition, the nurse calls *Pharmacy Services for clarification prior to the administration of the medication or if necessary contacts the prescriber for clarification. This interaction with the pharmacy and/or prescriber and the resulting order clarification are documented in the nursing notes and elsewhere in the medical record as appropriate. During a review of the facility's Policy and Procedures (P&P), titled, Pain Recognition and Management, dated 4/2025, the P&P indicated: It is the policy of this *facility to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, comprehensive and routine assessments, person-centered care plan, and the residents' goals and preferences. Pain will be identified and documented. using a scale of 1-10 is most common Management.Opioid treatment for pain is appropriately assessed and individualized for each resident. Monitoring: Monitor for effectiveness of interventions and/ or adverse consequences (e.g., constipation, sedation).The interdisciplinary care plan will reflect the location and type of pain, pharmacological, and non-pharmacological interventions, with evaluation and revisions as indicated.

Based on observation, interview, and record review, the facility failed to label and store drugs and biologicals in accordance with the facility's policy and procedure titled Medication Storage in the Facility and the federal regulations. 1. Ensure that Resident 123's and Resident 146's vials of Acetylcysteine 10 percent (%) for inhalation (a medicine that loosens mucus in the lungs, making it easier to clear.) were stored according to the manufacturer's specifications in two of three inspected Medication Carts (Med Cart B) on Station 4. 2. Label one opened vial of Even Care (blood glucose [BG] or blood sugar [BS] testing strips-used to monitor blood sugar levels) Test Strips Multi Use vial and one opened box of Glucose Control Test Solution (used to verify the accuracy of blood glucose meters) with an open date in one of three inspected Medication Carts (Med Cart A) on Station 4. 3. Ensure refrigerated medications were stored according to manufacturer recommendations and the facility's policy and procedure that required refrigerator temperature ranges from 36 degrees Fahrenheit ( F) to 46 ( F) in Nursing Station 4 where the Medication Storage Room refrigerator temperature read at 70 F with multiple refrigerated medications stored inside. These deficient practices had the potential to affect the potency, compromise the integrity and reduce the effectiveness of refrigerated medications administered to the residents, which included Resident 123, Resident 146. The failure also put residents at risk of inaccurate blood sugar readings which could lead to adverse health effects for the residents on Station 4 receiving medications and treatment from two of three Medication Carts (Med Cart A and Med Cart B) and one of two Medication Rooms inspected in the facility. Findings: 1. During a medication area observation on 7/28/2026 at 3:02 PM, with a Licensed Vocational Nurse (LVN) 6, 0n Station 4 of Medication Cart (Med Cart) B, the following was observed: 1a. During a review of Resident 123's admission Record, the admission Record indicated Resident 123 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 123's diagnoses included interstitial pulmonary disease (a lung condition causing scarring and breathing difficulties) and Type 2 Diabetes Mellitus (T2DM, a condition where the body has trouble controlling blood sugar). During a review of Resident 123's Minimal Data Set (MDS, a standardized assessment tool), dated 7/11/2026, the MDS indicated Resident 123's cognition (ability to think, remember, and reason) was severely impaired. During a review of Resident 123's Order Summary Report dated 7/30/2026, the OSR indicated physician's ordered Acetylcysteine Solution 10 %, inhale 10 milliliters (ml, unit of measure by volume) orally two times a day for mucous secretions, order dated 6/18/2026. During a concurrent observation, interview, and record review on 7/28/2026 at 3:10 PM, with LVN 6 on Station 4 at Med Cart B, Resident 123's Acetylcysteine Solution 10 % physician order, Medication Administration Record (MAR, a legal document showing what medicines were given to a resident, when, and by whom) for the Month of 7/2026, the medication vials labeled for Resident 123, and manufacturer's instructions were reviewed. The manufacturer's labeling on the package of Acetylcysteine Solution 10 % for Resident 123 indicated to store refrigerated after opening and expires 96 hours after first opening. LVN 6 stated that sometimes the resident is not in the facility and do not finish the vial of Acetylcysteine Solution 10 % within four days. LVN 6 reviewed Resident 123 vial of Acetylcysteine Solution 10 % and manufacturer's labeling indicated the medication needs to be refrigerated after opening and expires 96 hours after opening. LVN 6 stated the open date written on the label was 7/21/2026 and the medication expired on 7/25/2026. LVN 6 stated a dose from the opened vial was administered to Resident 123, today, on 7/28/2026. LVN 6 stated administering medication that require refrigeration and/ or after expiration could result in a loss of medication potency, change in taste or odor, and increase the potential for bacterial growth. 1b. During a review of Resident 146's admission Record, the admission Record indicated Resident 146 was initially admitted to the facility on [DATE]. The admission Record indicated Resident 146's diagnoses included Interstitial Pulmonary Disease (a lung condition causing scarring and breathing difficulties), Type 2 Diabetes Mellitus (T2DM, a condition where the body has trouble controlling blood sugar), and Chronic Obstructive Pulmonary Disease (COPD, a lung disease that causes blocked airflow and breathing difficulties). During a review of Resident 146's MDS, dated [DATE], the MDS indicated Resident 146's cognition (ability to think, remember, and reason) was moderately impaired. During a review of Resident 146's Order Summary Report dated 7/30/2026, the OSR indicated physician's ordered Acetylcysteine Solution 10 %, inhale 10 ml orally three times a day for mucous secretions, order dated 4/30/2026. During a concurrent interview and record review on 7/28/2026 at 3:14 PM, with LVN 6 on Station 4 at Med Cart B, Resident 146's Acetylcysteine Solution 10 % physician order, MAR for the Month of 7/2026, and the medication vials labeled for Resident 146 were reviewed. LVN 6 stated once the vial of Acetylcysteine Solution 10 % is opened it is stored in the medication cart. LVN 6 stated that she has administered Acetylcysteine Solution 10 % to Resident 146 and the medication was stored after opening inside of the medication cart. During an interview on 7/28/2026 at 5:29 PM with the Director of Nursing (DON), the DON stated Acetylcysteine Solution 10 % should have been stored in the refrigerator once opened and discarded after 96 hours. The DON stated there was a potential for Resident 123 and Resident 146 to experience side effects if administered expired medications. 2. During a medication area observation on 7/28/2026 at 2:39 PM, with a LVN 7, on Station 4 of Med Cart A, the following was observed: a. One undated opened vial of EvenCare Blood Glucose Test Strips b. One box of Glucose Control Test Solutions without an open date, but had a handwritten date of 12/7/2026 During an interview on 7/28/2026 at 2:45 PM, with LVN 7, LVN 7 stated that she did not know when the vial of EvenCare Blood Glucose Test Strips was first opened. LVN 7 an open date is needed to know when to the test strips expire and should be discarded. LVN 7 stated for the Glucose Control Test Solution that she did not know what the future date of 12/7/2026 meant and that there should have been a first opened date indicated on the box. LVN 7 stated the blood glucose monitoring, and test results for residents may not be accurate if the blood glucose test strips or the blood glucose control testing solutions are expired. During an interview on 7/28/2026 at 5:31 PM with the DON, the DON stated that expired blood glucose test strips and blood glucose control testing solutions would give inaccurate testing results and may cause residents to experience side effects or receive false blood glucose readings that can affect the resident's blood glucose control and health. A review of the manufacturer's labeling for Even Care Glucose Test Strips and Even Care Glucose Control Solution, dated 2022, indicated: Important: Do not use test strips that are expired.For vial test strips, record the date on the bottle when you open a new bottle of test strips. Discard any unused test strips six months after opening. Vial test strips are good six months after opening or until the expiration date on the bottle, whichever comes first. Note: Always check the expiration date of the control solution. Do Not use expired control solution. Record the date on the bottle when opening a new bottle of control solution. Discard any unused control solution three months after the opening date. Control solutions are good three months after opening or until the expiration date on the bottle, whichever comes first. During a review of the facility's policy and procedure (P&P) titled Medication Storage in the Facility dated August 2019, the P&P indicated Medication and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The P&P indicated Medications requiring refrigeration or temperatures between 2 degrees Celsius (36 degrees Fahrenheit) and 8 degrees Celsius (46 ( degrees F)) are kept in a refrigerator with a thermometer to allow temperature monitoring. The P&P indicated outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication, and reordered from the pharmacy, if a current order exists. Findings: During a review of the facility's Incineration: Medication Disposition/Non-Controlled Medications Form dated 7/29/2026 to 7/30/2026, the Form indicated the following medications were disposed by the facility: 1. Three vials of Acetylcysteine solution 10% (a liquid medicine that broke up thick mucus in the lungs or acted as a rescue antidote for acetaminophen [Tylenol, used to stop minor pain and lower a fever] poisoning). 2. One bottle of Acetylcysteine solution 20%. 3. One vial of Aplisol injection 5/0.1 milliliters (ml, metric unit used to measure the volume of a liquid) (used for tuberculosis [TB, a contagious bacterial infection that mostly attacked the lungs] skin test to check if the body had been exposed to the TB bacteria). 4.Five bottles of Brimonidine solution 0.2% (a prescription eye drop that lowered high fluid pressure inside of the eye). 5. One vial and one bottle of Cyanocobalamin injection 1000 micrograms (mcg, unit of weight used to measure very small amounts of medicine) (a man-made form of vitamin B12 [an essential nutrient that helped the body make red blood cells, keep the nervous system healthy, and build deoxyribonucleic acid (DNA, instruction book inside the body that decided eye color, hair type, and height)] given as a shot to treat low vitamin levels). 6. One vial of Epogen injection 4000 per ml (a lab-made hormone that told the body to make more red blood cells). 7. Seven pens of Glargine YFGN (four-letter tag for a biological copycat drug required by the United States food and drug agency) injection 100 units/ml (a long-acting man-made insulin [a hormone that removed excess sugar from the blood, could be produced by the body or given artificially via medication] used to treat diabetes [a health condition where the blood had too much sugar because the body could not move the sugar into the cells for energy] by lowering blood sugar levels over a 24-hour period). 8. Two vials of Humulin R 100 units/ml (a short-acting human insulin used to lower blood sugar in people with diabetes). 9. Three vials of Insulin Aspart injection 100/ml (such as Novolog, a fast-acting, man-made insulin used to lower blood sugar in adults and children with diabetes). 10. One bottle and 15 pens of Lantus Solostar 100 units/ml (a long-action prescription insulin used once a day to lower blood sugar in people with diabetes). 11. Three pens and seven bottles of Latanoprost solution 0.005% (a prescription eye drop used to lower high pressure inside of the eye to prevent vision loss). Two pens and one vial of Novolin N pen suspension 100 unit/ml (intermediate-acting insulin pen used to lower blood sugar in people with diabetes). One pen of Novolin R pen solution 100 unit/ml (a short-acting, human-made insulin used to lower blood sugar levels in people with diabetes). 17 pens of Novolog pen solution 100 unit/ml (a fast-acting liquid insulin used in a pen device to lower blood sugar around mealtime). One vial of Novolog solution 100 unit/ml. Three pens of Ozempic injection 2 milligrams (mg, unit of measurement)/3 ml (a pre-filled liquid pen used to treat type 2 diabetes by lowering blood sugar). Three vials of Retacrit 10,000 units/ml solution (an injectable liquid medicine that told the body to make more red blood cells, treating low blood counts [anemia] and containing 10,000 units of the drug in each single ml of fluid). Two vials and one bottle of Retacrit 20,000 units/ml. One pen and three vials of Triamcinolone injection 40 mg/ml (a strong man-made steroid medicine used to calm down heavy swelling, pain, and redness in the body). Two vials of Tubersol injection 5/0.1 ml (a standard liquid used for a routine TB skin test). Four pens of Wegovy injection 0.5 mg (a once-weekly prescription injection used for weight management that acted as the second step in the dose buildup schedule). During a concurrent observation and interview on 7/29/2026 at 4:26 PM with the Registered Nurse Supervisor (RNS) 1 in Nursing Station 4's Medication Storage Room, the thermometer inside the refrigerator had a reading of 60 degrees Fahrenheit. RNS 1 stated the facility staff check the refrigerator temperature daily between the nocturnal and day shift. RNS 1 stated the refrigerator temperature was supposed to be between 35 ( degrees F) to 46 ( degrees F). During a concurrent observation and interview on 7/29/2026 at 4:47 PM with RNS 1 in Station 4's Medication Storage Room, the thermometer inside the refrigerator had a reading of 70 ( degrees F). RNS 1 stated a new thermometer was placed inside the refrigerator, and the facility would have to replace the refrigerator if the temperature did not go down. During an interview on 7/29/2026 at 4:56 PM, the Director of Nursing (DON) stated all the medications in the refrigerator in Station 4's Medication Storage Room must be moved because the refrigerator was not working. During an observation on 7/30/2026 at 8:17 AM, RNS 2 stated the refrigerator was changed during the night shift on 7/29/2026 and all medications were re-ordered. RNS 2 stated the facility staff replaced all of the medications that were in the refrigerator because the facility staff were unaware how long the medications were in the refrigerator when the temperature was not within the goal range. RNS 2 stated ensuring the medications were preserved within the right storage was important otherwise the medications would not have been working properly and might have been ineffective. During a concurrent observation and interview on 7/30/2026 at 4:44 PM with RNS 2 in Station 4's Medication Storage Room, the thermometer inside the refrigerator had a reading of 49 ( degrees F). RNS 2 stated the thermometer was not working and was replaced. RNS 2 stated the medications would also be replaced for a second time. During an interview on 7/31/2026 at 10:14 AM, RNS 3 stated the correct temperature range for the medication storage refrigerator was between 36 ( degrees F) to 46 ( degrees F) but the facility staff try to maintain the temperature at 40 ( degrees F). RNS 3 stated if there was a problem with the refrigerator the first thing the facility staff should have done was to discard and re-order all of the medications that were stored in the refrigerator. RNS 3 stated the medication must be discarded because the facility staff did not know if the medications were still effective based on the manufacturer's guidelines. RNS 3 stated the medications were supposed to be stored in a specific way and if the temperature was not with the accepted range, then the medications could not be given. During an interview on 7/31/2026 at 10:50 AM, the DON stated the correct temperature range for the medication storage refrigerator was between 36 degrees Fahrenheit to 46 ( degrees F). The DON stated if there was a problem with the refrigerator the facility staff would have had to toss out everything that was inside because the facility staff would not know how long the temperature was not within the accepted range and that could have affected the integrity of the medication. The DON stated there was a potential for the residents to have a side effect from the medication if they were given because the medications were not within the manufacturer's recommendations. During a review of the facility's policy and procedure (P&P) titled Medication Storage in the Facility dated August 2019, the P&P indicated Medication and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The P&P indicated Medications requiring refrigeration or temperatures between 2 degrees Celsius (36 degrees Fahrenheit) and 8 degrees Celsius (46 ( degrees F)) are kept in a refrigerator with a thermometer to allow temperature monitoring. The P&P indicated outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication, and reordered from the pharmacy, if a current order exists.

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards of practice and the facility's policy and procedure titled, Storage of Food and Supplies, Sanitation, and Procedure for Refrigerated Storage by failing to properly cover food items in the refrigerator and during food delivery, close the coffee lid properly in the Kitchen, and keep the ice scooper container clean where melted water and two black dots were observed at the bottom of the container. These deficient practices had the potential for contamination of food, clean food-contact items and for residents to be at risk for food borne illness (illness caused by food contaminated with bacteria [tiny, single-celled living things that were too small to see], viruses [a tiny germ made of genetic material inside a protein shell], parasites [a living thing that lived on or inside another creature, called a host to get food and shelter], or toxins [a natural poison made by living things like plants, animals, or bacteria]). Findings: During a concurrent observation and interview on 7/28/2026 at 8:39 AM with the Dietary Supervisor (DS) in the Kitchen, 30 fruit cups with cantaloupe and melon were observed in the refrigerator without proper coverings, a coffee container did not have the lid properly closed, and the ice scooper container had melted water and two black dots at the bottom of the container. The DS stated the coffee lid should have been closed to prevent cross contamination and prevent bacteria. During an observation on 7/29/2026 at 11:54 AM in the Kitchen during Tray Line (an assembly line in a nursing home kitchen used to build resident food trays quickly), fruit cups were observed without the proper coverings and small cups containing lemon and cilantro also did not have the proper coverings and were open to air. During an interview on 7/29/2026 at 12:14 PM, the DS stated the lemon and cilantro, desserts, and fruit cups were not covered because those items went straight to the cart from the kitchen to the resident's room for consumption and the carts were covered. The DS stated the food cart stopped at each resident's room for delivery. During an observation on 7/29/2026 at 1:08 PM at Station 2/3, the food cart was observed parked in front of room [ROOM NUMBER] and facility staff were taking each tray out and transporting the tray to each resident's room. Facility staff were observed walking as far as four rooms away and did not stop at each room with the food cart to deliver the trays. Desserts and fruit cups were also observed without the proper coverings while delivering food trays to the residents. During an interview on 7/31/2026 at 1:22 PM, the Director of Nursing (DON) stated prepared foods should have been covered properly to ensure freshness of the food and for infection control (a set of practical methods and rules used to stop the spread of harmful germs like bacteria and viruses) purposes. During a review of the facility's policy and procedure (P&P) titled, Storage of Food and Supplies dated 2023, the P&P indicated, Food and supplies will be stored properly and in a safe manner. Bins/containers are to be labeled, covered, and dated. During a review of the facility's P&P titled, Sanitation dated 2023, the P&P indicated, Ice which is used in connection with food or drink shall be from a sanitary source and shall be handled and dispensed in a sanitary manner. During a review of the facility's P&P titled, Procedure for Refrigerated Storage dated 2023, the P&P indicated, Food should be covered and stored loosely to permit circulation of air.

Based on observation, interview, and record review, the facility failed prevent the spread the spread of infection in the facility in accordance with the facility's policy and procedures for infection control by failing to ensure: 1. To implement and maintain an effective infection prevention and control program by failing to ensure Licensed Vocational Nurses (LVN) followed the facility's policy and procedures (P&P) titled, Administration Procedures for All Medications, during medication administration for one of four residents (Resident 40) observed during the medication administration task by failing to wash hands with soap and water or sanitizing hands with an alcohol-based hand sanitizer. This deficient practice increased the potential for the transmission of infectious agents and placed Residents 40, other residents, and staff, at risk for infections. 2. Resident 17's indwelling catheter drainage bag (a flexible tube inserted into the bladder that remains there to provide continuous urinary drainage) was kept off the floor to facilitate flow of urine, preventing kinking of the tubing and back of urine to the bladder. The deficient practice had a potential for Resident 17 to develop recurrent urinary tract infection (UTI, an infection in any part of the urinary system). 3. Housekeeper 1 don (put on) personal protective equipment (PPE, clothing or equipment that is worn or used to provide protection against hazardous substances and/or environment) when entering and taking out the trash bag from Resident 76 room who was in contact-based precautions (a method used to stop the spread of bacteria or viruses by wearing PPE) for a Carbapenem-resistant Entrobacterales (CRE, Carbapenam-resistant enterobacterales ) a multi-drug resistant organism (MDRO, bacteria that are resistant to many common antibiotics) in accordance with the facility's policy and procedure (P&P) titled ICPC Standard and Transmission-Based Precautions. This deficient practice had the potential to result in the wide spread of infection throughout the facility. Findings: 1. During a review of Resident 40's admission Record, the admission Record indicated Resident 40 was admitted to the facility on [DATE] with diagnoses that included, Type 2 Diabetes Mellitus (T2DM) and hypertension (high blood pressure). During a review of Resident 40's History and Physical H&P dated 5/28/2026, the H&P indicated Resident 40 has the capacity to understand and make medical decisions. During a review of Resident 40's MDS dated [DATE], the MDS indicated Resident 40's cognition (ability to think, remember, and reason) was moderately impaired. During a concurrent medication pass observation and interview on 7/28/2026 between 9:32 AM to 9:46 AM with LVN 5 on Station 4 at Medication Cart C (Med Cart C), LVN 5 after preparing a total of eight medications for Resident 40, LVN 5 entered Resident 40's room without washing hands with soap and water or sanitizing hands with an alcohol-based hand sanitizer. LVN 5 administered the oral medication by mouth to Resident 40. LVN 5 stated that she was going to apply the topical Lidocaine 4 (four) percent (%) Pain Relief Patch to Resident 40's right shoulder. LVN 5 put on a pair of gloves without washing or sanitizing her hands first. During an interview on 7/28/2026 at 9:53 AM, with LVN 5, LVN 5 stated that she should have sanitized her hands before entering Resident 40's room and before putting on gloves to apply the lidocaine patch. LVN 5 stated that medication packages are touched and handled by multiple nurses and she should have sanitized her hands after preparing the medications and before entering Resident 40's room to administer medications. LVN 5 stated sanitizing or washing of the hands is necessary to prevent cross contamination or the spread of infection to residents and staff. During an interview on 7/28/2026 at 3:00 PM with the Director of Staff Development/ Infection Preventionist Nurse (DSD/IPN), the DSD/IP stated hand hygiene is a facility's standard of practice for licensed nurses to sanitize their hands: before entering a resident's room, upon exiting the room, before putting on gloves and after taking gloves off to prevent staff from spreading infections. During a review of the facility's P&P titled, Administration Procedure for All Medications, dated 6/2021, the P&P indicated, Cleanse hands using antimicrobial soap and water or facility-approved hand sanitizer before beginning a medication pass, before handling medication, and before contact with resident.When finished with each resident, wash hands with antimicrobial soap and water or use facility-approved hand sanitizer During a review of the facility's P&P titled, Medication Administration – General Guidelines, dated 11/2021, the P&P indicated, Hands are washed before and after examination gloves worn for administration of topical, ophthalmic, injections, enteral, rectal, and vaginal medications. 2. During a review of Resident 17's admission Record (AR), the AR indicated Resident 17 was admitted on [DATE] with diagnosis that included UTI, diabetes mellitus type 2 (DM2 - condition that results in too much sugar circulating in the blood), benign prostatic hyperplasia (BPH, age-associated prostate gland enlargement that can cause urination difficulty), and retention of urine (inability to completely empty the bladder). During a review of Resident 17's Order Summary Report (OSR), the OSR indicated Resident 17 had a physician order on 5/31/2026 for indwelling catheter in closed drainage system for BPH, and staff to provide indwelling catheter care every shift. During a review of Resident 17's Minimum Data Set (MDS, a resident assessment tool), the MDS indicated Resident 17's cognition (ability to think, remember, and reason) is moderately impaired and Resident 17 was dependent (helper does all of the effort) on toileting hygiene. During a review of Resident 17's care plan (CP), dated 5/31/2026, the CP indicated Resident 17 had an indwelling catheter in closed drainage system with the goal was that the resident will show no signs and symptoms of urinary infection and the interventions that included to provide catheter care every shift and as needed. During a concurrent observation and interview on 7/30/2026 at 3:25 PM with Certified Nursing Assistant (CNA) 1 in Resident 17's room, Resident 17's catheter drainage bag was resting on the floor. CNA 1 stated, the drainage bag should never be on the floor due to infection risks. During an interview on 7/31/2026 at 11:50 AM with Registered Nurse (RN) 3, RN 3 stated Resident 17's indwelling catheter drainage bag must never touch the floor to prevent UTIs because bacteria from the floor can travel up the tubing. During an interview on 7/31/2026 at 12:45 PM with the Director of Nursing (DON), the DON stated Resident 17's indwelling catheter drainage bag should be kept hanging off the floor. The DON stated that when the drainage bag touches the floor, bacteria can contaminate the exterior of the bag and potentially enter the closed drainage system, which can lead to UTIs. During a review of the facility's Policy and Procedure (P&P) titled, Catheter Drainage Bag, revised 4/2025, the P&P indicated position the drainage bad below the level of the resident's bladder and without resting on the floor. 3. During a review of Resident 76's admission Record (AR), the AR indicated that Resident 76 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses that include Type 2 Diabetic Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic peripheral venous insufficiency (condition where the leg veins do not allow blood to flow back up to the heart), and sepsis (a life-threatening blood infection). During a review of Resident 76's history and physical (HP), dated 6/24/2026, the HP indicated that Resident 76 had the capacity to understand and make medical decisions. During a review of Resident 76's Order Summary Report, a physician order, dated 7/24/2026, indicated that Resident 76 was placed on contact-based precaution for CRE. During a review of Resident 76's Minimum Data Set (MDS, a resident assessment), dated 6/27/2026, the MDS indicated that Resident 76's cognition (a resident's thought process) was intact. The MDS indicated that Resident 76 required maximal assistance (helper does more than half the effort) for Activities of Daily Living (ADLs, activities such as bathing, dressing, and toileting a person perform daily) such as toileting and showering and required supervision when repositioning self in bed or transferring from chair/bed to chair. The MDS indicated that Resident 76 had 1 venous and arterial ulcer (a small open sore or wound generally found in the stomach or on the skin) and an open lesion on her foot. The MDs indicated that Resident 76 was taking an antibiotic. During an observation on 7/29/2026 at 10:49 AM outside Resident 76's room, a contact- based precaution sign was posted outside Resident 76's room. During another observation on 7/30/2026 at 8:25 AM outside Resident 76's room, a contact precaution sign was posted on Resident 76's room. Housekeeper (HSK) 1 was observed in Resident 76's room removing a full trash bag from the trash bin only wearing gloves and not a gown. HSK 1 then was observed exiting Resident 76's room and walked down the hallway with a full trash bag wearing the same pair of gloves. During an interview on 7/30/2026 at 1:52 PM with HSK 1, HSK 1 stated that she was emptying out trashcans by Resident 76's room this morning (7/30/2026). HSK 1 stated that [she] cannot recall if [she] saw a contact precaution sign by [Resident 76's] room. During a concurrent observation and interview on 7/30/2026 at 2:04 PM with the HSK Supervisor, the contact precaution sign outside Resident 76's room was observed. The HSK Supervisor indicated that a contact precaution sign has been posted outside Resident 76's room because she has an infection. The HSK Supervisor stated all staff, including the HSK, to wear PPE when entering Resident 76's room. During an interview on 7/30/2026 at 3:25 PM with the Infectious Prevention Nurse (IPN), the IPN stated that CRE was a communicable disease, which can be spread through direct contact with the resident and their environment, and required posting an isolation precaution sign outside Resident 76's room. The IPN stated that the HSK should not have entered Resident 76's room without PPE because CRE can stay on high-touch surfaces such as tables or trashcan lids. The IPN stated that if the staff carried CRE on their hands and touched high-touched surfaces, there would be cross contamination among the residents and staff of the facility. During an interview on 7/31/2026 at 1:00 PM with the Director of Nursing (DON), the DON stated that she saw HSK 1 enter Resident 76's room without wearing PPE on 7/30/2026. The DON stated all staff members need to wear PPE when entering a contact isolation room to prevent the spread of MDRO throughout the facility. During a review of the facility's P&P titled IPCP Standard and Transmission-Based Precautions, dated 4/2025, the P&P indicated that the facility is to implement infection control measures to prevent the spread of communicable diseases and conditions. During a review of the same P&P titled IPCP Standard and Transmission-Based Precautions, dated 4/2025, the P&P indicated that Contact Precautions are used with a known infection that is spread by direct or indirect contact with the resident or the resident's environment. The P&P indicated that contact precautions/isolation are required for patients with MDROs, and the PPE required included to wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. The P&P indicated to wear PPE when entering a contact isolation room, removing the PPE and performing hand hygiene before leaving the contact isolation room.

Based on interview and record review, the facility failed to ensure informed consent (when a resident received clear facts about a medical test, medication, or treatment before the resident agreed to proceed) for psychotropic medications (medication that affects mood and behavior) were obtained and properly documented prior to administration for one of six sampled residents (Resident 67) in accordance with the facility's policy and procedure (P&P) titled Informed Consent and Psychotropic Medications. This deficient practice resulted in the administration of psychotropic medications without documented evidence of residents informed decision-making and acknowledgement of the associated risks, benefits, and alternatives. Findings: During a review of Resident 67's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included unspecified psychosis (a severe mental condition in which thought and emotions were so affected that contact was lost with reality), major depressive disorder (a mood disorder that caused a persistent feeling of sadness and loss of interest), and anxiety (feelings of fear, dread, and uneasiness that may have occurred as a reaction to stress). The AR indicated the resident was financially self responsible, and the Emergency Contact was the Responsible Party (RP) 1. During a review of Resident 67's History and Physical (H&P) dated 4/2/2026 at 1:20 PM, the H&P indicated the resident did not have the capacity to make medication decisions. During a review of Resident 67's Medication Administration Record (MAR) dated 6/1/2026 to 6/30/2026, the MAR indicated the resident received Abilify three mg PO at bedtime from 6/9/2026 to 6/30/2026 (a total of 22 doses). During a review of Resident 67's physician order dated 6/9/2026, the physician order indicated for the resident to have Abilify oral tablet (Aripiprazole, a prescription medicine that helped fix imbalances in brain chemicals that control your mood, thoughts, and behavior), give three milligrams (mg, unit of measurement) at bedtime for unspecified psychosis manifested by (m/b) paranoid delusions (strong, false beliefs that someone was out to harm, cheat, or spy on you) believing that others were out to get her. During a review of Resident 67's Minimum Data Set (MDS, a resident assessment tool) dated 6/17/2026, the MDS indicated the resident had severe cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated the resident was taking antipsychotic and antidepressant medications and a gradual dose reduction (GDR, slowly lowering the amount of medicine over time) had been documented by a physician as clinically contraindicated. During a review of Resident 67's undated Psychotherapeutic Drug Informed Consent Form, the Consent Form indicated Abilify three mg by mouth (PO) at bedtime for psychosis m/b delusions believing that others were out to get her and listed the risks and common side effects for an antipsychotic medication. The Consent Form included the facility staff's signature but did not include the date the facility staff obtained the consent from the resident's RP. The Consent Form did not include the physician's name, signature or date and did not include Resident 1's RP's signature and date. During a review of Resident 67's Medication Administration Record (MAR) dated 7/1/2026 to 7/31/2026, the MAR indicated the resident received Abilify three mg PO at bedtime from 7/1/2026 to 7/30/2026 (a total of 30 doses). During a concurrent interview and record review of Resident 67's Psychotherapeutic Drug Informed Consent Form for Abilify on 7/31/2026 at 10 AM, Licensed Vocational Nurse (LVN) 2 stated the form was supposed to be filled out by the facility staff who received the order from the physician and should have been filled out entirely. LVN 2 stated there was no physician's signature on the consent form but there should have been to indicate the physician explained the reason for treatment and the side effects to the resident or their family. During a concurrent interview and record review of Resident 67's Psychotherapeutic Drug Informed Consent Form for Abilify on 7/31/2026 at 10:35 AM, Registered Nurse Supervisor (RNS) 2 stated after the physician spoke with the resident/family, the facility staff would have confirmed the treatment for the medications. RNS 2 stated the physician's signature was important to indicate the physician spoke with the family about the reason for treatment. During a review of the facility's policy and procedure (P&P) titled Psychotropic Medications dated February 2024, the P&P indicated informed consent was to be obtained prior to medication use and every six months thereafter. The P&P indicated Upon change of condition or initiation of a new order for psychoactive medications, the facility will obtain consent prior to the initiation of the new medication. During a review of the facility's P&P titled Informed Consent dated May 2025, the P&P indicated It is the policy of this facility that residents are not violated and a copy of these rights and pertinent policies are made available to the resident and to any representative of the resident, including the right to consent to or to refuse any treatment or procedure. The P&P indicated Physician's orders related to the use of psychotherapeutic drug and physical restraints should not be initiated until an informed consent is obtained.

Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 85), who expressed a desire to self administer his medications was assessed for safety and given the right to administer his medication in accordance with the facility's policy and procedure titled Medication Administration - General Guidelines, dated November 2021, by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 4 reported the resident's preference for self administration to Registered Nurse (RN) 3. 2. Ensure the interdisciplinary team (IDT, a coordinated group of experts from several different fields) conducted a self administration assessment and obtained a physician's order before allowing the resident to self administer medications and before leaving medications at the bedside. These deficient practices resulted in the resident does not exercise his right to self administer medications. It also created a risk that Resident 85 self administer medications without confirmation of his ability to do so safely, including understanding dosing, timing, storage, side effects, and when to seek assistance. Findings: During a review of Resident 85's admission Record (AR), the AR indicated Resident 85 was admitted on [DATE] and readmitted on [DATE] with diagnosis that included enterocolitis (an inflammation that occurs throughout the intestines) due to clostridium difficile (a germ or bacterium that infects the large intestine), unspecified convulsions (a medical condition where body muscles contract and relax fast over and over), and hypertension (high blood pressure). During a review of Resident 85's History and Physical (H&P), dated 5/14/2026, the H&P indicated that Resident 85 has fluctuating capacity to understand and make decisions. During a review of Resident 85's Minimum Data Set (MDS, a resident assessment tool), dated 6/26/2026, the MDS indicated Resident 85's cognition (ability to think, remember, and reason) is intact and needed setup or clean-up assistance in eating. During a review of Resident 85's Order Summary Report (OSR), the OSR indicated a physician order dated 2/17/2026 for Hydralazine HCl (a prescription medicine that treats high blood pressure) 100 mg (milligram, unit of weight), to be administered orally three times daily for hypertension, and a physician order dated 5/8/2026 for Keppra (an anticonvulsant drug) 250 mg, to be administered orally every Monday, Wednesday, and Friday in the morning for seizure (a sudden burst of electrical activity in the brain) management. During a review of Resident 85's IDT documentation, care plan, and progress notes from 1/3/2026 to 7/31/2026, there was no documented evidence that Resident 85's ability to self administer medications was assessed or that the physician was notified of Resident 85's desire to self administer. During a concurrent observation and interview on 7/29/2026 at 12:55 PM in Resident 85's room, Resident 85 was seated in his wheelchair at the bedside eating lunch. A medication cup containing one pink pill was observed on his bedside table. Resident 85 stated he prefers to take his medications himself and that nurses usually leave his pills for him. Resident 85 stated he planned to take the pill after finishing his meal and identified the medication as Keppra, used for his seizures. During an interview on 7/29/2026 at 1:09 PM, LVN 4 stated that Resident 85 had just returned from hemodialysis and received his scheduled noon medications, including Hydralazine for blood pressure and Keppra for seizures. LVN 4 stated that Resident 85 prefers to take his medications himself. LVN 4 stated that after she handed him the pills, he took one and left the other on his bedside table, telling her he would take it after he finished eating, so she left the medication with him. LVN 4 stated Resident 85 can perform self-administration of medication, but she did not complete a self-administration assessment for Resident 85 or reported it to Registered Nurse (RN) 3. During a concurrent interview and record review on 7/31/2026 at 11:53 AM with RN 3, Resident 85's physician orders, IDT assessment, and care plan since admission on [DATE] were reviewed. RN 3 confirmed there was no IDT assessment, care plan entry, or physician order authorizing self administration for Resident 85. RN 3 stated that if a resident expresses a desire to self administer medications, the LVN must notify the RN and the physician so an IDT assessment can be completed, and a physician's order obtained before allowing the resident to self administer or leaving medications at the bedside. During an interview on 7/31/2026 at 12:45 AM with the Director of Nursing (DON), the DON stated that when a resident expresses a desire to self administer medications, the LVN is expected to notify the RN and the physician so the interdisciplinary team (IDT) can assess whether the resident can safely self administer and obtain a physician's order. The DON confirmed that without completing this assessment, the resident may be unable to exercise the right to self administer medications, or may self administer in an unsafe manner, which could result in harm. During a review of the facility's policies and procedures (P&P) titled, Medication Administration - General Guidelines, dated November 2021, indicated residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. During a review of the facility's P&P titled, Self-administration of Medications, the P&P indicated residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility. The results of the interdisciplinary team assessment are recorded in the resident's medical record.

Based on observation, interview and record review, the facility failed to address the resident's complaint for one of three sampled residents (Resident 36), who reported that staff often responded to her roommate first because both residents shared a single call light unit that did not distinguish who activated it. This deficient practice had potential for delays in Resident 36 receiving needed care and increased the risk that Resident 36 was feeling ignored and upset. During a review of Resident 36's admission Record (AR), the AR indicated Resident 36 was initially admitted on [DATE] and readmitted on [DATE] with diagnosis that included urinary tract infection (UTI, an infection in any part of the urinary system), anemia (when the number of red blood cells in the body gets too low), and hypertension (high blood pressure). During a review of Resident 36's Minimum Data Set (MDS, a resident assessment tool), dated 7/11/2026, the MDS indicated Resident 36's cognition (ability to think, remember, and reason) is moderately impaired and required substantial or maximal assistance (helper does more than half the effort) in personal hygiene (including combing hair, washing/drying face and hands) and was dependent (helper does all of the effort) in toileting hygiene. During a concurrent observation and interview on 7/28/2026 at 11:35 AM in Resident 36's room, Resident 36 stated that when she pressed her call light, staff frequently responded to her roommate instead of her. Resident 36 stated that her call light and her roommate's call light were connected to the same system, and because her roommate required frequent attention, staff often attended to the roommate first. Resident 36 stated she always waited for staff to complete their care for Resident 36's roommate before attending to Resident 36's needs, and most times Resident 36 would have to call out for facility staff to tend to Resident 36's own needs. Resident 36 stated she felt ignored and upset that the facility had not addressed or resolved the problem regarding Resident 36's needs not met or not being tended to when the call light was pressed. During an observation on 7/30/2026 at 4:28 PM in Resident 36's room, there was a wall mounted call light unit with one white cord split into two single button call lights, one for Resident 36 and one for Resident 36's roommate. Resident 36's call light was pressed. During an observation on 7/30/2026 at 4:40 PM in Resident 36's room, Certified Nurse Assistant (CNA) 1 entered the room and immediately went to Resident 36's roommate, who was seated in a wheelchair. The roommate requested help organizing her bedside table, and CNA 1 provided the assistance. As CNA 1 was leaving, Resident 36 stated to CNA 1 that every time she activated her call light, staff attended to Resident 36's roommate first, and that when Resident 36's roommate required extensive care, facility staff did not tend to Resident 36's needs. During an interview on 7/30/2026 at 4:50 PM with CNA 1, CNA 1 stated that the call lights for Resident 36 and her roommate were connected to the same unit, and the system did not distinguish which resident activated the call light. CNA 1 explained that Resident 36's roommate frequently required staff attention and often pressed her call light, creating a tendency for staff to assist Resident 36's roommate first, which caused the delays in Resident 36 receiving assistance. CNA 1 stated that Resident 36 had previously complained to CNA 1 about this issue, but CNA 1 did not report the concern to her supervisor. During an interview on 7/31/2026 at 11:33 AM with the Social Services Director (SSD), the SSD stated facility staff were expected to report any resident complaints or concerns to the SSD so that the SSD could address those complaints and/or concerns. The SSD stated she was not aware of Resident 36's concern. The SSD stated that when a resident's concerns are not reported or addressed, the resident can become upset and dissatisfied with the facility's care. During an interview on 7/31/2026 at 12:45 PM with the Director of Nursing (DON), the DON stated that she expected nursing staff to report any resident complaints or concerns to a licensed nurse or the social services department so that appropriate solutions could be identified to assist the resident. During a review of the facility's Policy and Procedure (P&P) titled, Grievance, revised 4/2025, the P&P indicated it is the policy of this facility to establish a grievance process that allows the resident(s) a way to execute their right to voice concerns or grievances to the facility or other agency/entity without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their facility stay. The facility will make information on how to file a grievance available to the residents and make prompt efforts to resolve grievances that the resident may have.

Based on interview and record review, the facility failed to complete the required Notice of Proposed Transfer/Discharge Form by not documenting the reason or basis for the transfer/discharge for one of one sampled resident (Resident 1). This deficient practice resulted in Resident 1 not receiving a complete written explanation of the basis for the transfer/discharge as required. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE] and re-admitted to the facility on [DATE], with diagnoses that included sepsis (a life-threatening blood infection), anxiety disorder (feelings of fear, dread, and uneasiness that may have occurred as a reaction to stress), and encephalopathy (a disease, disorder, or damage that affected the brain's structure or function). During a review of Resident 1's History and Physical (H&P) dated 7/9/2026, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 7/12/2026, the MDS indicated the resident had moderate cognitive impairment (a person was experiencing noticeable and significant difficulties with thinking, learning, remembering, and other cognitive skills that impacted their daily life). The MDS indicated the resident required substantial/maximal assistance (helper did more than half of the effort) from facility staff for toileting hygiene, showering, and transfers. During a review of Resident 1's physician's order dated 7/17/2026, the physician's order indicated to discharge Resident 1 home on 7/18/2026 per resident/family request. Follow up with urology and the primary care physician in one to two weeks and continue routine medications. The physician's order indicated Home Health for physical and occupational therapy and a home safety evaluation. Durable medication equipment included three in one commode. The physician's order indicated caregiver training with the family or caregiver was to be given prior to the resident's discharge. During a review of Resident 1's Notice of Proposed Transfer/Discharge Form dated 7/17/2026, the Form indicated for the resident to discharge/transfer on 7/18/2026 and an address was included. The form did not include the reasons explained as to the decision why the resident was to transfer/discharge from the facility, as required and in accordance with the facility's P&P. During a concurrent interview and record review on 7/30/2026 at 1:34 PM with the Medical Records Director (MRD), Resident 1's Notice of Proposed Transfer/Discharge Form dated 7/17/2026 was reviewed. The MRD stated the form was not filled out entirely but should have been to notify the family and the ombudsman for the reason/basis of the transfer/discharge. The MRD stated he was unsure why the form was not filled out and the facility staff must have missed that portion of the form. During a concurrent interview and record review on 7/30/2026 at 1:40 PM with Registered Nurse Supervisor (RNS) 3, Resident 1's Notice of Proposed Transfer/Discharge Form dated 7/17/2026 was reviewed. RNS 3 stated the facility staff that was in charge of the transfer was supposed to fill out the form and should have filled the form out entirely to indicate the reason the resident was transferring so the resident and the family would know why. During an interview on 7/31/2026 at 1:10 PM, the Director of Nursing (DON) stated having the Notice of Proposed Transfer/Discharge Form filled out entirely was important for the resident and the ombudsman to know the reason of the resident's transfer/discharge. During a review of the facility's policy and procedure (P&P) titled Admission, Transfer, and Discharge dated November 2016, the P&P indicated When the Facility transfers or discharges a resident, the Facility shall ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider. The P&P indicated When the Facility transfers or discharges a resident who meets the criteria specified above (A-F), the resident's medical record shall include documentation of the basis for the transfer.

Based on observation, interview, and record review, facility failed to ensure the MDS (a resident assessment and care screening tool), assessment correctly reflected the resident's actual condition for one of 32 sampled residents (Resident 30) who was placed on hospice care (specialized comfort and end of life care for terminally ill residents) on 3/25/2026, in accordance with the Centers for Medicare & Medicaid Services (CMS)' Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI). This deficient practice had the potential for Resident 30 not to receive adequate care plan necessary to address needs for hospice care. During a review of Resident 30's Face Sheet (FS), the FS indicated Resident 30 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of colon (a growth of cells that begins in a part of the large intestine) and hypertension (high blood pressure). During a review of Resident 30's Minimum Data Set (MDS, a resident assessment tool), dated 7/1/2026, the MDS indicated Resident 32 was not under hospice care (a specialized form of health care focused on comfort, dignity, and quality of life for individuals with a terminal illness who have a life expectancy of six months or less). During a review of Resident 30's Order Summary Report (OSR), dated 7/30/2026, the report indicated the physician ordered to admit Resident 30 under hospice care, starting on 3/25/2026. During a concurrent interview and record review on 7/28/2026 at 4:13 PM with the MDS Nurse (MDSN), Resident 30's MDS, dated [DATE], and OSR, dated 7/30/2026, were reviewed. MDSN stated Resident 30 was admitted under hospice care on 3/25/2026, but she did not document Resident 30 was under hospice on the resident's MDS assessment. The MDSN stated the MDS assessment should correctly reflect on the resident's actual condition to ensure the resident received necessary care. During an interview on 7/30/2026 at 4:17 PM with the Director of Nursing (DON), the DON stated it was important to document MDS accurately, so that the specific care area could be triggered and incorporated into the residents' care planning, ensuring the residents received necessary and consistent care. During a review of Centers for Medicare & Medicaid Services (CMS)' Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI), Version 1.20.1, dated 10/2025, the RAI indicated the RAI process has regulatory requirements, including the assessment accurately reflects the resident's status. The RAI indicated when a skilled nursing facility or nursing facility was the hospice resident's residence for purposes of the hospice benefit, the facility must assess the resident using the RAI, have a care plan and be provided with the services required under the plan of care. The RAI also indicated Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions.

Based on interviews and a thorough record review, the facility failed to develop and implement a comprehensive, resident specific, and individualized care plan for two of three sampled residents (Residents 6 and 156) in accordance with the facility's policy and procedure titled Comprehensive Person-Centered Care Planning. The facility failing to: 1. Ensure Resident 6, who was diagnosed with liver cirrhosis (severe and permanent scarring of the liver) and malignant ascites (accumulation of fluid in the abdomen caused by cancer) had a care plan to ensure for monitoring for signs and symptoms of abdominal distention, abdominal ascites, and shortness of breath. 2. Ensure Resident 156, who had a sacrococcygeal pressure injury (damage to the skin and tissue over the lower spine, tailbone, and upper buttocks), had an individualized care plan specifying the required turning frequency and schedule. The deficient practice resulted in Resident 6 not receiving necessary care and interventions for her history of malignant ascites, leading to repeated paracentesis procedures (medical procedure that used a thin needle or tube to drain extra fluid for inside the abdomen) and had the potential to lead to a decline in the resident's physical and psychosocial well-being that may lead to foreseeable risks, including severe abdominal distention and pain, respiratory compromise, and recurrent hospitalizations. The deficient practice had the potential to contribute to worsening of Resident 156's pressure injury. Findings: 1. During a review of Resident 6's admission Record (AR), the AR indicated that Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that include heart failure (a heart condition where it cannot effectively pump blood to the rest of the body), liver cirrhosis and malignant ascites (buildup of extra fluid inside the abdomen caused by cancer). During a review of Resident 6's Order Summary Report, the physician order, dated 4/5/2026, indicated to measure Resident 6's abdominal girth for ascites in centimeters (cm, unit of length) every Sunday. During a review of Resident 6's history and physical (HP), dated 4/4/2026, the HP indicated that Resident 6 had the capacity to understand and make medical decisions. The HP indicated Resident 6 had multiple readmissions to the General Acute Care Hospital (GACH) for complaints of shortness of breath, recurrent ascites that required paracentesis on each readmission to the GACH. The HP indicated to monitor Resident 6 for shortness of breath and to perform abdominal measurements for ascites. During a review of Resident 6's Minimum Data Set (MDS, a resident assessment), dated 7/2/2026, the MDS indicated that Resident 6's cognition (a resident's thought process) was moderately impaired. During a concurrent interview and record review on 7/31/2026 at 9:55 AM with Licensed Vocational Nurse (LVN) 2, Resident 6's Change of Condition (CoC) evaluation, dated 7/25/2026, was reviewed. LVN 2 stated that Resident 6 had critical abnormal laboratory blood results which resulted in Resident 6 being transferred to the GACH. LVN 2 stated that Resident 6 had laboratory results because she was supposed to receive her paracentesis. LVN 2 stated that Resident 6 regularly received paracentesis because she has abdominal ascites, and the last paracentesis was in May 2026. During an interview on 7/31/2026 at 11:30 AM with LVN 3, LVN 3 stated that Resident 6's pattern for paracentesis was about every 1 to 2 months and based on the Resident's discomfort. LVN 3 stated Resident 6 was alert enough to notify staff if she started to feel discomfort such as shortness of breath, abdominal discomfort, and abdominal pain. During a concurrent interview and record review on 7/31/2026 at 11:35 AM with Treatment Nurse (TXN) 1, Resident 6's Treatment Administration Record (TAR) for July 2026 was reviewed. TXN 1 stated Resident 6 did not have a baseline parameter to monitor her signs and symptoms of discomfort. TXN 1 stated there was no baseline parameter for Resident 6's abdominal girth. During a concurrent interview and record review on 7/31/2026 at 11:40 AM with the Minimal Data Set Nurse (MDSN), Resident 6's active care plans were reviewed. The MDSN stated there was no documented evidence of an active care plan related to her abdominal ascites, abdominal distention, or paracentesis. The MDSN stated there were no interventions monitoring Resident 6's signs and symptoms of abdominal ascites or post paracentesis procedures. During an interview on 7/31/2026 at 1:15 PM with the Director of Nursing (DON), the DON stated it was important to develop a care plan for Resident 6's abdominal girth and distention to provide baseline monitoring for her signs and symptoms of abdominal discomfort and shortness of breath and to provide baseline monitoring post-paracentesis procedure for all nursing staff. During a review of the facility's policy and procedure titled Comprehensive Person-Centered Care Planning, dated 4/20205, the P&P indicated that the interdisciplinary team shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs. The P&P indicated that the resident's comprehensive plan of care will be reviewed and/or revised by the interdisciplinary team after each assessment. 2. During a review of Resident 156's admission Record (AR), the AR indicated that Resident 156 was admitted on [DATE], and readmitted on [DATE] with diagnosis that includes sepsis (a body's overwhelming and life-threatening response to infection), pressure ulcer of sacral region stage 4 (a severe bedsore located on the lower back right above the tailbone), type 2 diabetes mellitus (DM2 - condition that results in too much sugar circulating in the blood), reduced mobility, and acquired absence of left and right leg above knee (leg was removed or lost higher than the knee due to an event, illness, or surgery). During a review of Resident 156's History and Physical (H&P), dated 7/10/2026, the H&P indicated Resident 156 does not have the capacity to understand and make decisions. During a review of Resident 156's Minimum Data Set (MDS, a resident assessment tool), dated 4/12/2026, the MDS indicated Resident 156's cognition (ability to think, remember, and reason) is moderately impaired and was dependent (helper does all of the effort, resident does none of the effort to complete the activity) on roll left and right (the ability to roll from lying on back to left and right side, and return to lying on back on the bed). During a review of Resident 156's physician Wound Progress Note (WPN) documented by Wound and Surgical Services, dated 6/9/2026, the WPN indicated the following: a. Resident 156 had pressure injury located in sacrococcyx area that measured at 4 cm x 2.4 cm x 0.6 cm (centimeter, unit of length) b. Resident 156 remains at exceptionally high risk for pressure injury progression due to complete dependence for mobility and repositioning. Ongoing pressure redistribution, frequent repositioning, nutritional support, moisture management, and skilled wound care remain medically necessary. c. Essential components of the treatment plan included pressure offloading, and routine repositioning. During a review of Resident 156's care plan (CP), revised 7/11/2026, the CP indicated Resident 156 had potential for pressure ulcer development and the interventions included that the resident required monitoring, reminding, and assistance to turn/reposition. During a review of Resident 156's care plan (CP), revised 7/8/2026, the CP indicated the resident had a pressure ulcer or risk for pressure ulcer development (sacro coccygeal stage 4 pressure injury) related to a history of ulcers and immobility. The CP indicated interventions that included educating the resident on transfer and positioning requirements, frequent repositioning, and wound evaluation and treatment by Wound and Surgical Services. During a concurrent observation and interview on 7/30/2026 at 9:45 AM in Resident 156's room, the resident was observed lying in bed on his back. On Resident 156's wall above the head of the bed, a signage was posted that indicated to turn and reposition every 2 hours (q2h). Resident 156 stated that staff had not assisted or reminded Resident 156 to turn every two hours. During an observation on 7/30/2026 at 10:30 AM in Resident 156's room, Resident 156 was observed lying on Resident 156's back. During an observation on 7/30/2026 at 11:30 AM in Resident 156's room, Resident 156 was observed still lying on Resident 156's back. During a concurrent interview and record review on 7/30/2026 at 11:30 AM with Treatment Nurse (TXN) 2, Resident 156's CP were reviewed. TXN 2 stated that all residents with pressure injuries required a signage to be posted to remind facility staff to turn and reposition the resident q2h to prevent wound worsening. TXN 2 stated that Resident 156's CP did not specify how often Resident 156 should be turned and repositioned. During an interview on 7/30/2026 at 11:45 AM with TXN 1, she stated there was no specific turning schedule for Resident 156. TXN 1 stated there was no way to know if the facility staff turned or repositioned the resident. TXN 1 stated that turning the resident was a shared responsibility among all staff, not just Certified Nurse Assistants (CNAs). During an interview on 7/31/2026 at 11:48 AM with CNA 2, CNA 2 stated the facility does not have a specific turning schedule. CNA 2 stated that she follows her own routine and will turn Resident 156 whenever she goes in to assist or change Resident 156. CNA 2 stated she did not document Resident 156's turning and repositioning on 7/30/2026 or 7/31/2026. During an interview on 7/31/2026 at 11:53 AM with Registered Nurse (RN) 3, RN 3 stated the facility has a turning schedule expectation that CNAs should know and follow, and that licensed nurses are responsible for overseeing compliance. RN 3 stated according to the facility's schedule, Resident 156 should have been turned to face the window at 9:45 AM and to face the door at 10:30 AM and 11:30 AM. RN 3 stated that if the resident was not in the correct position, licensed nurses should verify with the resident and CNAs whether the resident had not been assisted or refused turning. RN 3 also stated that Resident 156's CP should specify the turning schedule and frequency to prevent worsening of the wound. During an interview on 7/31/2026 at 12:45 PM with the Director of Nursing (DON), the DON stated that Resident 156's CP should be more specific regarding the turning schedule so staff can follow the plan of care and prevent worsening of the wound. During a review of the facility's Policy and Procedure (P&P) titled, Skin and Wound Monitoring and Management, revised 4/2025, the P&P indicated the facility that a resident having pressure injuries receives necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable pressure injuries from developing. The P&P indicated to identify risk factors which relate to the possibility of skin breakdown and/or the development of pressure injury which include but are not limited to impaired/decreased mobility and decreased functional ability; co-morbid conditions; cognitive impairment. The P&P indicated the facility would develop an individualized person-centered care plan based on the assessment and designed to minimize the possibility of skin breakdown. The P&P indicated to prevent the development of skin breakdown or prevent existing pressure injuries from worsening, nursing staff shall implement the following approaches as appropriate and consistent with the resident's care plan: reposition the resident. During a review of the facility's P&P titled Comprehensive Person-Centered Care planning, revised 4/2025, the P&P indicated the IDT shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.

Based on observation, interview and record review, the facility failed to provide Restorative Nursing Assistant) RNA assisted range of motion exercises (ROM- full movement potential of joint) to one of two sampled residents (Resident 118) who was ordered by the physician to receive ROM exercises to Bilateral Upper Extremities (BUE) by failing of the licensed staff to communicate with the Rehabilitation Department the change of physician's order to provide RNA assisted exercises to the resident daily for five times a week. The deficient practice had the potential to cause further decline and worsening of pain and ROM for Resident 118's bilateral upper extremities that could lead to increased contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to restricted joint mobility). During a review of Resident 118's Face Sheet (FS), the FS indicated Resident 118 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (a medical condition causing total or severe impairment on one side of the body) and hemiparesis (weakness affecting one entire side of the body). During a review of Resident 118's Joint Mobility Evaluation, dated 6/17/2026, the Evaluation indicated Resident 118 had moderate (50 percent to 75 percent of range intact) limitation of ROM for his left and right fingers, and left and right shoulder flexion (arms positioned in front of the body) and abduction (arms positioned at the sides of the body). During a review of Resident 118's Minimum Data Set (MDS, a resident assessment tool), dated 6/23/2026, the MDS indicated Resident 118 had severely impaired cognition (ability to think and reason) and memory. The MDS indicated Resident 118 required partial/moderate assistance with eating, oral hygiene and personal hygiene, and substantial/maximal assistance with chair/bed-to-chair transfer, toileting hygiene and shower/bathe self. During a review of Resident 118's Nurs Practitioner (NP) Progress Note (PN), dated 7/6/2026 timed 2 PM, the PN indicated Resident 118 reported having left shoulder intermittent (stopping and starting again at separate times) pain and was encouraged to do ROM exercises as tolerated with bilateral (both sides) upper extremities (BUE). During a review of Resident 118's Physician Order, dated 7/6/2026 timed at 3:21 PM, the order indicated the physician ordered the resident to receive Restorative Nursing Assistant (RNA) assisted exercises to BUE with active assistive ROM (AAROM) and passive ROM (PROM) daily five times a week as tolerated by Resident 118. During a review of Resident 118's PN, dated 7/6/2026 timed 3:23 PM, by Licensed Vocational Nurse (LVN) 1, the PN indicated NP ordered to receive ROM exercises to BUE assisted by RNAs daily as tolerated. During a review of Resident 118's Restorative Nursing, dated 7/1/2026 to 7/31/2026, the record indicated Resident 118 was scheduled to receive RNA assisted AA/PROM to BUE daily three times a week with a start date of 8/20/2025. The record indicated Resident 118 received RNA for AAROM/PROM daily three times a week and not five times a week as ordered by the physician. Resident 118 received AAROM/PROM on 7/1/2026, 7/3/2026, 7/6/2026, 7/8/2026, 7/10/2026, 7/13/2026, 7/15/2026, 7/17/2026, 7/20/2026, 7/22/2026, 7/24/2026, 7/27/2026, and 7/29/2026. During a concurrent observation and interview on 7/28/2026 at 10:08 AM with Resident 118, both Resident's hands were clenched into a fist and unable to open his fists independently. Resident 118 was unable to lift his shoulders, and he pointed to his left shoulder and stated he is currently having a shoulder pain. Resident 118 stated he received RNA exercise three times a week. During a concurrent interview and record review on 7/30/2026 at 9:06 AM with RNA 1, Resident 118's Restorative Nursing record, dated 7/1/2026 to 7/31/2026, and Physician Order, dated 7/6/2026 timed 3:21 PM, were reviewed. RNA 1 stated the RNAs only provided RNA exercise for Resident 118's BUE daily three times a week from 7/6/2026 to 7/30/2026. RNA 1 stated he was unaware of the physician order dated 7/6/2026 directing that the RNA exercise to be provided on BUE to the resident daily five times a week. RNA 1 stated he had been following Resident 118's Restorative Nursing record, which indicated a three-times-weekly schedule, as shown in the RNA binders. RNA 1 stated he did not receive any updated schedule on Resident 118's Restorative Nursing record reflecting daily, five-times-a-week order. During a concurrent interview and record review on 7/30/2026 at 9:10 AM with RNA 2, Resident 118's Restorative Nursing record, dated 7/1/2026 to 7/31/2026, and Physician Order, dated 7/6/2026, were reviewed. RNA 2 stated she only provided RNA exercises to resident's BUE daily three times a week from 7/6/2026 to 7/30/2026, as indicated schedule in the resident's Restorative Nursing record. RNA 2 stated RNAs received Restorative Nursing records and schedules directly from the rehabilitation department. RNA 2 stated she did not receive any updated order to increase the frequency of RNA assisted exercises to five times a week to Resident 118's BUE on 7/2026. During a concurrent interview and record review on 7/30/2026 at 9:25 AM with LVN 1, Resident 118's Physician Order, dated 7/6/2026 timed 3:21 PM, and PN, dated 7/6/2026 timed 3:23 PM, were reviewed. LVN 1 stated on 7/6/2026, the NP ordered an increase in the frequency of AA/PROM exercises for Resident 118's BUE by the RNAs, raising the schedule from three times a week to five times a week. LVN 1 stated she printed out a copy of the order and gave it to the Director of Staff Development (DSD), so the DSD could endorse the new order to the RNAs because the DSD oversee the RNAs. During a concurrent interview and record review on 7/30/2026 at 9:40 AM with the Rehabilitation Director (RD), Resident 118's Physician Order, dated 7/6/2026 timed 3:21 PM, and Restorative Nursing record, dated 7/1/2026 to 7/31/2026. The RD stated the physician order was confirmed by LVN 1, then, LVN 1 should print out a copy of the order and endorse it to the RNAs, so the RNAs could carry out the new order. The RD stated he was unaware of this physician order. The RD stated receiving RNA exercises less frequently than ordered could potentially affect the resident's muscle tone and comfort. During an interview on 7/30/2026 at 9:57 AM with the DSD, the DSD stated she had not received any RNA orders for Resident 118 from LVNs. The DSD stated she oversaw the RNA staffing, but she was not involved in receiving, endorsing, and implementing RNA orders. The DSD stated when the licensed nurses receive orders for RNA services, the licensed nurse should print out two copies of order and put one copy in the RNA binder and give one copy to the RNAs directly, to ensure the order was carried out. During an interview on 7/30/2026 at 4:19 PM with the Director of Nursing (DON), the DON stated Resident 118 had not received RNA exercises for his BUE five times a week as ordered by the physician for the month of July 2026, because the licensed nurses did not endorse the order correctly to rehabilitation department. The DON stated the normal process for RNA order was that the rehabilitation department staff received from a physician [NAME] placed a copy of Restorative Nursing record (flow sheet) in the RNA binder and hand a copy of that flow sheet to the RNAs directly to ensure the order was carried out. The DON stated If the licensed nurse receive an RNA order from a physician or a NP, the licensed nurse should give the order to the rehabilitation department, the rehabilitation staff would conduct assessment to see if it was appropriate or not, then, the rehabilitation staff would provide instruction to the RNAs with the order and flow sheet. The DON stated it was rarely for a licensed nurse to receive an RNA order from a NP directly, so LVN 1 did not know how to correctly process Resident 118's RNA order. As a result, Resident 118 missed eight days of his RNA exercise from 7/6/2026 to 7/30/2026, which could potentially affect his comfort and ROM. During a review of the facility's policy and procedure (P&P) titled, ROM and Contracture Prevention, dated 5/2019, the facility to ensure residents receive services, care and equipment to assure that every resident maintains, and/or improves to his/her highest level of ROM and mobility, and every resident with limited ROM and mobility maintains or improves function.

Based on interview and record review, the facility failed to provide the necessary care and services to implement a bowel and bladder training program (a program to establish a time routine to stimulate urine and bowel movement (stool) daily) for one of three sampled residents (Resident 141), who was assessed as a candidate for bowel and retraining program on 6/17/2026 and 7/8/2026, but the resident was not placed in the program as indicated in the assessment and the facility's policy and procedure (P&P) titled Bowel and Bladder Assessment & Training. This deficient practice resulted in the resident not being monitored and evaluated for effective bowel and bladder retraining and experienced constipation, abdominal discomfort, and increase risk for complications such as fecal impaction (a solid, dry mass of stool stuck in the lower intestine or rectum), bowel obstruction (physical blockage in the small or large intestine), and ileus (temporary slowdown or stoppage of the intestinal muscles). Cross Reference F684 and F697 Findings: During a review of Resident 141's AR, the AR indicated that Resident 141 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included abnormal gait and mobility and spinal stenosis (a chronic condition of having abnormal narrowing of the spinal cord which puts pressure on the spinal cord or spinal nerves, most often in the lower back or neck resulting in pain). During a review of Resident 141's Bowel and Bladder Evaluation record, dated 6/17/2026, the record indicated that Resident 141 was always incontinent of bowel and bladder and was a possible candidate for bowel and bladder re-training. During a review of Resident 141's MDS, dated [DATE], the MDS indicated that Resident 141's cognition (ability to process information) was moderately impaired. The MDS indicated Resident 141 needed supervision when performing toileting hygiene, repositioning self in bed, and transferring from the chair/bed to the chair or commode (a portable toilet, built like a chair with a bucket hidden under the seat). The MDS indicated that Resident 141 experienced frequent incontinence (loss of bladder or bowel control) of bladder and bowel, and there was no documented evidence that Resident 141 was on a bowel toileting program. During a review of Resident 141's Bowel and Bladder Evaluation record, dated 7/8/2026, the record indicated that Resident 141 was always incontinent of bladder and was a possible candidate for bowel and bladder re-training. During interview on 7/31/2026 at 12:13 PM with the MDSN, The MDSN stated that Resident 141 was not on a bowel toileting program because she did not think there was a problem and that the resident did not need to be on a bowel toileting program. The MDSN stated that she was not aware that Resident 141 had complaints of constipation. During a review of the facility's policy and procedure titled Bowel and Bladder Assessment & Training, dated 2/1/2023, the P&P indicated that the purpose of the bowel and bladder assessment is to offer a structured, goal-oriented approach with the intent that the resident attains the highest level of independence in bowel and/or bladder continence. The P&P indicated that the interdisciplinary team will identify if the resident is a candidate for the bowel and bladder retraining program.

Based on observation, interview, and record review, the facility failed to ensure that 2 of 3 sample residents (Resident 107 and Resident 141) were assed for the root cause of their pain - including location, quality, onset, and duration - and failed to re-evaluate the continued use of non-pharmacological and pharmacological pain interventions for their overall pain management regimen in accordance with the facility's policy and procedure (P&P) titled Pain Recognition and Management. This deficient practice resulted in the failure to identify the root cause of Resident 107 and Resident 141's ongoing complaints of pain that resulted in an ineffective pain management regimen. Cross Reference F684 Findings: 1.During a review of Resident 107's admission Record (AR), the AR indicated that Resident 107 was admitted to the facility on [DATE] with diagnoses that include surgical after care of the genitourinary system (urinary system [organ system that develop and remove urine] and the reproductive system (group of organ systems that work together to make babies), ovarian cyst (fluid-filled pocket formed inside the ovary) and generalized abdominal pain. During a review of Resident 107's history and physical (HP), dated 5/2/2026, the HP indicated that Resident 107 was able to make her needs known, with fluctuating (changing) capacity to make medical decisions. The HP indicated that Resident 107 had pain to her left upper and lower extremities and had surgical removal of a tumor resection (removal of the tumor), a hysterectomy (surgical removal of the uterus), and a bilateral salphingo-oopherectomy (surgical removal of the fallopian tube and ovaries) on 4/24/2026. During a review of Resident 107's Order Summary Report, a physician order, dated 4/29/2026, indicated that Resident 107 had a physician order for Tylenol Oral Tablet 325 mg with instructions to give 2 tablets by mouth every four hours as needed for mild pain (1-3/10 pain on the numerical pain scale [a way to rate pain intensity, ranging from 0 - no pain to 10 - worst pain felt]). During a review of Resident 107's Order Summary Report, a physician order, dated 4/29/2026, indicated that Resident 107 had a physician order for Norco 5-325 mg with instructions to give 1 tablet by mouth every 4 hours as needed for moderate pain (4-7/10 on the numerical pain scale). During a review of Resident 107's Order Summary Report, a physician order, dated 4/29/2026, indicated that Resident 107 had a physician order for Norco Oral tablet 10-325 mg with instructions to give 1 tablet by mouth every 4 hours as needed for severe pain (8 to10/10 on the numerical pain scale). During a review of Resident 107's care plan, developed on 4/30/2026, the care plan indicated that Resident 107 had acute (sudden and sharp pain) and chronic (ongoing pain that lasts longer than 3 to 12 months) pain related to encephalopathy (damage to the brain that causes confusion and change in mental function), hypertension (high blood pressure), and embolism (sudden blockage in a blood vessel by a clot). The care plan's intervention indicated to monitor/record pain characteristics: quality, severity, anatomical location, onset, and duration, to monitor for signs and symptoms of non-verbal pain such as changes in breathing, vocalizations, and mood changes, and to monitor/document for side effects of pain medication such as constipation, new or increased agitation, restlessness, confusion, dizziness, or nausea and vomiting. During a review of Resident 107's Minimum Data Set (MDS, a resident assessment), dated 5/4/2026, the MDS indicated that Resident 107's cognition (a resident's thought process) was severely impaired. The MDS indicated that Resident 107 was dependent on staff for activities of daily living, repositioning in bed, and transferring from chair/bed to commode. The MDS indicated that Resident 107 was receiving pain medication as needed. There was no documented evidence Resident 107 displayed indicators of pain such as non-verbal sounds (such as groaning, gasping, or crying), vocal complaints (such as ouch or stop), facial expressions (such as grimacing, wincing, or clenched teeth or jaw), or protective body movements (such as guarding, bracing, or tensing a body part). There was no documented evidence Resident 107 received an opioid (Norco 5-325 mg and Norco 10-325mg). During a review of Resident 107's Medication Administration Record (MAR) for June and July 2026, the MAR indicated in June MAR Resident 107 received Tylenol 325 mg 3 times, Norco 5-325mg 2 times, and Norco 10-325 mg 8 times from 6/1/2026 to 6/30/2026. On July 2026 the MAR indicated Resident 107 received Tylenol 22 times, Norco 5-325 mg 1 time, and Norco 110-325 mg 14 times from 7/1/2026 to 7/31/2026. During a concurrent interview and record review on 7/31/2026 at 11:45 AM with the Minimal Data Set Nurse (MDNS), Resident 107's July MAR and progress notes were reviewed. The MDSN stated that Resident 107 received Tylenol 325 mg 3 times, Norco 5-325 mg 1 time, and Norco 10-325 mg 14 times in July 2026. The MDSN indicated stated that pain assessment in the electronic MAR (e-MAR) progress notes for July 2026 had inconsistent pain assessment documentation. The MDSN stated the pain assessment was not consistent in assessing and documenting the pain's location, quality, onset, and duration. The MDSN stated there was a few documented evidence of Resident 107's pain location, but there was no documented evidence of the pain's quality, onset, and duration. During the same concurrent interview and record review on 7/31/2026 at 11:50 AM with the MDSN, Resident 107's care plan related to acute and chronic pain was reviewed. The MDSN stated that Resident 107's care plan indicated to monitor and document for pain assessment such as the location, quality, onset, duration, and severity. During the same interview on 7/31/2026 at 12 PM with the MDSN, the MDSN stated Resident 107 did not have an effective pain management regimen, especially since Resident 107 received Norco 10 325 mg 14 times in July 2026. The MDSN stated she was unaware that Resident 107 had requested Norco 10 325 mg 14 times from 7/1/2026 to 7/31/2026, and that the inconsistent pain assessments (location, duration, quality, and onset) resulted in ineffective pain management for Resident 107. 2.During a review of Resident 141's AR, the AR indicated that Resident 141 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that include Type 2 Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), spinal stenosis (abnormal narrowing of the spinal cord), and chronic kidney disease (long-term kidney disease). During a review of Resident 141's care plan, developed on 11/6/2023, the care plan indicated Resident 141 had acute and chronic pain related to urinary tract infection (UTI, an infection in the bladder/urinary tract) and left ankle sprain. The care plan's intervention indicated to monitor/record pain characteristics: quality, severity, anatomical location, onset, and duration, to monitor for signs and symptoms of non-verbal pain such as changes in breathing, vocalizations, and mood changes. During a review of Resident 141's Order Summary Report, a physician order, dated 5/29/2024, indicated that Resident 141 had a physician order for Tylenol 325 mg with instructions to give 2 tablets every 4 hours as needed for mild pain (1-3/10 on the numerical pain scale). During a review of Resident 141's Order Summary Report, a physician order, dated 9/12/2025, indicated that Resident 141 had a physician order for Norco 10-325 mg with instructions to give 1 tablet by mouth every 6 hours as needed for severe pain (8-10/10 on the numerical pain scale). During a review of Resident 141's Order Summary Report, a physician order, dated 1/6/2026, indicated that Resident 141 had a physician order for Norco 5-325 mg with instructions to give 1 tablet by mouth every 6 hours as needed for moderate pain (4-7/10 on the numerical pain scale). During a review of Resident 141's MDS, dated [DATE], the MDS indicated that Resident 141's cognition was moderately impaired. The MDS indicated that Resident 141 needed supervision when performing toileting hygiene, repositioning self in bed, and transferring from the chair/bed to the chair or commode. The MDS indicated that Resident 141 received a pain medication regimen and as needed pain medication. The MDS indicated that Resident 141 denied pain. There was no documented evidence Resident 107 displayed indicators of pain such as non-verbal sounds (such as groaning, gasping, or crying), vocal complaints (such as ouch or stop), facial expressions (such as grimacing, wincing, or clenched teeth or jaw), or protective body movements (such as guarding, bracing, or tensing a body part). The MDS indicated that Resident 141 received an opioid (Norco 5-325mg and Norco 10-325mg). During a review of Resident 141's MAR for June and July 2026, Resident 141 received Tylenol 325 mg, Norco 5-325 mg, and Norco 10-325 mg multiple times. The June MAR indicated Resident 141 received Norco 10-325 mg 19 times from 6/1/2026 to 6/30/2026. The July MAR indicated Resident 141 Received Tylenol 325 mg 6 times, Norco 10-325 mg 6 times, and Norco 5-325mg 38 times from 7/1/2026 to 7/31/2026. During a concurrent observation and interview on 7/28/2026 at 11:49 AM in Resident 141's room, Resident 141 was observed lying in bed with the occasional facial grimacing and pointed to her lower abdominal area. Resident 141 stated that she has had stomach pain all night because she has to poop. Resident 141 stated that her pain was 8/10 and [Resident 141] feels full. Resident 141 stated that her pain was in her stomach and described the location as a smile and pointed to her lower abdominal and the bilateral sides of her abdomen. Resident 141 stated her stomach pain was always present, but the intensity of the pain fluctuated with the highest intensity as an 8/10. During another concurrent observation and interview on 7/30/2026 at 3:25 PM in Resident 141's room, Resident 141 was observed lying sideways in bed with the occasional facial grimacing. Resident 141 stated she had a hard stool and it was in pieces. Resident 141 stated, my stomach hurts so bad that I would rather go to Heaven than deal with what I am dealing with right now! During an interview on 7/30/2026 at 3:30 PM with Licensed Vocational Nurse (LVN) 3, LVN 3 stated that Resident 141 had 3 as needed pain medications for her chronic pain from her recurrent UTIs. LVN 3 stated when Resident 141 received her pain medication, it is effective. Once the pain medication wears off, Resident 141 complains of lower abdominal pain again. During a concurrent interview and record review on 7/31/2026 at 12 PM with the MDSN, Resident 141's care plan related to acute and chronic pain was reviewed. The MDSN stated that Resident 141's care plan indicated to monitor and document for pain assessment such as the location, quality, onset, duration, and severity. During a concurrent interview and record review on 7/31/2026 at 12:05 PM with the MDSN. Resident 141's July MAR and progress notes were reviewed. The MDSN stated that Resident 141 received Tylenol 325 mg 6 times, Norco 10-325 mg 6 times, and Norco 5-325 mg 38 times from 7/1/2026 to 7/31/2026. The MDSN indicated stated that pain assessment in the e-MAR progress notes for July 2026 had inconsistent pain assessment documentation. The MDSN stated that the documented evidence of pain assessment was not consistent in assessing the pain's location, quality, onset, and duration. The MDSN stated there was a few documented evidence of Resident 141's pain location, but there was no documented evidence of the pain's quality, onset, and duration. During the same concurrent interview and record review on 7/31/2026 at 12:10 PM with the MDSN, Resident 141's Order Summary Report was reviewed. The MDSN stated that there was no active order to monitor for the side effects of Resident 141's Norco use. During the same interview on 7/31/2026 at 12:15 PM with the MDSN, the MDSN stated Resident 141 does not have an effective pain management regimen because Resident 141 received Norco 5-325 mg 38 times in the month of July 2026. During an interview on 7/31/2026 at 1:15 PM with the Director of Nursing (DON), the DON stated it was important to consistently and thoroughly assess the resident's pain for the location, intensity, frequency, and quality. The DON stated it was important to assess the quality of the resident's pain to ensure the proper intervention, pharmacological or non-pharmacological, was provided. The DON stated it was important to monitor the potential adverse side effects of an opioid as it may potentially harm the resident's physical and mental well-being. During a review of the facility's policy and procedure titled Pain Recognition and Management, dated 4/2025, the P&P indicated that pain management is provided to residents who require such services, consistent with professional standards of practice, comprehensive and routine assessments, person-centered care plan, and the residents' goal and preferences. During a review of the same P&P titled Pain Recognition and Management, dated 4/2025, the P&P indicated to monitor for effectiveness of interventions and/or adverse consequences (e.g. constipation, sedations) and the location and type of pain, pharmacological, and non-pharmacological interventions, with evaluation and revision as indicated.

Based on interviews and record reviews, the facility failed to provide necessary care and services for one of 4 sampled resident ( Resident 1) who was at risk for developing pressure ulcer (PU- a skin damage or injury due to poor circulation or prolonged unrelieved pressure) and complications from PU, in accordance with the facility ' s policy and procedure, care plan and the physician ' s order by failing to: 1. Ensure the facility ' s licensed staff was referred and followed up on Resident 1 ' s referral and appointment with a vascular physician (a doctor who specializes in the diagnosis, treatment, and prevention of diseases that affect the blood vessels, including arteries and veins), in accordance with Nurse Practitioner (NP) 1 ' s recommendations on 9/24/2024. Resident 1 was not evaluated until 1/17/2025 when Resident 1 was transferred to the GACH (General Acute Care Hospital) 1 emergency room (ER). 2. Ensure the facility ' s licensed staff identified and addressed Resident 1 ' s diagnoses of peripheral vascular disease and develop a comprehensive care plan starting 12/18/2024 upon receipt of the arterial doppler result indicating the findings was consistent with moderate PVD of the bilateral lower extremities to ensure appropriate treatment measures are provided to the resident. 3. Ensure the facility ' s licensed staff referred and followed up on Resident 1 ' s referral and appointment with a wound specialist to assess the Resident ' s right foot wound, in accordance with NP 1 ' s recommendations and orders on 12/25/2024. The physician ' s order was placed by the facility staff on 1/13/2025 (19 days from NP 1 ' s order to refer Resident 1 to a wound specialist) and was seen by the wound specialist for an outpatient appointment on 1/17/2025. These deficient practices resulted in delays of Resident 1 ' s wound assessment and interventions to the right and left foot. On 1/17/2025, Resident 1 was transferred to GACH (General Acute Care Hospital) 1 emergency room (ER) as ordered by the wound specialist due to infection and gangrenous changes to the right heel and left second toe. In GACH 1, Resident 1 was found to have worsening lower extremity gangrene that included malodorous (an unpleasant or offensive odor, often associated with rotting or decaying matter) dry gangrenous right heel ulcer with surrounding erythema (abnormal redness) and tenderness to palpation, left second toe with dry gangrene. Resident 1 was discharged from GACH 1 on 1/29/2025 to hospice care (a specialized form of end-of-life care that provides comfort, support, and medical assistance to terminally ill patients and their families) and passed away on 2/18/2025. The Certificate of Death indicated Resident 1 ' s immediate cause of death was sepsis (a life-threatening emergency that happens when your body's response to an infection damages vital organs and, often, causes death) secondary to osteomyelitis (infection in the bone that can cause inflammation, pain and damage to the bone), peripheral artery disease (also knows as peripheral vascular disease [PVD], is a circulatory condition where narrowed arteries reduce blood flow to the arms and legs, most commonly affecting the extremities), Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) Type II. Findings: During a review of Resident 1 ' s admission Record (AR), the AR indicated Resident 1 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses including pneumonia (a severe infection and inflammation of the lungs), chronic kidney disease (a condition when kidneys have become damaged overtime and unable to filter out fluids and toxins in the body) diabetes mellitus, and Parkinson ' s Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). During a review of Resident 1 ' s Braden Scale for Predicting Pressure Injury Risk (a Braden Scale used to predict the risk of developing pressure sores/injuries. Early identification allows for preventative measure to be taken, such as repositioning, pressure relief measures, and nutritional support) dated 3/14/2024, the total score indicated was 14 (categorized at moderate risk for pressure injury). During a review of Resident 1 ' s Care Plan dated 6/30/2024, the care plan indicated Resident 1 was at risk for developing PU related to UTI (urinary tract infection- an infection in the bladder/urinary tract), ESRD (End Stage Renal Disease-irreversible kidney failure) on hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). The care plan interventions included: the facility will assess/record/monitor wound healing, assess and document the wound perimeter (around the wound), report improvements and declines to the physician; administer treatment as ordered and monitor for effectiveness; provide pressure relieving/reducing device; weekly head to toe skin at risk assessment. During a review of Resident 1 ' s Podiatry (a medical care and treatment of the human foot) Evaluation and Treatment dated 8/19/2024, the Podiatry Evaluation indicated Resident 1 had absent hair growth on the foot and skin temperature was cool to touch. The evaluation indicated Resident 1 was assessed having onychomycosis (a fungal infection of the nails). During a review of Resident 1 ' s Braden Scale for Predicting Pressure Injury Risk dated 9/16/2024, indicated the total score was 14 (categorized at moderate risk for pressure injury). During a review of Resident 1 ' s Podiatry Evaluation and Treatment dated 10/22/2024, the Podiatry Evaluation indicated Resident 1 had absent hair growth on the foot with skin temperature cool to touch. The evaluation indicated Resident 1 was assessed having onychomycosis, The Podiatry evaluation added another diagnosis during this assessment and indicated Resident 1 had Type II Diabetes with PVD without gangrene (death of body tissue due to a lack of blood flow or a serious bacterial infection). Resident 1 ' s records did not indicate any other follow up Podiatry Evaluations after this visit on 10/22/2024. During a review of the Progress Notes dated 11/21/2024 indicated Resident 1 had a change in skin condition of the right heel which was noted with cracked skin, scant (small amount) bleeding and redness. The Progress Notes did not indicate the type of wound and/or measurement of the wound. During a review of Resident 1 ' s Care Plan, dated 11/21/2024 indicated Resident 1 had PU on right heel related to history of ulcers and immobility. The care plan interventions included placing heel protectors, assessing/recording/monitoring wound healing, wound perimeter, measure length, width, and depth of the wound. wound bed, and healing progress. The interventions also included reporting improvements and declines of the skin condition to the physician. During a review of Resident 1 ' s Skin Evaluation PRN (as needed) /Weekly dated 11/25/2024 indicated, Resident 1 ' s right heel was noted with a pressure wound measuring 1 centimeter (cm) x 1 cm with no staging (no documentation of the stage or depth of the wound/ulcer). Additional comments indicated Resident 1 ' s right heel had cracked skin. During a review of Resident 1 ' s Skin PU Weekly assessment dated [DATE] indicated, Resident 1 ' s right heel PU was reclassified to SDTI measuring 3 cm x 4 cm, with 100% (percent) maroon/purple discoloration and pain, the wound bed was assessed to have normal skin. The intervention was to clean with normal saline, pat dry, paint with Betadine (a solution that kills virus and bacteria) and cover with dry dressing, and offload (lift or remove) from pressure. During a review of the Minimal Data Sheet (MDS- a resident assessment tool) dated 11/29/2024, indicated Resident 1 had severe cognitive impairment (a condition that makes it very difficult for a person to think, learn, and remember) and had no behavior of refusal or rejection of care. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort, lifts, holds, or supports trunk or limbs, but provides less than half the effort) on rolling left and right, sitting to lying, lying on side of bed, and chair/bed-to-chair transfer and personal hygiene. The MDS indicated Resident 1 was assessed with one unstageable pressure injury presenting as deep tissue injury. Further review of the MDS indicated Resident 1 was not assessed as having any other issues or foot problems that included infection of the foot, diabetic foot ulcer (an open sore or wound on the foot of a person with diabetes, often located on the bottom of the foot) and/or other open lesions on the foot. During a review of Resident 1 ' s Care Plan dated 11/29/2024, indicated that Resident 1 had PU staged as SDTI on right heel related to immobility. The care plan interventions further indicated heel protectors (a medical device, often made of cushioned materials like foam or air, designed to protect and support the heels of individuals who are bedridden) in place, right heel open wound to be cleaned with normal saline, pat dry, and paint with betadine and cover with dry dressing, and off load from pressure. During a review of Resident 1 ' s Care Plan dated 12/9/2024, the care plan indicated Resident 1 ' s potential for complications due to pain on bilateral lower extremities and bilateral plantar foot. The care plan interventions included administering Neurontin 300 mg daily (medication for nerve pain) as ordered and monitoring the site and location of pain. During a review of Resident 1 ' s Braden Scale for Predicting Pressure Injury Risk dated 12/9/2024, the record indicated the total score was 15 (categorized at low risk for pressure injury). During a review of Resident 1 ' s Condition Follow Up Note dated 12/16/2024, the Note indicated Resident 1 had a new ischemic ulcer (an open sore or wound that develops due to lack of oxygen and nutrients to the tissues, caused by reduced blood flow in the arteries) on the right foot lateral and right fifth toe. The Note indicated Family 1 was made aware and informed of the new order for arterial doppler ultrasound to the bilateral lower extremities to check for circulation. During a review of Resident 1 ' s Skin Evaluation PRN/Weekly dated 12/16/2024, the assessment indicated the following: New skin changes with two closed wounds on right fifth toe and right metatarsal (lateral foot), measuring 0.8 cm x 0.7 cm x (UTD) -Unstageable Tissue Damage a condition where the stage of a pressure ulcer cannot be accurately determined because the wound bed is obscured by eschar or slough)) cm and 1.5 cm x 1 cm x UTD cm respectively, and both wounds were noted 100% maroon discoloration. Right heel SDTI measured 3 cm x 4 cm x UTD no documented evidence about wound assessment including description of the wound. During a review of Resident 1 ' s Care Plan dated 12/16/2024, the Care Plan indicated Resident 1 had a right metatarsal closed wound. The care plan interventions included to clean with normal saline (sterile water with salt that removes bacteria from the wound), pat dry, and paint with betadine and leave open to air, and keep skin clean and dry. During a review of Resident 1 ' s Physician Order dated 12/16/2024, the order indicated to obtain arterial ultrasound (a test that looks at the blood circulation in the arteries of upper or lower extremities [limbs]) on bilateral lower extremities due to pain. During a review of the Radiology (high-energy radiation) Interpretation report dated 12/18/2024 indicated an arterial doppler of the bilateral lower extremity was performed for Resident 1 due to pain in the right and left leg. The arterial doppler findings showed moderate plaque (hard substance around the artery) noted within visualized arteries bilaterally. The report indicated the findings was consistent with moderate peripheral vascular disease without occlusion, bilateral lower extremities. The arterial doppler findings further indicated moderate stenosis (narrowing or constriction of an opening/passage) between left popliteal artery and posterior tibial artery. A handwritten note on the document indicated Texted [Physician 1] and [NP 1] [on] 12/19/2024 at 6:50 pm. Awaiting response. NNO (No New Order). During a review of Resident 1 ' s Skin Evaluation PRN/Weekly dated 12/23/2024 indicated Resident 1 ' s wounds on right fifth toe and right lateral foot, measuring 0.8 cm x 0.7 cm x udt (unable to determine) cm and 1.5x1.0x UDT cm respectively, both were staged as SDTI and noted with dark maroon/ purple discoloration. No other details of PU assessment were documented. During a review of Resident 1 ' s Physician Progress Note dated 12/25/2024, authored by NP 1, the progress note indicated right foot wound was observed. NP 1 ' s notes indicated to see orders to follow up with a wound specialist (healthcare personnel specializing in wound care). During a review of Resident 1 ' s Physician Order dated 12/25/2024, indicated to obtain an Xray (photographic or digital image of the inside of the body) of right foot to rule out osteomyelitis. During a review of Resident 1 ' s Skin PU Weekly assessment dated [DATE], the assessment indicated the following: 1. Resident 1 ' s right heel with suspected deep tissue injury measuring 4 cm x 4.5 cm, staged as SDTI, with 100% (percent) maroon/ purple discoloration and skin breakdown noted on 25% of wound bed. The wound bed was assessed to be black/brown (eschar). The intervention was to clean with normal saline, pat dry, and paint with Betadine and cover with dry dressing and offload from pressure. 2. Resident 1 ' s right fifth toe was staged as unstageable (slough/eschar) measuring 0.8 cm x 0.7 cm x UDT cm. The intervention was to clean with normal saline, pat dry, and paint with betadine and cover with dry dressing and offload from pressure. 3. Resident 1 ' s right metatarsal foot was staged as SDTI measuring 1.5 cm x1 cm x UDT cm, the wound bed was noted as black/eschar. The intervention was to clean with normal saline, pat dry, and paint with Betadine and cover with dry dressing and offload from pressure. During a review of Resident 1 ' s Skin PU Weekly assessment dated [DATE], the assessment indicated the following: 1. Resident 1 ' s right heel with suspected deep tissue injury measuring 4.0 x4.5 cm, staged as SDTI, with 100% (percent) maroon/purple discoloration, skin breakdown noted on 25% of wound bed. The wound bed was assessed as black/brown (eschar). The intervention was to clean with normal saline, pat dry, and paint with betadine and cover with dry dressing and offload from pressure. 2. Resident 1 ' s right fifth toe was staged as SDTI measuring 0.8 x 0.7 x udt cm, and the wound bed was noted as black/brown (eschar). The intervention was to clean with normal saline, pat dry, and paint with betadine and cover with dry dressing and offload from pressure. 3. Resident 1 ' s right metatarsal foot was staged as unstageable measuring 1.5 x 1.0xudt cm, the wound bed was noted as black/eschar. The intervention was to clean with normal saline, pat dry, and paint with betadine and cover with dry dressing and offload from pressure. During a review of Resident 1 ' s Progress Note dated 12/28/2024 to 1/12/2025 indicated no documented evidence that Resident 1 ' s right foot SDTI condition was reported to Physician 1 or NP 1. During a review of Resident 1 ' s Physician Order dated 1/3/2025, the order indicated a podiatry appointment was scheduled on 1/8/2025 timed at 3:30pm. During a review of Resident 1 ' s Nursing Note dated 1/8/2025 timed at 3:49 PM, the Nursing Note indicated Resident 1 returned from a Podiatry appointment with Family 1. The Note further indicated Resident 1 was not seen by the Podiatrist since the Podiatrist was not in the office. During a review of Resident 1 ' s Physician Order dated 1/8/2025, the order indicated the podiatry appointment was rescheduled for 1/13/2025 at 2:30 pm. During a review of Resident 1 ' s Physician Order dated 1/13/2025 (19 days from NP 1 ' s progress notes to refer Resident 1 to a wound specialist dated 12/25/2024), the order indicated a wound consultant appointment for Resident 1 ' s wounds on the foot was scheduled for 1/17/2025 at 1:30 pm. During a review of Resident 1 ' s Daily Skilled Note dated 1/15/2025 timed at 7:04 PM, the Note indicated under Skin/Wound Report as of 1/12/2025 showed multiple areas of concerns, including Right heel wound with increasing size and 100% necrotic tissue (dead tissue in the body that may be caused by lack of blood supply or injury), wound unstageable. Right fifth toe metatarsal with maroon/purple discoloration but no skin breakdown. Wound healing needs to be supported . The Note indicated Resident 1 has impaired skin integrity related to compromised circulation and nutritional status as evidenced by Increasing size of necrotic tissue on the heel and discoloration of the right foot. The Note indicated the facility ' s interventions included continuing Renal diet (a dietary plan designed for individuals with kidney disease), recommend liquid protein (Prostat, 30 milliliter [ml]) for wound healing and muscle maintenance, reinforce fluid restriction, offer high calorie/high protein snacks to address poor intake. The Note indicated for Skin/Wound Care, to monitor the wound status of Resident 1 regularly, Family 1 informed and well understood. During a review of Resident 1 ' s Nursing note dated 1/16/2025, the Note indicated Family 1 verbalized concerns about Resident 1 ' s ischemic wound to the right heel. The Note indicated that it was explained to Family 1 that Resident 1 was already scheduled for a wound consult for 1/17/2025 and informed Family 1 if the Wound Physician wants to proceed with further work-up, the facility will adhere to the Wound Physician ' s recommendations. The Note indicated that the TXN updates Family 1 with on a daily basis with Resident 1 ' s wound condition, as well as any new orders and interventions. The Note indicated Once again, [Family 1] was provided with a recap of what had been done with Resident 1 ' s right heel ischemic wound. The Note indicated that Family 1 was reminded that the facility continues with nutritional approaches to wound healing, offloading heels but resident keeps on removing devices and not being compliant. The Note further indicated that a Doppler Ultrasound that was performed [12/18/2024] for the bilateral lower extremities showed Resident 1 has PVD and stenosis which can delay and/or impaired wound healing. During a review of Resident 1 ' s Wound Specialist handwritten document titled Physician Orders dated 1/17/2025 timed at 2:20 PM, the document indicated Patient [Resident 1] with gangrenous changes of [Right] heel and left second toe. Ischemic (inadequate blood supply in one part of a body) and infected foot. Please admit [to the GACH] for IV [intravenous-through the vein] antibiotics and revascularization (a medical procedure aimed at restoring blood flow to a body part or organ, typically by surgical or minimally invasive methods, to address a blockage or narrowing of blood vessels). During a review of Resident 1 ' s Nursing Note dated 1/17/2025 timed at 3:12 PM, the Note indicated Resident 1 came back to the facility with Family 1 from the Wound Specialist appointment with an order to transfer Resident 1 to GACH 1 ER due to gangrenous changes of the right heel. During a review of Resident 1 ' s Nursing Note dated 1/17/2025 timed at 7:25 PM, the Note indicated Resident 1 was picked up by ambulance via gurney to transfer to GACH 1, in the presence of Family 1. During a review of Resident 1 ' s Physician Order dated 1/17/2025, the order indicated transfer Resident 1 to GACH emergency room per wound consultant for ischemic (reduced blood flow to an area of the body) and infected wound evaluation. During a review of Resident 1 ' s GACH 1 record titled ED [Emergency Department] Triage Note dated 1/17/2025 indicated Resident 1 arrived at GACH 1 ED on 1/17/2025 at 7:43 PM with a chief complaint of Lower Extremity Pain. The ED Triage Note indicated [Resident 1] presented with infection and gangrene of the right heel and left second toe. Patient [Resident 1] sent from nursing home. No fall or injury. She has diabetes and peripheral vascular disease. The ED Triage Note Physical Exam for Resident 1 indicated Resident 1 had Dry gangrene of the right heel with surrounding erythema and tenderness to palpation. Patient does have capillary refill to the toes. Left second toe with dry gangrene. The ED Triage Note ' s Medical Decision Making indicated Patient [Resident 1] presenting with gangrene of the right heel and left second toe. Lab [laboratory tests] shows leukocytosis (an increase in the number of white cells in the blood, especially during an infection), acute on chronic kidney disease, hypokalemia (low potassium level). [Resident 1] was given vancomycin and Zosyn. She [Resident 1] will be admitted . During a review of GACH 1 Right Foot X-ray date 1/17/2025 indicated an impression of Extensive vascular calcifications of peripheral arterial disease. During a review of Resident 1 ' s GACH 1 Physician History and Physical (H&P) dated 1/18/2025, indicated Resident 1 was admitted to GACH 1 due to Worsening lower extremity gangrene. The GACH 1 H&P indicated Resident 1 was unable to give any information but complained of lower extremity pain. During a review of GACH 1 ' s Interventional Radiology Consultation dated 1/18/2025, the record indicated Resident 1 was a poor historian but stated she has had an infection for about three months in her leg. The record indicated Resident 1 presented with gangrenous wounds to the feet. Unable to exam them (both feet) as [Resident 1] had severe pain with soft touch. Her [Resident 1] pain extends to both her calves bilaterally . Although she [Resident 1] appears to be a generally poor candidate for limb salvage due to her listed comorbidities, it is reasonable to try and conservatively heal her wounds depending on the severity, with wound care and angiogram (a medical imaging technique that uses X-rays to visualize blood vessels) for revascularization. During a review of GACH 1 Podiatry Consult dated 1/18/2025 timed at 5:21 PM, the Podiatry Consult indicated Resident 1 was seen at bedside with Family 1. The Podiatry Consult indicated The past few weeks her (Resident 1) toes and heel became red and discolored. [Family 1] stated that he talked to the [facility] staff who said it [toes and heel] looked okay and normal until it became black. [Resident 1] was referred to the [GACH 1] Wound Center and the Wound Physician referred Resident 1 to the GACh 1 ED for treatment. The Physical Exam indicated Non-palpable dorsalis pedis and posterior tibialis pulses bilaterally. No edema. Capillary filling time is delayed for toes 1 through 5. Digital hair growth is absent. Gangrenous changes to the distal tips of the lesser toes. Sensation is intact to touch and there is pain with palpation . Gangrenous changes to both third and fourth and fifth toes. Malodorous (an unpleasant or offensive odor, often associated with rotting or decaying matter) gangrenous right heel ulcer. Erythematous (exhibiting abnormal redness of the skin). No drainage. The exam further indicated Resident 1 ' s general appearance as No acute distress . pedal pulses absent. The Podiatry Consult further indicated under Problem List indicated severe peripheral arterial disease, diabetes mellitus with peripheral angiopathy with gangrene, gangrene of the right foot, bilateral toe gangrene. The Podiatry Consult indicated prognosis is guarded and awaiting arterial doppler and interventional radiology consultation. If there are large amounts of small vessel disease treatment with angioplasty (surgical repair or unblocking of a blood vessel), the heel may not heal and require below knee amputation. Continue offloading at this time. Order right ankle magnetic Resonance Imaging (MRI - to create detailed images of the body's internal structures) to assess heel ulcer. During a review of GACH 1 ' s Extremity Angiogram Unilateral with Intervention dated 1/22/2025, the record indicated Resident 1 ' s angiogram was performed to Resident 1 on 1/22/2025. The record indicated an impression that showed the following: 1. Chronic total occlusion of the distal superficial femoral artery successfully recanalized with balloon angioplasty. 2. Moderate popliteal and severe anterior tibial artery origin flow-limiting stenoses successfully treated 3 millimeters balloon angioplasty. 3. Severe microvascular disease of the foot. Chronically occluded peroneal and posterior tibial arteries without distal targets for recanalization (the process of restoring or reopening a blocked or narrowed vessel, particularly a blood vessel, to allow for improved blood flow). During a review of GACH 1 ' s Physician Discharge Summary documented on 1/30/2025, the Discharge Summary indicated Resident 1 was discharged from the facility on 1/29/2025. The discharge diagnoses include but not limited to acute osteomyelitis of the right foot, chronic heel ulcer, PAD, gangrene of the right foot, diabetes mellitus with peripheral angiopathy, ESRD on dialysis, obesity, malnutrition. During a review of Resident 1 ' s Certificate of Death (COD) signed by a physician on 2/20/2025, the COD indicated Resident 1 ' s date of death was 2/18/2025. The COD indicated Resident 1 ' s immediate cause (final disease or condition resulting in death) of death was sepsis. The COD indicated the list of conditions leading to the cause of death or the underlying cause of death (disease or injury that initiated the events resulting in death) were osteomyelitis, peripheral artery disease, Diabetes Mellitus type II. During a record review and concurrent interview on 4/28/25 at 10:20 am with the Treatment Nurse (TXN), the TXN state when Resident 1 ' s right heel cracked skin occurred on 11/21/2024, Resident 1 ' s right heel did not look like a PU, therefore staging was not indicated in the Change in Condition Progress Note. The TXN stated she documented the right heel as PU on Skin Evaluation PRN/Weekly dated 11/25/2024 while it looked like a cut on Resident 1 ' s right heel initially noted on 11/21/2024. During a record review and concurrent interview on 4/28/25 at 11:30 am with the TXN, the TXN stated she documented the measurement for Resident 1 ' s right heel SDTI on Skin PU Weekly dated 11/29/2024 but did not measure the right heel open wound. The TXN stated she should have measured and documented the right heel open wound. During a record review and concurrent interview on 4/28/25 at 1:20 pm The TXN stated she did not notify Physician 1 on 12/28/2024 when Resident 1 ' s right fifth toe and metatarsal PU were noted with black/eschar because Nurse Practitioner (NP) 1 visited Resident 1 on 12/25/2024 and knew about Resident 1 ' s wounds also ordered an Xray and a laboratory test. The TXN stated she thought the current wound treatment at that time was appropriate. TXN 1 stated that Resident 1 had been noncompliant with wearing the heel protector and offloading both heels. During an interview with NP 1 on 4/29/2025 at 10:40 am, NP 1 stated she had reviewed Resident 1 ' s arterial doppler of the bilateral lower extremity result on 12/19/2024. NP 1 stated that Magnetic Resonance Angiogram (MRA) and Computed Tomography Angiography (CTA) was not ordered right away because Resident 1 needed to be evaluated by a vascular surgeon. NP 1 stated We are trying to schedule for a vascular surgeon and podiatry consult. NP 1 stated that in her progress notes dated 9/24/24, she wrote that Resident 1 had a vascular physician appointment pending for Resident 1. NP 1 stated she was made aware by facility staff that Resident 1 ' s family had refused In-house Podiatry. NP 1 stated she did not have documentation of Resident 1 ' s family ' s refusal of inhouse podiatry but the facility staff noted it. NP 1 stated she did not know what happened to the pending vascular physician referral since 9/24/24. NP 1 stated she was not sure what to say why the facility did not refer Resident 1 right away when it was ordered on 12/25/2024. NP 1 stated she informed the facility ' s TXN to follow up the order for Resident 1 ' s wound specialist/consult. During a record review of Resident 1 ' s progress notes and concurrent interview with the TXN on 4/29/25 at 11:59 am, the TXN stated she was given a verbal order from NP 1 on 12/25/2024 about Resident 1 ' s podiatry and vascular physician referral but did not place the order in the resident ' s records. The TXN stated the facility did not make a referral or an appointment over the phone for Resident 1 because the phoneline was down at the GACH 1 medical group where Resident 1 needed to be referred during that time (December 2024). The TXN stated they had Resident 1 ' s Family 1 walk into the GACH 1 medical group to make the appointments for podiatry and wound physician/specialist for Resident 1. The TXN stated Family 1 was not able to make an appointment to a vascular physician during that time. The TXN stated the facility did not do anything when Family 1 was not able to make an appointment for the vascular physician. The TXN stated she could not find documented evidence documented on 12/2024 and January 2025 resident ' s records why Resident 1 was not referred to a wound specialist or vascular physician when it was written and ordered by NP 1 to follow up on 12/25/2024. During an interview with the DON on 4/29/2025 at 11:15 am, the Director of Nursing (DON) stated, the facility did not think about getting another wound specialist for Resident 1 if there was difficulty getting an appointment for Resident 1. The DON stated she could not remember why the vascular physician appointment were not made and could not find documented evidence anywhere in resident ' s records why Resident 1 was not referred to a vascular physician when it was recommended since September 2024 and December 2024. During a record review and concurrent interview on 4/29/25 at 1:40 pm with the DON, the DON stated the wound specialist referral was not scheduled immediately due to a systemwide problem experienced by the GACH 1 medical group in December 2024 and was unable to make appointments thru the GACH 1 medical group online system where Resident 1 needed to be referred to for the wound specialist in December 2024. The DON stated the facility did not make other attempts to make an appointment prior to [1/13/2025]. The DON stated she was not aware of the change in condition for Resident 1 ' s wounds on the right and left feet on 12/28/2024 compared with 12/16/2024. The DON stated Resident 1 was not referred to a different wound specialist or a vascular physician at a different medical group that was not affected by the GACH 1 systemwide problem. The DON stated she was not aware of the verbal order of NP 1 to the TXN for vascular and wound specialty referral. The DON stated the facility should have made the necessary appointments for Resident 1 and ensured care and services were not delayed. The DON stated she could not find documented evidence that a comprehensive care plan was developed for Resident 1 ' s PAD/PVD or for stenosis or occlusion/plaques found during Resident 1 ' s arterial doppler performed on 12/18/2024. The DON stated NP 1 did not point out or informed a licensed nurse about the wound specialist follow up note written in NP 1 ' s progress notes on 12/25/24, so nobody saw the note until 1/13/25, when facility staff placed the referral order in the physician progress notes. During an interview with Family[TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 143) with history of falls (move downward, typically rapidly and freely without control, from a higher to a lower level) was provided supervision, monitoring and assistance as indicated on the resident's care plan (a document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) of high risk for falls and facility's policy and procedure to prevent falls by failing to: 1. Ensure Resident 143's room was well lit and had adequate lighting and not kept dark, in accordance with the resident's care plan dated 6/8/2024, and 6/14,2024 to prevent hazards, falls and accidents. 2. Ensure Resident 143's care plan addressed high-risk factors identified on the resident's Fall Risk Evaluation dated 6/8/2024 to ensure an individualized care plan is developed that includes measurable objectives and timeframes. The care plan interventions will be developed to prevent falls by addressing the risk factors and will consider the elements of the evaluation that put the resident at risk. 3. Implement IDT's (Interdisciplinary Team, a team of staff that review and develop the resident's plan of care) recommendation and resident's care plan on 6/25/2024, to place Resident 143 on a Bowel and Bladder Schedule by offering the resident toilet use upon rising (the act of getting out of bed in the morning, or at some other time during the day), at mealtimes, at bedtimes and as needed. As a result, after the first fall in the facility on 6/25/2024, on 7/6/2024 at 4:20 AM, Resident 143 fell again on the floor with complaint of the right hip pain after the fall. An Xray (medical procedure that generate images of tissues and structures inside the body) was performed which revealed a right hip fracture (broken bone). Resident 143 was transferred to General Acute Care Hospital (GACH)'s Emergency Department (ED) on 7/6/2024 at 10:33 PM (18 hours after the resident fell on [DATE] at 4:20 AM) for further treatment and evaluation for severe, constant right hip pain. On 7/8/2024, Resident 143 had hemiarthroplasty (a surgical procedure that replaces only the ball portion of the hip joint, not the socket portion) right hip due to right femoral neck fracture (broken bone of the thigh bone near the hip joint). Findings: During a review of Resident 143's Admission Record, indicated Resident 143 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that included dementia [the loss of cognitive functioning (thinking, remembering, and reasoning) to such an extent that it interferes with a person's daily life and activities], muscle weakness, abnormality of gait (a manner of walking) and mobility (ability to move freely), osteoporosis (a condition that causes bones to become weak and lose their strength, making them break more easily than normal bones), history of fall, fractures (broken bone) of lower end of right radius (one of two major bones in the forearm from the elbow to the wrist), fracture of right pubis (broken three main bones that make up the pelvis, a structure located between the abdomen and thighs). The record indicated, on 7/11/2024, Resident 143 was readmitted to the facility with a diagnosis of the right femur (thigh bone) fracture. During a review of Resident 143's Fall Risk Evaluation, dated 6/8/2024, indicated Resident 143 was at high risk for fall due to history of one (1) to two (2) falls in the past 3 months, and was regularly incontinent (no control of bladder to urinate and bowel to have bowel movement), and had balance problem. During a review of Resident 143's Care Plan, dated 6/8/2024, indicated Resident 143 was at risk for falls related to post (after) fall at home on 6/5/2024. The Care Plan indicated to ensure Resident 143 was free from falls and serious injury, the facility will anticipate the resident's needs, by providing a safe environment with adequate lighting, and will keep personal items within reach. The interventions also indicated the facility will review information from Resident 143's past falls and will attempt to determine cause of falls, record possible root causes, and alter/remove any potential causes of fall if possible. The care plan did not address the resident being at high risk for fall as indicated in the Fall Risk Evaluation dated 6/8/2024 to ensure the care plan include measurable objectives and interventions that addressed risk factors to prevent falls. During a review of Resident 143's Care Plan, dated 6/14/2024, indicated Resident 143 was at risk for fall due to osteoporosis, with the intervention to keep inside of resident's room well lit at night. During a review of Resident 143's Bowel and Bladder Evaluation, dated 6/8/2024, indicated Resident 143 was a likely candidate for Bowel and Bladder re-training (a program for toileting schedule when the nurse promotes a patient's toileting every two hours to avoid overfilling the bladder to decrease the chance of incontinence). During a review of Resident 143's History and Physical (H&P), dated 6/9/2024, indicated Resident 143 had fluctuating (changing) capacity to understand and make decisions. During a review of Resident 143's GACH record titled Physician Discharge Summary, dated 6/10/2024, indicated Resident 143 was admitted to GACH from 6/5/2024 to 6/8/2024 due to a fall at home that resulted in fractures of the right radius and the right pubis and received nonsurgical intervention for the right ramus (branch of the arm bone) fracture and, underwent an open reduction and internal fixation (ORIF, surgical procedure to fix a severe bone fracture. Open reduction means surgery is needed to realign the bone fracture into the normal position) of the right radius. During a review of Resident 143's Minimum Data Set (MDS, a comprehensive assessment and screening tool) dated 6/13/2024, indicated Resident 143's cognitive skills (ability to think, remember and reason) were moderately impaired, was dependent (full staff performance, resident does none of the effort to complete activity) in toileting hygiene [ability to maintain perineal (relating to the area between the anus and genitals) hygiene, adjust clothes before and after voiding or having a bowel movement) and toilet transfer (ability to get on and off a toilet or commode). The MDS indicated, Resident 143 required moderate assistance (helper lifts, holds, or supports trunk or limbs but provides less than half the effort) in walking 10 feet in the room and walking at least 50 feet and make two turns. During the same review of Resident 143's MDS, dated [DATE], indicated, Resident 143 was frequently incontinent (unable to control bladder to urine and bowel to have a bowel movement), balance problem while standing/walking, and required the use of assistive devices (such as cane, walker, wheelchair) with urine and was on a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) to manage the resident's urinary continence. The MDS assessment did not address Resident 143's history of falling at home where the resident sustained a right radius and right pubis fracture on 6/5/2024 prior to admission to the facility on [DATE]. During a review of Resident 143's SBAR (Situation, Background, Assessment, Recommendation) Communication Form, (a form used for consistent process to facilitate concise, clear, focused communication in the facility), dated 6/25/2024 (no time indicated), indicated Resident 143 was found sitting on the floor outside of the bathroom and reported having pain at the level of 2/10 in pain scale (0 for no pain and 10 for severe pain) and Tylenol (pain medication) was given. During a review of Resident 143's Progress Notes-Nursing, dated 6/25/2024, documented by Licensed Vocational Nurse (LVN) 6 indicated on 6/25/2024 at approximately 1:45 AM, a Certified Nursing Assistant (CNA) (unspecified) found the resident sitting on the floor outside of bathroom. The record indicated Resident 143 stated she got up to use the bathroom without assistance. The record indicated Resident 143 received Tylenol for pain. During a review of Resident 143's Progress Notes-Nursing, dated 6/25/2024, documented by Registered Nurse (RN) 4, indicated on 6/25/2024 at 1:50 AM, a CNA (unspecified) found the resident sitting upright on the floor in front of the bathroom and 1 cm (centimeter, unit of length) skin tear was found on the resident's left knuckle of the middle finger. During a review of Resident 143's Fall Risk Evaluation, dated 6/25/2024, documented by RN 4 after the fall incident, indicated Resident 143 was at medium risk for fall due to history of 3 or more falls in the past 3 months. The record indicated Resident 143 had improved elimination status from regularly incontinent (no control bladder and bowel) to regularly continent and improved her gait/balance/ambulation that she no longer had balance problem. During a review of Resident 143's Post-Event IDT Review, dated 6/25/2024, indicated on 6/25/24 at around 1:50 AM, a facility's staff (unspecified who) found Resident 143 sitting upright on the floor in front of the bathroom. The record indicated, IDT recommended for Resident 143 to be placed on bowel and bladder scheduling by offering toileting upon rising, at mealtimes, at bedtimes and as need and the care plan needed update to include new interventions. During a review of Resident 143's Care Plan, dated 6/25/2024, the care plan indicated, Resident 143 had an actual fall and sustained a skin tear on left middle finger related to poor safety awareness. The care plan interventions indicated Resident 143 will be placed on Bowel and Bladder Scheduling by offering toilet use upon rising in bed, at mealtimes, at bedtimes and as needed (PRN). During a review of the facility's Fall Investigation, dated 6/26/2024, indicated on 6/25/24 at 1:50 AM, a CNA (unspecified) reported to RN 4 that Resident 143 fell . RN 4 went to the resident's room and found Resident 143 on the floor near the bathroom. The report indicated Resident 143 was alert and oriented, able to verbalize that she needed to use the bathroom. The report indicated Resident 143 stated she was walking then lost her balance and fell . The report also indicated the fall resulted in Resident 143's skin tear measuring one centimeter on the left knuckle of the middle finger and the IDT recommended for bowel and bladder scheduling to offer toileting upon rising, at mealtimes, at bedtimes and PRN. During a review of Resident 143's SBAR Communication Form, dated 7/6/2024, documented by LVN 6, the SBAR indicated on 7/6/2024 (unspecified time) Resident 143 had a fall that resulted in mild right hip pain. Tylenol (pain medication) was given. During a review of Resident 143's Order Summary Report, for July 2024, indicated the Resident 143's primary physician ordered on 7/6/2024 (unspecified time) to obtain X-Rays of the resident's bilateral (both sides) pelvis and hips post (after) fall. The order summary indicated to transfer the resident to General Acute Care Hospital for further evaluation. During a review of Resident 143's Progress Notes-Nursing, dated 7/6/2024, documented by LVN 6, indicated Resident 143 attempted to use the bathroom without assistance and sat down on the floor due to room being too dark. During a review of Resident 143's Progress Notes-Nursing, dated 7/6/2024, documented by RN 4, indicated on 7/6/2024 at 4:20 AM, a CNA (unspecified) found Resident 143 sitting upright on the floor next to her bed in the dark. The record indicated Resident 143 complained of 2/10 pain when performing both active (moving a part of your body without assistance) and passive (someone or something is creating the movement) range of motion (ROM) of the right lower extremity and refused to take pain medication. The record indicated Resident 143 reported that she needed to use the bathroom. The record indicated, Resident 143's primary physician was notified of incident and Xray was ordered. During a review of Resident 143's Progress Notes-Nursing, dated 7/6/2024, indicated on 7/6/2024 at approximately 6:25 PM, the ordered Xray was done on the right hip due to unwitnessed fall with result of fractured right hip. The record indicated, the result was reported to Resident 143's primary physician and was given an order to send the resident out to GACH. The record indicated Resident 143 was provided with her pain medication (Norco 5-325 mg) at approximately 9 PM. The record indicated Resident 143 was transferred to GACH at 10:15 PM. During a review of Resident 143's eMAR [electronic Medication Administration Record (MAR)]-Medication Administration Note, and MAR, dated 7/6/2024, indicated on 7/6/2024 at 11:48 AM, Resident 143 received Norco (pain medication) oral (given by mouth) tablet 5-325 mg (milligram, unit of weight) for moderate to severe pain (4-10) of the hip area with the pain level of 7/10. During a review of Resident 143's MAR, dated 7/6/2024, indicated on 7/6/2024 at 8:49 PM, Resident 143 was experiencing a level of 5/10 pain with no identified location of pain and was given Norco to relieve pain as ordered. During a review of Resident 143's GACH record titled, Physician History & Physical (H&P), dated 7/7/2024, indicated Resident 143 was admitted to GACH with a chief complaint of right hip pain after an unwitnessed fall on 7/6/2024. The record indicated, Resident 143 landed on her right hip after a mechanical fall (fall caused by outside or environmental factors) and experienced severe pain at the right hip and unable to put weight on the right leg. The record also indicated Resident 143 had sharp, constant, severe right hip pain with more pain when the resident moved her right leg. During a review of Resident 143's GACH's record titled, ED Note, dated 7/7/2024, indicated on 7/6/2023 at 10:33 PM, Resident 143 was admitted to GACH's ED for complaint of right hip pain. The record indicated Resident 143 had a history of dementia and had unwitnessed fall and Resident 143 stated that she was trying to stand up, lost her footing and fell . The record indicated on 7/6/2024 at 11:37 PM, a hip X-ray was done that showed a result of the right femoral neck fracture. The record indicated, Resident 143 required admission to GACH with orthopedic (the medical specialty that focuses on injuries and diseases of the body's bones and muscles system) consult for closed right femoral neck fracture related to fall. During a review of Resident 143's GACH's record titled, Orthopedic Surgery Consult, dated 7/7/2024, indicated on 7/6/2024, Resident 143 had a fall when she got up unsupervised injuring her right hip with immediate pain and unable to bear weight and get up. The record indicated Resident 143 needed hemiarthroplasty of the right hip due to right femoral neck fracture. During a review of Resident 143's GACH's record titled, Operative Report, dated 7/8/2024, indicated, on 7/8/2024 at 3:44 PM, Resident 143 underwent a surgical procedure for right hip hemiarthroplasty procedure. During a review of the facility's Written Investigation Summary Report (WISP), dated 7/11/2024, signed by the Director of Nurses (DON), indicated CNA 4's interview statement that on 7/6/2024, CNA 4 changed Resident 143's brief around 2:30 AM, then at 4:20 AM, while finishing care with another resident, CNA 4 heard a sound from Resident 143's room. CNA 4 quickly went inside the room and saw Resident 143 sitting on the floor next to her bed. CNA 4 instructed Resident 143 not to move as CNA 4 rushed to the nursing station and informed RN 4 of the resident's fall incident. RN 4 immediately went to assess Resident 143 while the resident was still sitting on the floor. CNA 4 and RN 4 assisted Resident 143 back to bed. During the same review of facility's WISP, dated 7/11/2024, indicated RN 4's interview statement that on 7/6/2024, RN 4 was at the nursing station around 4:20 AM when CNA 4 came to tell him that Resident 143 fell . RN 4 immediately went to the room and saw Resident 143 sitting on the floor on the right side of her bed facing the television, with her legs stretched forward. The record indicated Resident 143 got up by herself, tried to stand up, but she slipped, lost her balance, slid on the floor, landed on her buttocks and she leaned to the right side. The record indicated, RN 4 completed a body assessment and noted resident complained of pain at 2/10 on the pain scale when performing both active and passive ROM of the right lower extremity. The record indicated Resident 143 stated she wanted to use the bathroom on her own. During the same review of facility's WISP, dated 7/11/2024, indicated on 7/6/2024, Resident 143's physician was notified and ordered to obtain X-Rays to bilateral hips and pelvis due to the resident's history of previous falls. The record indicated the result from the X-ray taken in the facility on 7/6/2024 revealed in a right hip fracture and the resident was sent to GACH for further evaluations and interventions. The record indicated, on 7/8/2024 at 11:10 AM, the DON spoke with Resident 143's GACH's physician regarding Resident 143's X-ray's result of the right femoral neck fracture and that the resident was scheduled for partial right hip replacement (a surgical procedure in which the hip joint is replaced by artificial part made of metal, ceramic, or plastic) later on 7/8/2024. During a concurrent observation and interview on 7/26/2024 at 7:45 AM, Resident 143 was sitting on the wheelchair next to her bed eating breakfast. Resident 143 stated she had right hip pain when moving from one position to another. Resident 143 stated she could not recall the last time she fell in the facility. Resident 143 stated, she had a habit of going to the bathroom every time she woke up, even when she did not feel the urge to urinate. Resident 143 stated, she always wanted to go to the bathroom first when she woke up because she would not have to worry about going to the bathroom later for at least a few hours. Resident 143 stated, she preferred to go to the bathroom than use an incontinent brief and/or bedpan. Resident 143 stated who would want the bedpan and pee in bed? During an interview on 7/26/2024 at 8:45 AM with CNA 4, CNA 4 stated, on 7/6/2024, she was assigned to Resident 143 during the night shift (11PM-7AM). CNA 4 stated, she changed Resident 143's incontinent brief around 2 AM before she went on break. CNA 4 stated, she came back from break and assisted another resident around 4:20 AM when she heard a sound from Resident 143's room. CNA 4 stated, she finished up assisting the other resident before she went to check on Resident 143 who was found on the floor. CNA 4 stated, Resident 143 told her that Resident 143 wanted to go to the bathroom but did not want to bother CNA 4 and did not call for help. CNA 4 stated, Resident 143 was forgetful. CNA 4 stated, Resident 143 was not on bowel and bladder scheduling program, and she did not offer Resident 143 with scheduled toilet use upon rising in bed, at bedtimes and as needed. CNA 4 stated, at nighttime, she would change Resident 143's incontinent brief in bed or as needed, and she did not offer the resident to go to the bathroom because of Resident 143's history of falls and fractures. During an interview on 7/26/2024 at 9:13 AM with RN 4, RN 4 stated he was the RN Supervisor for the night when Resident 143 fell on [DATE]. RN 4 stated, Resident 143's room was located at the end of the hallway and about five rooms away from Nursing Station (NS) 4. RN 4 stated, around 4:20 AM, he was sitting at NS 4 charting when he was notified by CNA 4 that Resident 143 was found on the floor. RN 4 stated, Resident 143 was sitting on the floor about three (3) feet away from her bed. RN 4 stated, Resident 143 previously fell in the facility on 6/25/2024 around 1-2 AM with the same reason that she wanted to go to the bathroom. RN 4 stated, he was working during the night of 6/25/2024 and he saw Resident 143 on the floor close to the bathroom. During an interview on 7/26/2024 at 9:53 AM, LVN 6 stated she was the Charge Nurse during the shift when Resident 143 fell on [DATE]. LVN 6 stated, Resident 143 told her that she wanted to go to the bathroom but did not want to bother or wake anybody up, so she stood up by herself and walked a few steps, then she got scared and uneasy because it was too dark, so she slid on the floor. LVN 6 stated, Resident 143 had another fall on 6/25/2024 with the same reason that Resident 143 wanted to go to the bathroom. LVN 6 stated, during the nighttime, the facility was usually dark. LVN 6 stated Resident 143 was very forgetful. During an interview on 7/26/2024 at 10:37 AM with Resident 143's family member (FAM) 1, FAM 1 stated, before admitted to the facility, Resident 143 fell at home. FAM 1 stated, Resident 143 was able to walk when she was first admitted to the facility. FAM 1 stated, after falling two times in the facility, the resident was no longer able to walk. During an interview on 7/26/2024 at 11:02 AM, CNA 4 stated, she usually had the bathroom's light on and have the bathroom's door opened wide so that it was not too dark in the resident's room. CNA 4 stated, there was no other light aside from the overhead light in the hallway outside the resident's room and the resident's bathroom light. CNA 4 stated, Resident 143's bed was by the window, which was far away from the bathroom and the entrance door. During a concurrent interview and record review on 7/26/2024 at 11:40 AM with CNA 7, Resident 143's CNA Tasks for July 2024 was reviewed. CNA 7 stated, Resident 143 was not on any bowel and bladder scheduling program. CNA 7 stated, if Resident 143 was on bowel and bladder program, there would be a charting system that would remind the CNA to offer the resident to the bathroom every two hours. CNA 7 stated, there was no task to offer Resident 143 to the bathroom every two hours. CNA 7 stated, she offered Resident 143 to the bathroom when the resident requested by pressing the call light only. During a concurrent interview and record review on 7/26/2024 at 1:45 PM with LVN 7, Resident 143's CNA Tasks, and Order Summary Report for July 2024 were reviewed. LVN 7 stated, Resident 143 had no documented evidence that Resident 143 was placed on any bowel and bladder scheduling program because she did not see any documentation in the CNA tasks or physician order. During a concurrent interview and record review of Resident 143's electronic record on 7/26/2024 at 2:52 PM with the DON, Resident 143's Tasks (an electronic record used by the CNA to indicate that the resident was offered and assisted to use the toilet on scheduled time), Medication Administration Record, Care plan, and Order Summary Report for June and July 2024 were reviewed. The DON stated, there was no documented evidence that Resident 143 was placed on a bowel and bladder schedule as indicated in the care plan. The DON stated there should be a documentation in the CNA Task that the CNAs asked and offered Resident 143 to go to the bathroom every two hours so they could assist the resident to prevent fall. The DON stated, she could not find any proof that the CNAs had been offering to assist Resident 143 to the bathroom. During a review of the facility's policy and procedure (P&P) titled, Fall Management System, revised 1/2024, the P&P indicated the following information: -It is the policy of the facility to provide an environment that remains as free of accident hazards as possible. It is also the policy of the facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. -Residents with high risk factors identified on the Fall Risk Evaluation will have an individualized care plan developed that includes measurable objectives and timeframes. The care plan interventions will be developed to prevent falls by addressing the risk factors and will consider the particular elements of the evaluation that put the resident at risk. -A review of the fall incident will include investigation to determine probable causal factors. -The investigation will be reviewed by the Interdisciplinary Team. Fall IDT summary and recommendations will be documented in the resident's Clinical Record. -Resident's care plan will be updated. During a review of the facility's P&P titled, Fall Prevention - Falling STAR Program, revised 1/29/2020, the P&P indicated: -It is the policy of the facility to reduce the number and severity of falls and to identify high risk residents and take precautionary measures. -Interventions included: Appropriate toileting program to be followed, and staff to check at the beginning of every shift for correct application of safety devices.

Based on interview and record review, the facility failed to provide safety measures by assisting, and monitoring to prevent falls and injury for one of five sampled residents (Resident 1) by failing to: 1. Ensure Resident 1, who was assessed at high risk for falls was free from falls and injury when the resident fell hitting her forehead on the floor in her room on [DATE] and on [DATE], when Resident 1 slipped on her feces on the floor and fell . 2. Ensure facility staff immediately assisted Resident 1 when the resident activated the call light (communication system that link facility staff to the needs of residents) on [DATE] as indicated in the facility's policy on Responding to Call lights, and Resident 1's care plan for Risk for Falls and Actual Fall. Resident 3, (Resident 1's roommate) reported Resident 1 activated the call light and facility staff did not come in the room to assist immediately on [DATE]. These deficient practices resulted in Resident 1 losing her balance, hitting the wall, and falling onto the floor on [DATE] at 10:30 AM. Resident 1 vomited three times, then stopped responding to verbal commands (became non-responsive). [DATE] emergency services were called at 10:35AM by facility staff and chest compressions (the act of applying pressure to someone's chest to help blood flow through the heart in an emergency) were initiated. On [DATE] at 10:50 AM (20 minutes after Resident 1 was found on the floor), Resident 1 was pronounced dead. Cross referenced to F677 Findings: A review of Resident 1's Admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included urinary tract infection, abnormalities of gait (walking) and mobility, muscle weakness, and acute kidney failure (occurs when kidneys suddenly unable to filter waste products from the blood). A review of Resident 1's Fall Risk Evaluation (an assessment tool to evaluate how likely an individual is likely to fall), dated [DATE], indicated Resident 1 was evaluated at high risk for falls. A review of Resident 1's care plan for Activities of Daily Living (ADL) self-care Performance Deficit, dated [DATE], indicated Resident 1 required staff participation with transfers. The care plan indicated Resident 1 required staff assistance to wash hands, adjust clothing, clean self, transfer onto toilet, transfer off toilet and to use toilet. A review of Resident 1's care plan for Risk for Falls dated [DATE], indicated Resident 1 needs a safe environment. The care plan indicated the goal of Resident 1 to be free from falls and will not sustain serious injury through the review date. The interventions included for facility staff to be sure the resident's call light is within reach and encourage to encourage the resident to use the call light when calling for assistance. The interventions also included Resident 1 needing a safe environment and to ensure the floor was free from spills and clutter. A review of Resident 1's care plan Actual Fall dated [DATE], indicated to continue interventions with previous Risk for Falls care plan dated [DATE] and reeducated the resident to call for assistance whenever help is needed. A review of Resident 1's Minimum Data Set (MDS; a standardized assessment and care screening tool) dated [DATE], indicated the resident was severely impaired of cognition (thought process). The MDS indicated Resident 1 was assessed requiring one-person limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing support) with walking, including transfers from wheelchair to bed, vice versa, or to a standing position. The MDS indicated Resident 1 was assessed requiring extensive assistance with movement between locations inside her room, including self-sufficiency in the wheelchair. The MDS also indicated Resident 1 was occasionally incontinent (lack of involuntary control to urinate and bowel movement) of bowel and occasionally incontinent of bladder. A review of Resident 1's Progress Notes dated [DATE] timed at 10:14 AM, indicated Resident 1 was found on the floor and that Resident 1 complained of pain stating she hit her head on the floor. The Notes further indicated a bump was noted on the resident's left frontal head (forehead). A review of Resident 1's Progress Notes under Fall Committee Interdisciplinary Team (IDT) dated [DATE] at 9:47 AM, indicated on [DATE], during the morning shift, the charge nurse reported the resident bent down to pick up her cellphone when the resident fell on the floor and fell on her head. The Notes indicated Resident 1 complained of slight pain stating she (Resident 1) hit her head on the floor. The Progress Notes further indicated met and discussed Resident 1's fall incident and recommended interventions to reeducate the resident to call for assistance when help is needed, rehab (rehabilitation) department for safety training, and provide frequent visual checks every two (2) hours for 72 hours. A review of Resident 1's Progress Notes dated [DATE] at 3:21 PM, indicated Resident 1 reported waking up with blood on the pillowcase and to monitor Resident 1's right ear bleed. A review of Resident 1's Progress Notes dated [DATE] at 9:58 PM, indicated for Resident 1 to continue to be monitored from the previous fall. The Progress Notes indicated Resident 1 was reminded to use call light when needing assistance. A review of Resident 1's Progress Notes dated [DATE] timed at 3:50 PM, indicated at around 10:30 AM, authored by Licensed Vocational Nurse (LVN) 1, indicated LVN 1 was called to Resident 1's room and that Resident 3 (Resident 1's roommate) stated Resident 1 tried opening the curtain, defecated (had a bowel movement), and slipped on the feces. The Progress Notes also indicated Resident 1 had three (3) episodes of emesis (vomiting). The Notes further indicated the resident was assessed by the Registered Nurse (RN) Supervisor; alert, responsive, able to move all limbs (arms and legs). The resident then, stopped responding to verbal commands. The Progress Notes indicated that at 10:35 AM, [DATE] emergency services were called and arrived at the facility at 10:40 AM. The Progress Notes indicated the resident was moved to the bed to begin chest compressions (the act of applying pressure to someone's chest to help blood flow through the heart in an emergency). The Progress Notes indicated at 10:50 AM, Resident 1 expired. A review of Resident 3's Admission Record, indicated the resident was admitted on [DATE] with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) of the left side and muscle weakness. A review of Resident 3's MDS, dated [DATE], indicated the resident was moderately impaired of cognition. The MDS indicated Resident 3 did not have impaired communication and was able to understand others and be understood. The MDS indicated the resident required one-person extensive assistance with bed mobility, transfer, walk in room and corridor, locomotion (resident moves to and from) on unit, dressing, toilet use and personal hygiene. The MDS indicated Resident 3 was always incontinent of bladder and frequently incontinent of bowel movement. A review of Resident 3's care plan for ADL Self Care Performance Deficit, dated [DATE], indicated the resident required staff participation with personal hygiene. The care plan also indicated the resident required physical assistance with transferring. During an interview on [DATE] at 12:37 PM, Resident 3 stated she feels uneasy and very upset when the facility staff does not attend to her promptly when she pressed her call light for assistance. Resident 3 stated facility staff never come on time to assist. It would take facility staff 30 minutes to come and help to change her. During the same interview, on [DATE] at 12:37 PM, Resident 3 (Resident 1's roommate) stated her roommate (Resident 1) fell a few days ago while waiting for facility staff to assist her. Resident 3 stated on [DATE], at around 9:30 AM, she observed Resident 1 walk over to Resident 3's bedside of the room trying to open the drapes (window curtain) when Resident 1 lost her balance. Resident 3 stated she saw Resident 1 fall back against the wall and the resident slipped on the bowel movement on the floor. Resident 3 stated she recalled after Resident 1 fell hearing Resident 1 verbalized, Oh God . I pushed the button, but no one came. Resident 3 stated she also screamed and yelled for facility staff to come and assist Resident 1. Resident 3 stated Certified Nurse Assistant (CNA) 1 finally came to their room and attended to Resident 1 about an hour later around 10:30 AM. Resident 3 stated Resident 1 was bleeding from her left elbow and the treatment nurse (TN1) took care of the resident's elbow. Resident 3 stated I was yelling my head off and no one came. During the same interview, on [DATE] at 12:37 PM, Resident 3 stated she saw the licensed nurses lay Resident 1 on the bed and performed cardiopulmonary resuscitation (CPR; an emergency lifesaving procedure performed when the heart stops beating). Resident 3 stated Resident 1 died shortly after [DATE] emergency services arrived in their room. Resident 3 stated she was very upset because she did not know what to do because she was screaming and yelling for facility staff, and no one came to assist. During an interview on [DATE] at 2 PM, CNA 1 stated Resident 1 was supposed to be discharged home on [DATE] when the resident fell . CNA 1 stated Resident 1 had tendencies of getting up without waiting for facility staff assistance. On [DATE], CNA 1 stated she arrived in Resident 1's room at around 10:30 AM to respond to the activated call light in the room. CNA1 stated she was busy in another room attending to another resident prior to seeing Resident 1's call light. CNA1 stated she observed Resident 1 on the floor with feces on her legs. CNA1 stated it looked like Resident 1, Sat on her feces. CNA1 stated she called the charge nurse (LVN 1) and the TN 1. CNA1 stated Resident 1 was still alert and able to respond when she arrived in the room. CNA 1 stated LVN 1 asked her to clean Resident 1, but Resident 1 started vomiting on the chair. CNA 1 stated she assisted to clean the vomit off the resident when RN 1 arrived in Resident 1's room. CNA 1 stated the licensed nurses (LVN 1 and RN 1) stated they were going to call [DATE]. CNA 1 then stated at around 10:34 AM, CNA1 stepped out of Resident 1's room while the licensed nurses assessed Resident 1. CNA1 stated she cleaned up Resident 1's feces off the resident's legs at around 10:43 AM, prior to the arrival of the [DATE] paramedics. During an interview, on [DATE] at 2:10 PM, LVN 1 stated on [DATE], when Resident 1 fell , CNA 1 called her to Resident 1's room. LVN 1 stated when LVN 1 arrived at Resident 1's room, LVN 1 saw Resident 1 on the floor with feces on her legs and on the floor. LVN 1 stated Resident 3 informed her that Resident 1 slipped on her feces. LVN 1 stated when she was assessing Resident 1, Resident 1 vomited and then after a few minutes vomited two more times. LVN 1 stated after vomiting, Resident 1 started to lose consciousness (loss of consciousness refers to a state in which an individual lacks normal awareness of self and the surrounding environment. The individual is not responsive and will not react to any activity or stimulation). During an interview with TN 1 on [DATE] at 2:20 PM, TN 1 stated, Answering the call light should only take a minute because in case of emergencies, or if the resident needs to use the restroom. During an interview with RN 1 on [DATE] at 2:39 PM, RN 1 stated Answering a call light should take less than 5 minutes because it can be like a fall or anything urgent like that. RN 1 stated that on [DATE] when Resident 1 fell , she was notified at around 10:20 AM and went to the resident's room. RN 1 stated at 10:25 AM, Resident 1 was still responding and stated, I'm ok. RN 1 stated she did not have a chance to call the physician because she had to call [DATE] when Resident 1 started to have nausea and vomiting and became lethargic (abnormal drowsiness, lack of energy). RN 1 stated Resident 1 was high risk for falls because the resident had previous falls. A review of the facility policy titled Nursing Clinical - Responding to call light, dated ,d+[DATE] all staff can assist in answering call lights. The policy indicated that staff would provide assistance for resident's call lights. On [DATE] at 3:24 PM, during a concurrent interview and record review of the facility's policy and procedure titled Nursing Clinical - Responding to call light, dated ,d+[DATE] with the Director of Nursing (DON), the DON stated that according to the facility's policy, all staff can assist in answering call lights and that nursing staff would provide assistance. During the policy review, the DON stated answering or responding to resident's call lights should be less than five (5) minutes in case the residents required urgent assistance such as toileting or a fall. The DON stated the timeframe for facility staff to answer resident's call lights was not included in the facility's written policy on Nursing Clinical - Responding to call light, but it should had been included in the facility policy. The DON also stated the falls on [DATE] and [DATE] was not thoroughly analyzed or investigated. The DON stated a thorough investigation of resident falls helps to prevent further occurrence of falls. A review of the facility's policy and procedure titled Fall Management Program dated [DATE], indicated the facility is to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. Additionally, all resident falls in the facility are analyzed and trended through the Quality Improvement Review Process to maintain a safe environment.

Based on observation, interview, and record review, the facility failed to promote dignity and respect for one of 24 sampled residents (Resident 21) and one of six randomly selected residents (RSR (Resident 27)). Resident 21, who was continent of bowel and bladder (ability to control), but wore diapers at night, was told by the staff to urinate (act of urinating) in her diaper and was not assisted to the bathroom (Cross referenced to F 315 a). Resident 27, who used the bedpan (a receptacle used by a bedridden patient as a toilet) complained the staff would leave her on the bedpan for long periods of time, which resulted in Resident 27 having back pain. These deficient practices resulted in Residents 21 and 27's dignity and respect being denied and expressed that they felt pain, unimportant, and discomfort, and wanted to go home. Findings: a. On 11/15 /16, at 10 a.m., during a quality of life (QOL) group interview, with 11 alert residents, three (Residents 20, 21, and 22) of the 11 residents stated their call lights were not being answered timely. Resident 21 stated the facility's nursing assistants (CNAs), during the nightshift, would tell her on several occasions to urinate in her diaper when she put her call light on for assistance to go to the bathroom. Resident 21 stated an unidentified CNA told her because she was at risk for falls and did not want Resident 21 to stand up. Resident 21 stated when she urinated in her diaper it made her feel uncomfortable and unhappy. A review of Resident 21's Admission Face Sheet and clinical records indicated Resident 21 was admitted to the facility on [DATE]. Resident 21's [DIAGNOSES REDACTED]. A review of Resident 21's Minimum Data Set (MDS), a standardized resident assessment and care screening tool, dated 8/9/16, indicated Resident 21 was able to be understood and understand others. Resident 21 had a Brief Interview for Mental Status (BIMS) score of 9 (8-15=interviewable). According to the MDS, Resident 21 required limited assistance with a one-person physical assist for walking, transferring, and toilet use. On 11/16/16 at 2:55 p.m., during an interview, Resident 21 stated she urinated a lot, and had to wait long periods of time for the CNAs to come and assist her to the bathroom, which resulted in Resident 21 holding her urine and having pain. On 11/17/16 at 10:20 a.m., during an interview, Resident 21 stated the CNAs put diapers on her at night, just in case. Resident 21 also stated at night the CNAs would encourage her to urinate in her diaper, because they do not want her to get up and fall. Resident 21 stated she felt hopeless and bad. At 10:35 a.m., on 11/17/16 a registered nurse (RN 3) was interviewed regarding what his thoughts were on telling a resident, who was continent (had control) and goes to the bathroom, to urinate in their diaper. RN 3 replied that it was not right and the residents had the right to choose whether they want to go to the bathroom, use a bedpan, and/ or bedside commode (portable toilets). On 11/17/16 at 10:41 a.m., CNA 7 was asked if she was familiar with Resident 21. CNA 7 stated that she was familiar with Resident 21 and her preferences. CNA 7 was asked if she would ever encourage a resident to urinate in their diaper, CNA 7 stated, No because it was inappropriate, especially if a resident was alert, and can go to the bathroom. On 11/17/16 at 12:29 p.m., during an interview with a physician (Physician 1), a nephrologist (a physician who specialized in kidney care and treating diseases of the kidneys), was asked if holding urine can result in UTI. Physician 1 stated, It is advisable to void (urinate) frequently and older residents may have stress incontinence (the involuntary leakage of urine) so they may want to train the resident to void timely at least every four hours. Holding urine can be a complicating factor to develop a UTI. On 11/18/16 at 9:48 a.m., the director of staff development (DSD) was asked if certified nursing assistants would encourage a resident to urinate in their diaper if they normally go to the bathroom. The DSD replied, They would get in trouble. It's not appropriate. The DSD also stated that it would be an automatic write up. When the DSD was asked if residents that go to the bathroom during the day, should go to the bathroom during the night, the DSD replied, Definitely. A review of an article by the American Urological Association, titled, What Causes a UTI? indicated holding urine in the bladder can increase the risks of UTI at <http://www.urologyhealth.org/urologic-conditions/urinary-tract-infections-in-adults/causes> b. On 11/14/16 at 7:31 a.m., during the facility's initial tour, Resident 27 was observed lying on the bed. Resident 27 was alert, talking about her daily activities and expressing concerns regarding her care. Resident 27 stated, It's always cold in this room, and they don't come fast enough to change my diaper. A review of Resident 27's Admission Face Sheet indicated Resident 27 was newly admitted to the facility on [DATE]. Resident 27's [DIAGNOSES REDACTED]. A review of Resident 27's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 11/5/16, indicated Resident 27 was alert with cognition intact and had a Brief Interview for Mental Status (BIMS) score of 13 (9-15 score is interviewable). According to the MDS, Resident 27 was assessed as requiring extensive assistance with personal hygiene, dressing, bathing, and toileting. The MDS indicated Resident 27 was frequently incontinent (inability to control) of bowel and bladder. A review of Resident 27's physician's orders [REDACTED]. During an interview on 11/17/16 at 7:35 a.m., Resident 27 tearfully stated, They take a long time to change my diaper. They come much later after being called. The certified nurse assistants (CNA) leave me on the soiled bed pan for a long time, which resulted in my back hurting. I feel bad about it, I feel like a bother. I don't want to stay here, I want to go home. On 11/17/16 at 7:42 a.m., Resident 27 gestured for the surveyor to come to her bedside and she stated, Please, I need my diaper changed. A licensed vocational nurse (LVN 5) was called into Resident 27's room and was told that Resident 27 was requesting a diaper change. LVN 5 was observed changing Resident 27's diaper and a bath towel was observed in between Resident 27's legs and the diaper. The towel was soiled, but the diaper was dry. LVN 5 stated, A towel is not supposed to be there (between the legs) and I will speak to the CNA immediately. On 11/17/16 at 8:32 a.m., during a subsequent interview, LVN 5 stated that bed pans are to be taken immediately after use and it was not normal to put a towel between a resident's legs at any time. At 1:05 p.m., on 11/17/16, during an interview, CNA 9 initially denied placing a towel between Resident 27's legs, but then stated, It is a habit of mine to place a towel on top or between the resident's legs to prevent the urine from leaking onto the diaper. I should not have put a towel there. A review of the facility's policy titled, Dignity and Respect, with a revision date of 5/2007, indicated that all residents should be treated with kindness, dignity, and respect and that staff should display respect for the resident when caring for them as a constant encouragement of their individuality and dignity as human beings.

Based on observation, interview, and record review, the facility failed to ensure residents received the necessary care and services to prevent urinary tract infections ((UTIs) an infection of the urinary tract that causes urgency, pain, and a burning feeling upon urination) and were catheterized (placement or insertion of a latex or silicone tube known as a urinary catheter into the urinary bladder through the urethra, allowing urine to drain freely) only when necessary for three of 24 sampled residents (Residents 3, 21, and 23). Resident 23, who had a history of [REDACTED]./abdomen area while the urine was observed back flowing toward the bladder. Resident 21, who waited for periods of time, holding her urine, while waiting for assistance to go to the bathroom, developed four UTIs with abdominal pain within a six month period requiring antibiotic therapy. Resident 3 had no clinical indication for the need to have an indwelling urinary catheter. These failures resulted in the residents developing recurrent UTIs and having pain, which had the potential to result in urosepsis (a life-threatening bacterial infection, a complication of urinary tract infections). Findings: a. During a quality of life (QOL) group interview, conducted on 11/15/16, at 10 a.m., with 11 alert residents in attendance, Resident 21 stated the staff does not answer her call light timely resulting in her holding her urine for long periods of time, having accidents, and not getting changed on time. During the QOL interview, the ombudsman (a patient advocate) in attendance stated on her many visits to the facility she would see the CNAs (certified nurse assistant) huddled in one area talking amongst themselves. A review of Resident 21's Admission Face Sheet and clinical record indicated Resident 21 was admitted to the facility on [DATE]. Resident 21's [DIAGNOSES REDACTED]. A review of Resident 21's Minimum Data Set (MDS), a standardized resident assessment and care screening tool, dated 8/9/16, indicated Resident 21 was able to be understood and understand others. Resident 21's Brief Interview for Mental Status (BIMS) score was 9 (8-15=interviewable). According to the MDS, Resident 21 required limited assistance with a one-person physical assist for walking, transferring, and toilet use. On 11/16/16 at 2:55 p.m., during an interview, Resident 21 stated she urinated a lot and had a history of [REDACTED]. Resident 21 stated it hurts her abdomen when she had to wait long to urinate. Resident 21 stated sometimes she had to wait so long for the CNA to come and assist her to the bathroom she would wet herself. Resident 21 stated during her eight month stay at the facility, the CNAs would sometimes come in and turn off the call light and not assist her. Resident 21 stated the CNAs would say, I'll get your nurse, but no one ever comes back. When Resident 21 was asked how she felt when it happened she stated, It doesn't make me feel too good. A review of Resident 21's nurse's notes/clinical record indicated Resident 21 had four UTIs over a six month period from (4/2016-10/2016), on 4/21/16, 6/1/16, 8/21/16, and 10/10/16. A review of Resident 21's Medication Administration Record [REDACTED]. A review of Resident 21's laboratory urinalysis ((UA) analysis of urine to detect the presence of disease) results, dated 6/1/16, and timed at 11:41 a.m., indicated the leukocyte esterase (a type of enzyme produced by white blood cells (indicative of UTI)) result was out of range at 2+ (normal reference range (NRR) results should be negative). Resident 21's white blood cell ((WBC) indicative of the presence of an infection if elevated) count on the same date was elevated at 11-20 (NRR should be 0-5). A review of Resident 21's physician orders, dated 6/1/16, and timed at 9 p.m., indicated Resident 21 was started on another antibiotic. The physician ordered ceftriazone sodium (an antibiotic used to treat bacterial infections) solution one (1) gram (one thousand milligrams) intravenously ((IV) into the vein) for 10 days at bedtime for UTI. A review of Resident 21's laboratory UA results, dated 8/20/16, and timed at 6:02 p.m., indicated the leukocyte esterase was 3+ (NRR=should be negative), the WBC count was >50 (greater than 50 ), and the bacteria was moderate (NRR should be negative). According to a nurses' note, dated 8/20/16, and timed at 10:29 p.m., Resident 21 complained of lower abdominal discomfort and had dysuria (pain while urinating). According to Resident 21's MAR, for the month of 8/2016, Resident 21 received a new order for medication on 8/21/16 at 1 p.m., for [MEDICATION NAME] (an antibiotic used to treat a bacterial infections) 500 mg three times (TID) a day for 10 days. A review of Resident 21's laboratory UA results, dated 10/3/16, and timed at 8:58 a.m., indicated [MEDICATION NAME] was present (which is indicative of a UTI ) was positive (NRR=should be negative), leukocyte esterase was 3+, WBC count was >50, and the bacteria was few. Resident 21's MAR, for the month of 10/2016 indicated Resident 21 received [MEDICATION NAME] (an antibiotic used to treat a number of bacterial infections) 250-125 mg TID. A review of Resident 21's UA results, dated 10/24/16, and timed at 9:49 a.m., the leukocyte esterase was noted as trace, the WBC count was elevated at 11-20, and the bacteria was few. Resident 21's urine culture (a test to find and identify germs (usually bacteria) that may be causing a urinary tract infection), dated 10/27/16, and timed at 3:32 p.m., indicated that two organisms were present in Resident 21's urine, Escherichia coli (a germ, or bacterium, that lives in the digestive tracts of humans and animals) and Providencia stuartii (a bacterial species isolated from urinary tract infections and from small outbreaks and random cases of diarrheal disease). A review of Resident 21's MAR, for the month of 10/2016, indicated Resident 21 received [MEDICATION NAME] (a medication used to treat pain, burning, increased urination, and the increased urge to urinate) tablet 100 mg TID for dysuria (painful urination). The MAR, also indicated Resident 21 was started on cranberry tablets (is acidic and can interfere with unwanted bacteria in the urinary tract) 450 mg, every day for [MEDICATION NAME] (prevention of UTI), started on 10/26/16 at 2:38 p.m. On 11/17/16 at 10:20 a.m., during an interview, Resident 21 stated she waited at least 10-15 minutes for a CNA to assist her to the bathroom. Resident 21 stated she had pains in her abdomen sometimes and it started since she had been in the facility. Resident 21 stated, I think my pain is happening because they make me wait so long. A review of an article by the American Urological Association, titled, What Causes a UTI? indicated holding urine in the bladder can increase the risks of UTI at <http://www.urologyhealth.org/urologic-conditions/urinary-tract-infections-in-adults/causes> On 11/17/16 at 10:35 a.m., during an interview, a registered nurse (RN 3) stated a resident's call light should be answered as soon as possible, even if it was not that CNA's resident. When RN 3 was asked what could happened if a resident hold their urine for long periods of time, RN 3 stated, A backflow of urine could happen, which could cause an infection (sic). On 11/17/16 at 10:41 a.m., CNA 7 was asked how long should it take for a resident's call light to be answered after it was activated; CNA 7 stated the resident should not wait longer than one minute. CNA7 was asked if 10-15 minutes was a long time to wait for assistance, CNA 7 stated, Fifteen minutes is too long. Five minutes is too long. My coworkers should go, if I can't answer it (the call light). A review of Resident 21's care plan, dated 8/20/16, and titled, At risk for UTI related to dysuria, abdominal discomfort and scanty urine, indicated the staff's interventions included to check Resident 21 for incontinence (a loss of control of the bladder), encourage adequate fluid intake, monitor intake and output, and obtain vital signs as ordered per the facility's protocol. A review of Resident 21's care plan, dated 10/10/16, titled, On antibiotic therapy related to UTI, indicated the staff's interventions included to administer medication as ordered, and noted that any antibiotic may cause diarrhea, nausea, vomiting, anorexia, and hypersensitivity/allergic reactions, to monitor every shift for adverse (harmful) reaction, observe for possible side effects every shift, and report pertinent lab results to the physician. On 11/17/16 at 12:29 p.m., during an interview with a physician (Physician 1), a nephrologist (a physician who specialized in kidney care and treating diseases of the kidneys), was asked if holding urine can result in UTI and Physician 1 stated, It is advisable to void (urinate) frequently and older residents may have stress incontinence (the involuntary leakage of urine) so they may want to train the resident to void timely at least every four hours. Holding urine can be a complicating factor to develop a UTI. On 11/18/16 at 9:22 a.m., during a telephone interview, Resident 21's family member stated Resident 21 told him that she had been holding her urine. Resident 21's family member stated that he had witnessed the staff take a long time to take Resident 21 to the bathroom. Resident 21's family member stated Resident 21 would wait up to 15 minutes sometimes. Resident 21's family member stated, There's a trick to it. When the light goes on, they (staff) come and turn it off, because it's on a timer and leave and no one comes back to assist her (Resident 21). I have seen it. On 11/18/16 at 9:48 a.m., during an interview, the facility's director of staff development (DSD) stated that the call lights are on a timer and when the resident pushes the call light, the timer starts. A review of the facility's policy titled, Call Light/Bell, with a revision date of 5/2007, indicated the staff should answer the call light within a reasonable time (3-5 minutes), listen to the resident's request/need, and to respond to the request. b. On 11/17/16 at 9:59 a.m., Resident 23 was observed in bed with the urinary catheter bag with straw-colored urine draining in the bag and tubing. The catheter's bag was lying on top of Resident 23's chest/abdomen area. Resident 23 stated she was waiting for the certified nursing assistant (CNA 6) to come back with the lift to transfer her to the wheelchair. The urine was observed in the catheter tubing back flowing upward toward Resident 23's bladder. Resident 23 stated the CNAs always placed the catheter bag on top of her for transferring. A review of an article by Drugs.com, titled Foley Catheter Placement and Care, indicated the drainage bag should be below the level of the waist, which helps the urine from moving back up the tubing and into the bladder. The article indicated the tubing should not be looped or kinked, because it can also cause urine to back up and collect into the bladder <https://www.drugs.com/cg/foley-catheter-placement-and> care.html. At 10:03 a.m., on 11/17/16, a registered nurse (RN3) was called into Resident 23's room to see the resident's catheter bag placement above her bladder. RN 3 came to Resident 23's bedside and stated the catheter should not be higher than the bladder. Resident 23 stated, It's okay, this is how we do the transfer to the wheelchair. RN 3 stated Resident 23 had a history of [REDACTED]. On 11/17/16 at 11:05 a.m., during an interview, CNA 6 stated she had cared for Resident 23 for over three years, because the resident was particular what CNA cared for her due to the resident's pickiness and routine. CNA 6 stated she knew Resident 23's habits and how the resident liked things. CNA 6 stated she gets Resident 23 up in the wheelchair every day and she understands the importance of the urinary catheter bag placement being below the bladder to prevent backflow and UTIs, because she was just in-serviced by RN3. A review of Resident 23's Admission Face Sheet indicated Resident 23 was admitted to the facility on [DATE]. Resident 23's [DIAGNOSES REDACTED].(GERD) a disorder where the stomach's digestive juices flows back up and caused heartburn). A review of Resident 23's Minimum Data Set (MDS), an assessment and care screening tool, dated 8/15/16, indicated Resident 23 had a Brief Interview for Mental Status (BIMS) score of 14 ((cognition intact) had the ability to make decisions). According to the MDS, Resident 23 had the ability to understand and be understood. The MDS, under Section G0110 B., for Functional Status (ADL Self Performance), indicated Resident 23 required an extensive assistance of a two-plus person physical assist with bed mobility and transferring. The MDS indicated Resident 23 was incontinent (inability to control) of bowel/bladder and had a supra pubic catheter. The following are Resident 23's urine culture results: 1. On 12/29/15, a urine culture was positive for the organism Morganella Morganii. Resident 23 started on Ertapenem 1 gm IV (into the vein (used to treat severe infections of the skin, lungs, stomach, pelvis, and urinary tract)) piggy back given for seven days. 2. On 2/9/16, a urine culture was positive for the organisms Proteus mirabilis > (greater than) 100,000 colonies/ml. A handwritten note on the lab results indicated 10 doses of oral [MEDICATION NAME] 500mg were ordered until culture and sensitivity results. 3. On 3/8/16, a urine culture was positive for Proteus mirabilis (>100,000 colonies/ml) and an [MEDICATION NAME] species (50,000 colonies/ml). According to the handwritten note on the UA report, Resident 23 was started on [MEDICATION NAME] (an antibiotic) 3.375g every six hours for 10 days. 4. On 5/10/16, a urine culture was identified to have many bacteria and was positive for the organism [DIAGNOSES REDACTED] pneumoniae (>100,000 colonies/ml) and Staphylococcus aureus (50,000 colonies/ml). 5. On 6/24/16, a urine culture/chemistry indicated Resident 23's urine was positive for 3+ Leukocyte Esterase (indicative of a UTI), turbid in appearance (cloudy, opaque or thick), red blood cell >30, white blood cell >50, bacteria few, and budding yeast. The urine culture was positive for Proteus mirabilis. On 6/27/16, [MEDICATION NAME] (an antibiotic) 500 mg was started TID for 10 days. A review of Resident 23's physician's orders [REDACTED]. Another physician's orders [REDACTED]. A review of Resident 23's care plan, initiated on 6/27/16, identified Resident 23 at risk for a potential problem with receiving antibiotic therapy related to UTI [MEDICATION NAME]. The goal indicated Resident 23 would be free of any discomfort or adverse side effects of the antibiotic therapy through a review date of 11/24/16. The staff interventions included to administer medication (antibiotic) as ordered. A review of a medication regimen review (MRR) for Resident 23, conducted by the facility's pharmacist consultant (PC), dated 8/8/16, indicated that an antibiotic used for [MEDICATION NAME] was not recommended due to the risk of bacteria developing resistance to the antibiotic. The PC documented, Please evaluate for a stop date. A review of Resident 23's Medication Administration Records (MARs) for the months of 8/2016, 9/2016, and 10/2016, indicated Resident 23 continued to receive the [MEDICATION NAME] every day until 10/8/16, two months after the PC recommended discontinuing the antibiotic. On 11/17/16 at 2:15 p.m., during an interview, the Minimum Data Set Nurse (MDS Nurse 1) stated they provided teaching to Resident 23 regarding the level of the indwelling urinary catheter bag placement. MDS Nurse 1 stated Resident 23 was adamant about placing the catheter bag on her chest/abdomen area, since it was her routine throughout the years. MDS Nurse 1 stated Resident 23 stated, I have been here for over [AGE] years doing the same thing, and I am not going to change anything! The MDS Nurse 1 stated the staff met and decided to have Resident 23's urinary catheter clamped during transfer to avoid the urine backflow into Resident 23's bladder. A review of the facility's undated policy, titled, Prevention of Urinary Tract Infection/Indwelling Urinary Catheter, indicated an unobstructed downward flow will be maintained at all times unless the catheter is clamped for a procedure. The policy also indicated the urine collection bag will be maintained below the level of the bladder. c. A review of Resident 3's admission record indicated Resident 3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment and care screening tool) indicated Resident 3 required extensive assistance (weight bearing support) with daily activities, such as bed mobility, dressing, toilet use and personal hygiene. A review of Resident 3's physician's orders [REDACTED]. During an interview on 11/16/16, at 7:20 a.m., a licensed nurse (MDS 2) stated that an indwelling urinary catheter was indicated for pressure ulcers that were at Stage III or Stage IV (full thickness skin loss), but not for Stage II pressure ulcers. A review of Resident 3's care plan, dated 11/15/16, indicated the resident had a Stage II pressure ulcer on the coccyx area upon admission to the facility. The goal was for the pressure ulcer to show signs of healing and to remain free from infection. Interventions included to administer treatments as ordered and to assess/record/monitor wound healing. There was no indication for care for the use of an indwelling urinary catheter. The facility's policy and procedures, Pressure Ulcer Management Protocol, revised 5/2007, indicated that an indwelling urinary catheter may be used for wound management of Stage III or Stage IV pressure ulcer, per physician's orders [REDACTED].>

Based on interview and record review, the facility's licensed nurses failed to ensure Resident 1 was free from a significant medication error by not administering [MEDICATION NAME] (medication used to reduce the amount of ammonia (a nitrogen waste that is normally excreted in the urine; when there is excessive accumulation of Ammonia in blood it becomes toxic to the body) in blood of patient with liver disease) Solution 20 gram daily as ordered by the physician for two consecutive weeks for one of one sample resident (Resident 1). This failure resulted in Resident 1 was subjected to abnormally high Ammonia (a nitrogen waste that is normally excreted in the urine; when there is excessive accumulation of Ammonia in blood it becomes toxic to the body) blood level which placed the resident at risk for confusion, lethargy and hepatic [MEDICAL CONDITION] (a decline in the brain function, usually triggered by a buildup of toxins in the bloodstream. This occurs when the liver fails to break down toxins properly. The liver removes toxic chemicals such as ammonia from the body) and possible brain damage. Findings: According to Resident 1's admission record, the resident was originally admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), a standardized assessment and care screening tool, dated August 11, 2015, Resident 1 had intact cognitive skills for daily decision making and required extensive assistance with one or two persons-physical assistance for activities of daily living. Resident 1's Order Summary Report dated July 31, 2015, the physician's order dated July 16, 2015, indicated [MEDICAL TREATMENT] at the [MEDICAL TREATMENT] center three times a week on Monday, Wednesday and Friday at 8: 30 a.m. According to the physician's order dated July 28, 3015, Resident 1's transportation pick up time was at 8 a.m. on [MEDICAL TREATMENT] days. There was another physician's order dated July 20, 2016, to administer to Resident 1, [MEDICATION NAME] Solution 20 gram (gm) per 30 milliliter (ml) by mouth one time a day for [MEDICAL CONDITION] starting on July 21, 2015. A review of Resident 1's clinical record indicated that the [MEDICATION NAME] Solution was scheduled for administration at 9 a.m. daily. According to the Medication Administration Record [REDACTED] 1. On Monday August 3, 2015. 2. On Wednesday August 5, 2015. 3. On Friday August 7, 2015. 4. On Monday August 10, 2015. 5. On Wednesday August 12, 2015. 6. On Friday August 14, 2015. According to the MAR indicated [REDACTED]. A review of Resident's clinical record indicated there was no physician's order to hold [MEDICATION NAME] Solution administration on the [MEDICAL TREATMENT] days. On May 25, 2016, at 9 a.m., during a phone interview, the licensed vocational nurse (LVN 1) stated that Resident 1 did not want to take [MEDICATION NAME] because he would either has visitors come visit him or would keep going to the bathroom. LVN 1 stated she remembered notifying the resident's physician about lack of administration of [MEDICATION NAME] for two weeks, but could not remember if she documented about it. LVN 1 stated Resident 1 had periods of altered mental status starting on August 15, 2015. A review the licensed nurses progress notes dated August 15, 2015, at 3:32 p.m. indicated Resident 1's family member verbalized a concern regarding the resident's cognitive function. On August 5, 2016, at 12:41 p.m., during a phone interview, Resident 1's family member stated the resident was lethargic, had shortness of breath, and his stomach was getting bigger and bigger. The physician ' s order dated August 14, 2015, at 9:58 p.m., indicated that Ammonia level blood test was to be performed on August 15, 2015. A review of Diagnostic Laboratories report dated August 15, 2015, indicated Resident 1's Ammonia level was 109. The reference normal range was 16 to 53. Ammonia is a nitrogen waste compound that is normally excreted in the urine. An elevated blood ammonia level is an excessive accumulation of ammonia in the blood. An elevated blood ammonia level occurs when the kidneys or liver are not working properly, allowing waste to remain in the bloodstream. Ammonia, like many other waste products in the body can be poisonous to body cells, and an elevated blood ammonia level can affect entire body. According to studies on patients with [MEDICAL CONDITION] who had minimal hepatic [MEDICAL CONDITION] (MHE), a condition in which behavioral, psychological and neurological changes are associated with advanced liver disease, found that cognitive function and health related quality-of-life improved when they took [MEDICATION NAME] Solution. [MEDICATION NAME] is a drug used to help eliminate toxins such as Ammonia that are normally cleared by the liver. (American Association for the Study of Liver Diseases (AASLD), March 2007 https://www.aasld.org/publications/practice-guidelines). On August 16, 2015, a new physician's order indicated to increase the administration of [MEDICATION NAME] Solution of 20 gm per 30 ml from once a day to twice a day, for a total of 40 gm daily for Resident 1. On August 18, 2015, Resident 1 was transferred to the acute care hospital due to a change of condition. According to the emergency department admission note dated August 18, 2015, Resident 1 had Ammonia level of 73. The reference normal range is 16 to 53. On May 25, 2016, at 10:08 a.m., during a phone interview, Physician 1 stated I was not aware Resident 1's was not receiving [MEDICATION NAME] for two weeks. If the resident just refused or did not receive [MEDICATION NAME] once or twice would be fine but if it was a pattern then it was important to let me know. Physician 1 confirmed there was no order to hold [MEDICATION NAME] on the resident's [MEDICAL TREATMENT] days. Physician 1 stated Resident 1 should have received his [MEDICATION NAME] after returning from the [MEDICAL TREATMENT]. A review of Resident 1's clinical record indicated there was no documented evidence that [MEDICATION NAME] was scheduled for the administration before or after the resident's [MEDICAL TREATMENT]. On May 25, 2016, at 11:10 a.m., during an interview, the director of nursing (DON) confirmed that according to the MAR indicated [REDACTED]. The DON stated the physician should have been notified of [MEDICATION NAME] not being administered after three attempts to administer medication. The DON stated the [MEDICATION NAME] administration time should have been adjusted and scheduled for administration after the resident's [MEDICAL TREATMENT]. The medication nurses were not proactive enough to communicate to the registered nurse supervisor or the physician about the pattern of not administering [MEDICATION NAME]. A review of the facility's undated policy and procedure on Administration of Medications indicated the following: 1. The licensed nurse should enter an explanatory note on the reverse side of the MAR indicated [REDACTED]. The Director of Nursing Services and the Attending Physician should be notified when two medication doses were refused or not administered. 2. When a resident is away from his or her room or unavailable during the medication pass, the charge nurse should flag the MAR (i.e., paper clips, fold down, etc.). Once the medication pass has been completed, the nurse should administer medications to missed residents.

The Department received an entity reported incident (ERI) on 10/26/12, alleging a resident (Resident 1) complained of pain on the right elbow during care. On the day of the incident (10/21/12) Resident 1 reported hearing a crack in her right arm, while being lifted by a mechanical lift (SARA lift) by two certified nurse assistants (CNA) and felt pain. According to the report, after an assessment of Resident 1's right arm, the right arm was swollen with pain and the resident was unable to move the right arm. The medical doctor (MD) was notified, Dilaudid (narcotic pain medication) was given for pain, and an x-ray was ordered, and the right arm was placed in a sling. On 10/30/12, at 2:05 p.m., an unannounced complaint investigation was conducted. Based on observation, interview, and record review, the facility's staff failed to properly assess whether 1 of 1 resident (Resident 1) was appropriate for transferring with the SARA lift (mechanical lift). The facility failed to follow Resident 1's plan of care, which indicated a two-person assist was required for transferring, and adhere to the resident's and family member's request to not use a SARA lift to transfer the resident. During a transfer with a SARA lift on 10/21/12, Resident 1 repeatedly requested the staff to stop the lift because her arm was breaking, but the CNAs (CNAs 1 and 2) involved failed to stop the transfer. These failures of Resident 1 not being suited for the use of the Sara lift, resulted in Resident 1 sustaining a displaced right humerus (upper arm) spiral fracture (bone twisted and broken), being admitted to a general acute care hospital (GACH) for four days, and transferring to another skilled nursing facility (SNF) per the family's request. Findings: On 10/30/12 at 2:05 p.m., during an initial tour of the facility, Resident 1's roommate (Resident 2), who was alert and oriented, stated on the date of the incident (10/21/12), Resident 1 was being transferred and was afraid. She stated she heard the CNAs say, "Put your arms in and be still." Resident 2 stated she heard a noise then the resident state, "You broke my arm." Resident 2 stated the resident (Resident 1) would often cry out with pain in her legs. On 10/30/12, at 2:40 p.m., the CNA that transferred the resident (CNA 1) was interviewed. CNA 1 stated on 10/21/12, the resident requested to go to the bathroom. She stated she got the resident up out of bed to the edge of the bed by herself, although the resident required a two-person assist in bed mobility and transferrin, and placed the SARA lift straps around the resident's waist. CNA 1 stated she asked the housekeeper to go get help to transfer the resident. CNA 2 came to assist CNA 1 in transferring the resident. CNA 1 stated Resident 1 complained of right arm pain after the transfer. CNA 1 stated she noticed the resident's right arm was "deformed " and called the charge nurse. On 10/30/12 at 2:55 p.m., during an observation, CNA 1 demonstrated how the SARA lift was used to transfer the resident in the presence of the director of staff development (DSD). According to the observation, the lift required a resident to have a firm grip on the hand rails; use upper and lower body strength, bear weight ; have a good range of motion; and maintain posture during the transfer. On 10/30/12, at 3:07 p.m., the facility's rehabilitation director was interviewed. He stated on 10/8/12, Resident 1 was started on physical therapy (PT) due to muscle weakness and difficulty in walking. The director stated the Hoyer lift (mechanical lift) should be used for residents with osteoporosis (weak bones) and the SARA lift (mechanical lift) should not be used for non-weight bearing residents with contractures. A review of the PT evaluation and certification report for the time period of 10/9/12-11/6/12 indicated the resident was totally dependent in: bed mobility; transfers; gait and had impaired range of motion (ROM) for lower extremity (LE); poor balance with support while sitting or standing; Upper extremity support and was unable to weight shift. According to the SARA lift manufacturer's manual, dated 2011, "A resident must be able to support the majority of their own weight, otherwise injury may occur." A review of Resident 1's Admission Face Sheet on 10/30/12, at 3:30 p.m., indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of a Fall Risk Assessment, dated 10/9/12, indicated the resident had a total score of 18 (a total score above 10 represents high risk for falls). The assessment, under gait/balance, indicated the resident had a low score for balance in standing and walking, and had jerking movements. On 10/30/2012, a review of the Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 9/12/12, indicated Resident 1 was alert and oriented with clear speech and was able to communicate. According to the MDS, the resident required a two-person assist in transferring and all activities of daily living (ADL). The resident had functional impairment of both the upper and lower extremities on both sides. A review of a care plan, dated 4/2/12, the resident's risk for injury/fall, indicated the resident had potential for injury/fall due to her poor balance, limited mobility, lack of awareness, Parkinson's disease, and sensory deficits. The staff's plan of approach included assisting the resident as necessary with a two-person assist in care and transferring. The facility's investigation report, dated 10/21/12 and timed at 10:30 a.m., indicated the resident sustained [REDACTED]. Due to the worsening of the right arm pain, at 4:30 p.m., the same day, the resident was transferred to the emergency room per the physician's orders [REDACTED]. A review of the GACHs' records on 10/31/12 indicated the resident was seen at 3:30 p.m., complaining of severe right arm and elbow pain with deformity. An x-ray was ordered upon admission. The x-ray report from the GACH, dated 10/21/12, indicated the resident had a displaced spiral fracture of the distal right humerus, approximately two centimeter overriding with the distal bony fragment displaced medially. According to OrthoPod.com, a spiral fracture is also called a torsion fracture, can only be caused when a limb (arm or leg) is twisted in such a way that causes the bone to break. The resident was admitted to the GACH for four days for pain management and orthopedic treatment. Resident 1 was discharged to another skilled nursing facility (SNF) on 10/24/12. On 10/30/12, at 4:06 p.m., during an interview, the director of nursing (DON) stated a complete investigation of the incident was conducted by interviewing Resident 1, CNA 1 , CNA 2, and the charge nurse (LVN 1). The DON stated Resident 1's fracture occurred during a transfer on the SARA lift. The DON stated she was unaware of the resident having fear while using a SARA lift and had requested for the SARA lift to not be used for her transfer. The DON stated licensed nurses decides which lift (Hoyer or SARA) is to be used for each resident. On 10/31/12, at 9:10 a.m., Resident 1's other roommate (Resident 3 ), who was alert and oriented, was interviewed and stated she heard the resident scream "My arm!, My arm!" but she could not see the resident since the curtains were drawn. At 10/31/12, at 10:50 a.m., a telephone interview was conducted with CNA 2. She stated she was called to Resident 1's room by a housekeeper. CNA 2 stated the resident already had the SARA lift straps on and was sitting on the bed when she arrived to the room. CNA 2 stated she held the shower chair while the resident was transferred to the shower chair. CNA 2 stated the resident then complained of pain, but still wanted to go to the bathroom. A telephone interview was conducted with the resident's family member on 10/31/12, at 11:10 a.m.. She stated she attended an interdisciplinary meeting (IDT) in September 2012, and requested for the facility to stop using the SARA lift to transfer the resident because Resident 1 did not like it and was afraid. On 10/31/12 at 12:08 p.m., during a telephone interview, the registered nurse (RN 1), who was in charge the day of the incident, stated Resident 1 told her she heard her right arm crack while on the SARA lift and she had severe pain. RN 1 stated she called the MD and an x-ray was ordered and Dilaudid was given. She stated although the x-ray was read as no fracture initially, the resident continued to have severe pain. RN 1 stated the resident still had severe pain after being medicated for pain, so she called the MD again. The MD ordered to transfer the resident to the GACH for further evaluation. During an interview, on 10/31/12, at 1:40 p.m., a licensed vocational nurse (LVN 1) stated she was called to Resident 1's room to assess the resident's right arm after the incident on 10/21/12. LVN 1 stated, "The resident's arm was swollen with two bumps (displaced fracture) and bent while the resident complained of pain." On 10/31/12 at 3:30 p.m., Resident 1 was interviewed and a declaration obtained at another SNF where the resident was transferred after discharge from the GACH on 10/24/12. Resident 1 was observed to be in distress and verbalizing pain in the right arm, which was her dominant arm. The right arm was in an open cast (fracture brace) and a sling. The resident's hands had bilateral contractures and the resident was observed to have constant whole body tremors (Parkinson's disease). The resident was asked if she could grip a cylindrical cup and she attempted, but was unable to grab the cup due to the contractures in the hands and the tremors from Parkinson's disease. On 10/31/12 at 4:10 p.m., Resident 1 was asked if she remembered what happened to her right arm. She stated while at the other facility she had called for help to go to the bathroom and CNA 1 got her up out of the bed and placed her on the edge of the bed. The resident stated CNA 1 placed the SARA strap around the waist. The resident stated, "I told them I did not want to use that lift days before the incident, but they did not listen. My family even told them not to use it, but they told me they use it to protect themselves, not me." Resident 1 stated you have to put your hands like you are going to catch a ball then the lift is supposed to lift you in an upright (standing) position. Resident 1 stated it was hard to put her hands on the bar and lift. Resident 1 stated when the CNA pulled the cord it hurt, but she continued to pull the cord and, "I told her to stop three times and told her you broke my arm. She did not do anything, but was supposed to stop to see what happened." Resident 1 stated, "If I tell you to stop and not keep going then you should stop, and see what happened. I think this injury could have been prevented. " On 11/2/12 at 12:10 p.m., during a telephone interview, Resident 1's MD stated he was notified of the resident's injury while using a SARA lift. He stated he was not familiar with the SARA lift, but stated he could see how the fracture could occur using a lift because the resident was very weak and could not stand on her own. During a subsequent transfer demonstration of the SARA lift, in the presence of the facility's staff on 11/2/12 at 1:10 p.m.. CNA 4 demonstrated on CNA 5 how to lift and transfer a resident. CNA 5 had to tell CNA 4 to pull the belt tighter. CNA 5 was observed, and stated it required a firm grip to hold onto the lift and upper body strength to maintain her balance during the transfer. During the demonstration, CNA 3 stated Resident 1 had complained several times that she did not want to use the SARA lift. CNA 3 was asked if it was reported and she stated, "Yes, the charge nurses were made aware." CNA 4 stated Resident 1's hands were always cold, so she would wear gloves and her legs were stiff and painful. CNA 4 stated, " the resident was unable to walk or grip with hands." On 11/2/12 at 2:55 p.m., RN 2 stated, "The resident have to be able to hold on the SARA lift and use some weight bearing." RN 2 stated the decision to use a SARA lift was a nursing judgment of the residents' strength. RN 2 stated if a resident says to stop, the CNA should stop and see what happened and call the charge nurse.

The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.On 6/22/12, at 8:40 a.m., an unannounced visit was made to the facility to investigate an entity reported incident and a complaint related to Resident 1 ' s quality of care.Based on observation, interview and record review, the facility failed to ensure Resident 1, who was assessed as requiring extensive assistance and two or more person physical assist with transfer, received the necessary assistance and assistive device by failing to:1. Provide two persons assist during transfer from wheelchair to bed as assessed.2. Ensure staff used a gait belt during transfer for safety as per policy. On 4/7/12, Resident 1, while being manually transferred by one person, Certified Nursing Assistant 1 (CNA 1), from the wheelchair to bed, fell on to the floor on her knees and on 4/9/12, was diagnosed with [REDACTED].On 6/22/12, a review of the clinical record revealed the resident was a [AGE] years old female originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - standardized assessment and care planning tool) dated 3/12/12, indicated the resident had memory problems, was able to communicate, had no mood or behavioral problems, required extensive assistance with two or more person physical assist during bed mobility, transfer and locomotion, and required extensive assistance and one person physical assist with walking, eating, personal hygiene and bathing. The resident was assessed as having an unsteady balance during walking, moving from seated to standing position and surface-to-surface transfer. The resident did not have functional limitation on the range of motion (ROM) on the lower extremities. The resident used a walker and a wheelchair as mobility devices and was frequently incontinent of bladder function and occasionally incontinent of bowel function.The plan of care dated 3/16/12, was developed for the resident's activities of daily living (ADLs) deficit with need of assistance or dependence in bed mobility, transfer, locomotion and walking, poor safety judgment, unsteady gait, limited endurance and balance problems. The goal with a target date of 6/14/12, was for the resident to maintain the existing ADL self-performance level and the approaches included to provide assistance with ADL care as needed and provide the appropriate level of assistance to promote safety. Another plan of care dated 3/16/12, developed for the resident's risk of fracture and injury related to osteoporosis had a goal with a target date of 6/14/12, for the resident not to experience any fracture/injury. The approaches included to give the medication (Fosamax) as ordered and to assist the resident as needed.A Fall Risk Assessment completed on 3/14/12, documented the resident was at high risk for falls.A physician's orders [REDACTED]. According to the RNA ' s notes for the month of 3/2012 and from 4/1/12 to 4/7/12, the resident was able to walk approximately 15 feet with maximum assistance. The physician's orders [REDACTED].According to a Change In Condition Report - Post Fall/Trauma dated 4/8/12, the resident had a fall incident in her room on 4/7/12, at 8:30 p.m., and complained of pain rated 8 over 10 (8/10 - pain rating scale from zero to 10, zero indicating no pain and 10 indicating the worst possible pain) on the right knee. The physician was informed and ordered a stat (immediate) x-ray to the right knee.The x-ray result dated 4/7/12, taken at 10:52 p.m., and reported to the physician on 4/8/12, at 6:55 a.m., indicated no fracture on the right knee.On 4/9/12, timed at 10:32 a.m., a nursing note indicated the resident was identified with swelling to the right thigh, had severe pain and was unable to move the leg. The physician was informed and ordered an x-ray of the right hip at 11:30 a.m. At 3 p.m., the x-ray result reported a right femoral shaft (body of the femur) fracture. The result was relayed to the physician, who ordered the resident to be transferred to an acute care hospital for further evaluation. At 4:20 p.m., the nursing note documented the resident was transferred to the hospital via ambulance. The x-ray result of the right knee dated 4/9/12, indicated a femoral shaft fracture overlying the stem of a hip prosthesis. The bones were moderately osteopenic (a condition of subnormal mineralized bone) and the fracture appeared acute or subacute. According to the nursing notes, the Pain Assessment Flowsheet and the medication administration record (MAR) from the time of the fall (4/7/12 at 8:30 p.m.) to the time of transfer (4/9/12 at 4:20 p.m.) approximately 46 hours, the resident complained of right knee/leg pain rated from 6/10 to 8/10 and two tablets of Percocet were administered seven times. According the acute care hospital physician progress notes [REDACTED]. The plan was to immobilize the resident and give pain medications. The resident returned to the facility on [DATE], three days later, with orders for pain management. According to the facility ' s attending physician's progress note dated 4/13/12, the resident had a mechanical fall, fractured the right proximal femur, was sent to the hospital but was not a candidate for an operation and was sent back with pain medications.The significant change in status MDS assessment dated [DATE], revealed the resident was no longer ambulatory and had ROM limitation on both lower extremities. A review of the Pain Assessment Flowsheet, MAR and nursing notes revealed the resident manifested pain to the right leg/thigh almost daily since she was readmitted to the facility on [DATE] to 7/13/12, not including 4/15/12 through 4/20/12, when the resident was in the acute care hospital secondary to a low oxygen saturation (low oxygen level in the blood) and returned with [DIAGNOSES REDACTED]. From 4/21/12 to 5/28/12, (excluding 5/20/12 and 5/24/12 -5/27/12) the resident received daily IV Morphine for severe right hip pain (8-10/10). For the month of 6/2012, the resident was medicated 20 times for severe pain (8-10/10) and three times for moderate pain (4-7/10). For the month of 7/2012 the resident received Percocet two tablets for 6/10 and 8/10 pain to the right leg five times.According to the facility's Incident Investigation Form, Summary of Investigation dated 4/9/12, on 4/7/12 at 8:30 p.m., a CNA (CNA 1) assisted the resident from the wheelchair to the bed manually. The resident was able to stand up, but lost her balance while being held by the CNA. The CNA lowered the resident down on the floor on her knees. The resident also hit her head against the closet at the time. The facility's policy and procedure on Safe Transfer of a Resident dated 5/2007, indicated gait belts are assistive devices used to help ensure the safety of the resident and staff during transfers and ambulation. The procedures included to use the gait belt for all transfers if a gait belt was not contraindicated.The facility's investigation report and the clinical record did not address the use or lack of use of a gait belt during the transferring procedure that led to the resident ' s fall on 4/7/12. A review of the CNAs ' documentation from 3/20/12 to 4/7/12, revealed seven out of 38 times the resident was transferred with only one person physical assist. On 7/13/12, at 8:30 a.m., during an interview, the director of nursing stated after a fall on the knees an x-ray should include the hip especially with a resident with a history of hip fracture.On 7/13/12, at 10:40 a.m., during an interview, RNA 1 stated prior to the fall, the resident was walking with a walker and two persons assistance. On 7/13/12, at 11:42 p.m., the resident was observed in her room sitting in a wheelchair. Registered Nurse 1 (RN 1), CNA 2 and a Family Member 1 were present in the room. The resident complained of severe pain (9/10) on the right thigh and leg. She was crying and stated she could not stand it. The right knee had greenish/bluish discoloration. CNAs 2 and 3 proceeded to transfer the resident from the wheelchair to the bed using a mechanical lift. On 7/13/12, at 12:23 p.m., during an interview, Family Member 1 stated he visits the resident twice daily for lunch and dinner and prior to the fall, the resident was able to go to the bathroom and use the sink to wash her hands with the assistance of the nursing staff; however, after the fall incident, the resident was no longer able to use the bathroom. On 7/13/12, at 3:10 p.m., during an interview, RN 2 stated the CNAs were aware of the use of a gait belt during all transfers. A review of CNA 1 ' s personnel file revealed a date of hire of 3/22/12, and was terminated on 4/13/13, due to failure to follow facility ' s policy and procedures. Three attempts were made to contact CNA 1 by telephone but there was no answer and messages were not returned. The facility failed to ensure Resident 1, who was assessed as requiring extensive assistance and two or more person physical assist with transfer, received the necessary assistance and assistive device by failing to:1. Provide two persons assist during transfer from wheelchair to bed as assessed.2. Ensure staff used a gait belt during transfer for safety as per policy. On 4/7/12, Resident 1, while being manually transferred by one person, CNA 1, from the wheelchair to bed, fell on to the floor on her knees and on 4/9/12, was diagnosed with [REDACTED].The above violation presented either an imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result to Resident 1. Based on observation, interview and record review, the facility failed to ensure Resident 1, who was assessed as requiring extensive assistance and two or more person physical assist with transfer, received the necessary assistance and assistive device to prevent accident. On 4/7/12, Resident 1, while being manually transferred by one person, Certified Nursing Assistant 1 (CNA 1), from the wheelchair to bed, fell on to the floor on her knees and on 4/9/12, was diagnosed with [REDACTED]. This deficient practice resulted in the resident sustaining a right hip fracture that could not be surgically repaired, a decline in the resident's ability to walk and pain. Findings: On 6/22/12, at 8:40 a.m., an unannounced visit was made to the facility to investigate an entity reported incident and a complaint regarding Resident 1's quality of care. On 6/22/12, a review of the clinical record revealed the resident was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - standardized assessment and care planning tool) dated 3/12/12, indicated the resident had memory problems, was able to communicate, had no mood or behavioral problems, required extensive assistance with two or more person physical assist during bed mobility, transfer and locomotion, and required extensive assistance and one person physical assist with walking, eating, personal hygiene and bathing. The resident was assessed as having an unsteady balance during walking, moving from seated to standing position and surface-to-surface transfer. The resident did not have functional limitation on the range of motion (ROM) on the lower extremities. The resident used a walker and a wheelchair as mobility devices and was frequently incontinent of bladder function and occasionally incontinent of bowel function. The plan of care dated 3/16/12, was developed for the resident's activities of daily living (ADLs) deficit with need of assistance or dependence in bed mobility, transfer, locomotion and walking, poor safety judgment, unsteady gait, limited endurance and balance problem. The goal with a target date of 6/14/12, was for the resident to maintain the existing ADL self-performance level and the approaches included to provide assistance with ADL care as needed and provide the appropriate level of assistance to promote safety. Another plan of care dated 3/16/12, developed for the resident's risk of fracture and injury related to osteoporosis had a goal with a target date of 6/14/12, for the resident not to experience any fracture/injury. The approaches included to give the medication (Fosamax) as ordered and to assist the resident as needed. A Fall Risk Assessment completed on 3/14/12, documented the resident was at high risk for falls. A physician's orders [REDACTED]. According to the RNA's notes for the month of 3/2012 and form 4/1/12 to 4/7/12, the resident was able to walk approximately 15 feet with maximum assistance. The physician's orders [REDACTED]. According to a Change In Condition Report - Post Fall/Trauma dated 4/8/12, the resident had a fall incident in her room on 4/7/12, at 8:30 p.m., and complained of pain rated 8 over 10 (8/10 - pain rating scale from zero to 10, zero indicating no pain and 10 indicating the worst possible pain) on the right knee. The physician was informed and ordered a stat (immediate) x-ray to the right knee. The x-ray result dated 4/7/12, taken at 10:52 p.m., and reported to the physician on 4/8/12, at 6:55 a.m., indicated no fracture on the right knee. On 4/9/12, timed at 10:32 a.m., a nursing note indicated the resident was identified with swelling to the right thigh, had severe pain and was unable to move the leg. The physician was informed and ordered an x-ray of the right hip at 11:30 a.m. At 3 p.m., the x-ray result reported a right femoral shaft (body of the femur) fracture. The result was relayed to the physician, who ordered the resident to be transferred to an acute care hospital for further evaluation. At 4:20 p.m., the nursing note documented the resident was transferred to the hospital via ambulance. The x-ray result of the right knee dated 4/9/12, indicated a femoral shaft fracture overlying the stem of a hip prosthesis. The bones were moderately osteopenic (a condition of subnormal mineralized bone). The fracture appeared acute or subacute. According to the nursing notes, the Pain Assessment Flowsheet and the medication administration record (MAR) from the time of the fall (4/7/12 at 8:30 p.m.) to the time of transfer (4/9/12 at 4:20 p.m.) approximately 46 hours, the resident complained of right knee/leg pain rated from 6/10 to 8/10 and two tablets of Percocet were administered seven times. According the acute care hospital physician progress notes [REDACTED]. The plan was to immobilize and give pain medications. The resident returned to the facility on [DATE], three days later with orders for pain management. According to the facility's attending physician's progress note dated 4/13/12, the resident had a mechanical fall, fractured the right proximal femur, was sent to the hospital but was not a candidate for an operation and was sent back with pain medications. The significant change in status MDS assessment dated [DATE], revealed the resident was no longer ambulatory and had ROM limitation on both lower extremities. A review of the Pain Assessment Flowsheet, MAR and nursing notes revealed the resident manifested pain to the right leg/thigh almost daily since she was readmitted to the facility on [DATE] to 7/13/12, not including 4/15/12 through 4/20/12, when the resident was in the acute care hospital secondary to a low oxygen saturation (low oxygen level in the blood) and returned with [DIAGNOSES REDACTED]. From 4/21/12 to 5/28/12, (excluding 5/20/12 and 5/24/12 -5/27/12) the resident received daily IV Morphine for severe right hip pain (8-10/10). For the month of 6/2012, the resident was medicated 20 times for severe pain (8-10/10) and three times for moderate pain (4-7/10). For the month of 7/2012 the resident received Percocet two tablets for 6/10 and 8/10 pain to the right leg five times. According to the facility's Incident Investigation Form, Summary of Investigation dated 4/9/12, on 4/7/12 at 8:30 p.m., a CNA (CNA 1) assisted the resident from wheelchair to the bed manually. The resident was able to stand up, but lost her balance while being held by the CNA. The CNA lowered the resident down on the floor on her knees. The resident also hit her head against the closet at that time. The facility's policy and procedure on Safe Transfer of a Resident dated 5/2007, indicated gait belts are assistive devices used to help ensure the safety of the resident and staff during transfers and ambulation. The procedures included to use the gait belt for all transfers if a gait belt was not contraindicated. The facility's investigation report and the clinical record did not address the use or lack of use of a gait belt during the transferring procedure that led to the resident's fall on 4/7/12. A review of the CNAs' documentation from 3/20/12 to 4/7/12, revealed seven out of 38 times the resident was transferred with only one person physical assist. On 7/13/12, at 8:30 a.m., during an interview, the director of nursing stated after a fall on the knees an x-ray should include the hip especially with a resident with history of hip fracture. On 7/13/12, at 10:40 a.m., during an interview, RNA 1 stated prior to the fall, the resident was walking with a walker and two persons assist. On 7/13/12, at 11:42 p.m., the resident was observed in her room sitting in a wheelchair. Registered Nurse 1 (RN 1), CNA 2 and a Family Member 1 were present in the room. The resident complained of severe pain (9/10) on the right thigh and leg. She was crying and stated she could not stand it. The right knee had greenish/bluish discoloration. CNAs 2 and 3 proceeded to transfer the resident from the wheelchair to the bed using a mechanical lift. On 7/13/12, at 12:23 p.m., during an interview, Family Member 1 stated he visits the resident twice daily for lunch and dinner and prior to the fall, the resident was able to go to the bathroom and use the sink to wash her hands with the assistance of the nursing staff; however, after the fall incident, the resident was no longer able to use the bathroom. On 7/13/12, at 3:10 p.m., during an interview, RN 2 stated the CNAs were aware of the use of a gait belt during all transfers. A review of CNA 1's personnel file revealed a date of hire of 3/22/12, and was terminated on 4/13/13, due to failure to fallow facility's policy and procedures. Three attempts were made to contact CNA 1 by telephone but there was no answer and messages were not returned. ---------------------------------------------------------------------------------------------