Every finding on record at The Pavilion at Sunny Hills

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement the facility's infection prevention and control program in accordance with the facility's P&P for three of 34 final sampled residents (Residents 117,154, and 231). * The facility failed to ensure PT Assistant 1 had donned on the proper PPE (gown) during transfer from bed to wheelchair for Resident 117 on enhanced barrier precautions. * The facility failed to ensure LVN 8 observed proper hand hygiene during Resident 231's wound care treatment. * The facility failed to ensure facility staff did not keep/store personal belongings in the clean laundry room and no Sani-cloth disinfectant wipe containers being kept with the clean linen. * The facility failed to ensure Resident 154's urinary catheter drainage bag was not touching the floor. These failures placed the residents at risk for increased risk of infection and transmissions of diseases. Findings: Review of the facility's P&P titled Enhanced Barrier Precautions revised 1/2025 showed the facility has an established infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. - Enhanced Barrier Precautions (EBP): An infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. - Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. - EBP should be used for any residents who meet the above criteria, wherever they reside in the facility. - The staff will implement EBP for residents who are indicated when performing the following high-contact resident care activities: Dressing, bathing/showering, and transferring. 1. On 6/30/26 at 1007 hours, an observation was conducted for Resident 117 with PT Assistant 1. Resident 117's outside door had a posted sign for EBP. PT Assistant 1 was observed with bilateral gloves and was not using a gown. Resident 117 was observed lying in bed and PT Assistant 1 helped Resident 117 to sit on the edge of the bed. PT Assistant 1 bent and wrapped around his hand on Resident 117's back and transferred the resident from bed to wheelchair. Medical record review for Resident 117 was initiated on 6/29/26. Resident 117 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 117's H&P examination dated 6/22/26, showed Resident 117 did not have decision-making capacity. Review of Resident 117's Order Summary Report showed a physician's order dated 6/22/26, for enhanced barrier precautions (EBP) due to the gastrostomy tube (GT) device use. On 6/30/26 at 1011 hours, an interview was conducted with PT Assistant 1. PT Assistant 1 verified that he did not use the proper PPE when he transferred Resident 117 from bed to wheelchair. PT Assistant 1 further stated that he should have used the gown to prevent potential transmission of infection. On 7/2/26 at 0837 hours, an interview was conducted with DON. The DON was asked about the protocol when a resident was placed on EBP. The DON stated that she expected staff to wear the proper PPE when providing care for the residents. The DON verified above findings. On 7/2/26 at 1416 hours, an interview was conducted with the Administrator and Assistant Administrator. The Administrator and Assistant Administrator were informed and acknowledged the above findings. 2. Review of the facility's P&P titled Hand Hygiene revised February 2025 showed hand hygiene is always the final step after removing and disposing of personal protective equipment. The use of gloves does not replace hand hygiene procedures. Medical record Review for Resident 231 was initiated on 6/29/26. Resident was admitted to the facility on [DATE]. Review of Resident 231's Order Summary Report dated 6/30/26, showed the following physician's orders dated 6/25/26: - To cleanse left buttock extended to left ischium, and to left posterior leg deep tissue injury with normal saline, pat dry, apply skin prep and leave open to air every day. - To cleanse left buttock Stage 3 pressure injury with normal saline, pat dry, apply skin prep to wound perimeter, apply calcium alginate (wound dressing used by transforming from fiber to gel upon contact with wound fluid) to wound bed, and cover with 4X4 foam boarder dressing every day shift. - To cleanse right buttock Stage 3 pressure injury with normal saline, pat dry, apply skin prep to wound perimeter, apply calcium alginate to wound bed, and cover with 4X4 foam boarder dressing every day shift. - To cleanse right buttock extended to right ischium, and to right posterior leg deep tissue injury with normal saline, pat dry, apply skin prep and leave open to air every day. On 7/1/26 at 1122 hours, a wound care treatment observation was conducted for Resident 231 with LVN 8. LVN 8 was observed to have kept some spare gloves in her pocket. LVN 8 cleansed Resident 231's wound on the right buttocks, removed the gloves, donned new pair of gloves from her pocket, and placed the calcium alginate and dry dressing to the wound. LVN 8 washed her hands in the sink and put on a new pair of gloves. LVN 8 cleansed Resident 231's wound on the left buttocks, removed the gloves, donned new pair of gloves from her pocket, and placed the calcium alginate and the dry dressing over the wound. On 7/1/26 at 1215 hours, an interview was conducted with LVN 8. LVN 8 verified she failed to do hand hygiene after cleansing Resident 231's wounds and after removing the soiled gloves, prior to donning new gloves. LVN 8 stated she was used to keeping the pairs of gloves on her pocket and should stop this practice. On 7/2/26 at 1006 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 3. On 7/1/26 at 0756 hours, an inspection of the facility's clean laundry room was conducted with Laundry Aides 1 and 2 and a concurrent interview with the Laundry Aides and Maintenance Director. The following was identified in the clean linen area: - Staff's personal cellphone was sitting on the clean linen folding table, with direct contact to the clean linen. - Staff's personal lunch bag and purse were hanging on a hook touching clean sorting gowns. - Staff's personal plastic drinking bottle was sitting on the clean linen folding table, with direct contact to the clean linen. - A container of Sani-Cloth disinfectant wipes was left on clean linen folding table, with direct contact to the clean linen. - Staff's personal plastic water bottle was on the table touching a pile of clean residents' clothing. - A container of Sani-Cloth disinfectant wipes was on the table touching a pile of clean residents' clothing. The Maintenance Director and Laundry Aides 1 and 2 verified the above findings and stated the personal belongings and disinfectant wipes should not be near or in direct contact with the clean residents' clothing and linen. 4. On 6/29/26 at 1304 hours, during the initial tour of the facility, Resident 154 was observed in bed. Resident 154 had a urinary catheter and the drainage bag was observed to had been placed at the side of the bed and touching the floor. Medical record review for Resident 154 was initiated on 6/29/26. Resident 154 was admitted to the facility on [DATE]. Review of Resident 154's Order Summary Report dated 7/1/26, showed the following physician's order for the indwelling catheter dated 6/1/26: - For catheter bag change every week on Friday and as needed, and - For an indwelling catheter care daily and as needed. On 6/30/26 at 1429 hours, an observation and concurrent interview with CNA 3 at Resident 154 bedside was conducted. CNA 3 verified Resident 154 had an indwelling urinary catheter. CNA 3 stated she measured the urine output from the catheter bag and recorded it. CNA 3 was asked about Resident 154's catheter drainage bag touching the floor. CNA 3 verified and acknowledged the catheter bag was not placed on a basin and was directly touching the floor. On 7/1/26 at 0859 hours, an interview and concurrent medical record review for Resident 154 was conducted with the ADON. The ADON was informed of the findings. The ADON verified and stated the catheter drainage bag should not be touching the floor for infection control practices. On 7/2/26 at 1416 hours, an interview and concurrent medical record review for Resident 154 was conducted with the DON. The DON stated the catheter drainage bag should not touch the floor. The DON was informed and verified the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to maintain the essential equipment in a safe operating conditions for one of 34 final sampled residents (Resident 231) and three nonsampled resident (Resident 52, 171, and 235). * The facility failed to ensure Resident 52 and 231's the oxygen concentrator filter was free of thick, dust like particles. This failure had the potential to negatively affect the residents' respiratory health. * LVNs 4 and 11 used the non-facility issued automatic BP machines to take Resident 171 and 235's BP reading. This failure had the potential for the residents to have inaccurate BP measurements. Findings: Review of the facility's P&P titled Storage Maintenance and Handling of Oxygen revised January 2026 showed ensure any cleaning repair, or filling of oxygen equipment is performed by qualified trained staff. 1. On 6/29/26 at 1133 hours, during the initial tour of the facility, Resident 52's oxygen concentrator was at bedside. The oxygen concentrator was observed with grayish dust like particles. Medical record review for Resident 52 was initiated on 6/22/26. Resident 52 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 52's H&P examination dated 1/20/26, showed Resident 52 had no capacity to understand and make decision. On 6/29/26 at 1531 hours, an observation of Resident 52's oxygen concentrator and concurrent interview was conducted with RN 3. RN 3 verified Resident 52's oxygen concentrator had grayish dust like particles. On 7/2/26 at 1022 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 2. On 6/29/26 at 1012 hours, during the initial tour of the facility, Resident 231's oxygen concentrator was at bedside. The oxygen concentrator was observed with grayish dust like particles. Medical record Review for Resident 231 was initiated on 6/29/26. Resident 231 was admitted to the facility on [DATE]. Review of Resident 231's Order Summary Report dated 6/30/26, showed a physician's order dated 6/24/26, to administer oxygen at a rate of 2-3 liters per minute via nasal cannula continuously. On 6/29/26 at 1516 hours, an observation of Resident 231's oxygen concentrator and concurrent interview was conducted with LVN 12. LVN 12 verified Resident 231's oxygen concentrator had grayish dust like particles. On 7/2/26 at 1023 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 3. Review of the facility P&P titled Maintenance Services – General dated 11/2025 showed the purpose of the policy is to ensure the facility maintains safe, functional, and sanitary physical conditions through a scheduled maintenance program that complies with federal, state, and life safety requirements. Further review of the policy showed to maintain all essential equipment, building systems, and structures in good repair. Review Blood Pressure Monitor Instruction Manual # TMB-1598-S (undated) showed under precaution This device is intended for indoor, home use . On 6/29/26 at 0926 hours, a medication administration observation for Resident 171 was conducted with LVN 4 inside Resident 171's room. Prior to administering the medications for Resident 171, LVN 4 obtained Resident 171's BP reading using a non-facility issued automatic wrist BP machine (TMB-1598-S). The first name of LVN 4 was observed written in black ink on the non-facility issued BP machine. LVN 4 stated Resident 171's BP reading was 138/58 mmHg and the heart rate was 60 beats per minute using the non-facility issued BP machine. On 6/29/26 at 1443 hours, an interview was conducted with LVN 4. LVN 4 stated the automatic wrist BP machine belonged to her and was brought from home. LVN 4 stated the automatic wrist BP machine was bought from a store. LVN 4 stated the maintenance had not checked the BP machine to make sure it was functioning properly. 4. On 6/30/26 at 0919 hours, a medication administration observation for Resident 235 was conducted with LVN 11 inside Resident 235's room. LVN 11 stated Resident 235's BP was checked using the automatic wrist BP machine (TMB-1598-S). However, LVN 11 did not remember what Resident 235's first set of BP readings was. LVN 11 was then observed checking Resident 235's second set of BP readings using an automatic arm BP machine (Blood Pressure Monitor Model No: C02). LVN 11 stated Resident 235's BP reading was 138/80 mmHg and the heart rate of 69 beats per minute. The first name of LVN 11 was observed labeled on the non-facility issued BP machines. On 6/30/26 at 0937 hours, an interview was conducted with LVN 11. LVN 11 stated the automatic wrist BP machine (TMB-1598-S) and automatic arm BP machine (Blood Pressure Monitor Model No: C02) belongs to her and was bought from the store. LVN 11 stated the maintenance had not checked the BP machine to make sure it was functioning properly. On 7/1/26 at 1002 hours, an interview was conducted with the DON. The DON stated the facility would provide medical equipment to assess the residents and keep them in the medication carts. The DON stated they told the staff to use the facility equipment. The DON further stated the staff should not be using personal equipment brought from home. On 7/2/26 at 1010 hours, a document review and concurrent interview was conducted with the DON. The DON verified the automatic wrist BP machine (TMB-1958-S) manual showed the device was intended for home use. On 7/2/26 at 1108 hours, a follow-up interview was conducted with the DON. The DON stated the facility's resident care equipment was for industrial use and more accurate.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the informed consent for the psychotropic medications and treatments were complete for five of 34 final sampled residents (Residents 3, 6, 9, 69, and 231). * The facility failed to ensure Resident 3's informed consent for the sertraline hydrochloride (antidepressant medication), mirtazapine (antidepressant medication), Ativan (antianxiety medication), and Ativan-Benadryl-Haldol (ABH, antipsychotic medication) medications included the behavioral manifestation related to the use of the medications per physician's orders. In addition, the facility failed to ensure the informed consent for Resident 3's Ativan (antianxiety) medication included the duration for the use of the medication per physician's order. * The facility failed to ensure Resident 6's informed consent for the bupropion hydrochloride (antidepressant medication), hydroxyzine hydrochloride (antidepressant medication) and sertraline hydrochloride (antidepressant medication) medications included the behavioral manifestation related to the use of the medications per physician's orders. * The facility failed to ensure Resident 9's informed consent for the olanzapine (antipsychotic medication) medication included the behavioral manifestation related to the use of the medication as per the physician's order. * The facility failed to ensure Resident 69 informed consent for the alprazolam (antianxiety medication) medication included the behavioral manifestation related to the use of the medications per the physician's orders. * The facility failed to ensure Resident 231's informed consent for the fluoxetine hydrochloride (antidepressant medication) medication included the behavioral manifestation related to the use of the medications per the physician's orders. These failures posed the risk for the residents and their responsible parties to not have complete information and make informed decisions related to the use of psychotropic medications. Findings: Review of the facility's P&P titled Informed Consent revised 1/2026 showed the following: - The facility provides with all information that is material to an individual patient's decision concerning whether to accept or refuse any proposed treatment or procedure including the disclosure of material information for administration of psychotherapeutic drugs or physical restraints or the prolonged use of a device that may lead to the inability to regain use of a normal bodily function; - Each resident has the right to participate in their healthcare planning and decision making including the request, refusal, and/or discontinue treatment, and the right to receive written disclosure in a language they understand; and - The facility shall verify the written informed consent, obtained by the prescribing physician/LHP, is present in the medical record and specifies the disclosure of material information for proper informed consent for a prescription for psychotherapeutic drugs prior to administration, which includes: a. the reason for the treatment and the nature and seriousness of the patient's illness; and b. the nature of the procedures to be used in the proposed treatment including their probable frequency and duration. Review of the AFL 25-38.1 titled Notice of Release of Psychotherapeutic Drug Informed Consent Form dated 2/3/26, showed the facilities may use the CDPH (California Department of Public Health) Psychotherapeutic Drug Informed Consent Form or use their own in-house form as long as the in-house form contains all the data elements on the CDPH form. The form must be in use by January 1, 2026, for new residents, residents being prescribed a new psychotherapeutic drug, and residents having a psychotherapeutic drug dosage change. Review of the CDPH 9168 document titled Psychotherapeutic Drug Informed Consent Form dated 12/2025 showed to include the following psychotherapeutic drug information: drug category, drug name, dosage prescribed, frequency, duration, administration method, caution and warning summary, reason for use of the psychotherapeutic drug and benefits, the probable side effects and significant risks associated with the use of the psychotherapeutic drug, and the reasonable alternative mode(s) of treatment or possible non-pharmacological approaches that could address the resident's needs. 1. Medical record review for Resident 3 was initiated on 7/1/26. Resident 3 was readmitted to the facility on [DATE]. Review of Resident 3's H&P examination dated 2/13/26, showed Resident 3 had no capacity to understand and make decisions. Review of Resident 3's Order Summary Report showed the following physician's orders: - dated 11/13/23, to administer sertraline hydrochloride (antidepressant medication) 75 mg one tablet by mouth one time a day for depression as manifested by verbalization of sadness; - dated 10/16/25, to administer mirtazapine (antidepressant medication) 15 mg 0.5 tablet by mouth at bedtime for depression as manifested by poor intake, less than 50%; - dated 6/14/26, to administer Ativan (antianxiety medication) 0.5 mg one tablet by mouth one tablet every eight hours as needed for anxiety as manifested by verbalization of anxious for 30 days; and - dated 6/19/26, to administer Ativan-Benadryl-Haldol (ABH, antipsychotic medication) apply one ml to inner wrist in the afternoon for psychosis as manifested by disorganized thinking. a. Review of Resident 3's Antidepressant Drug Informed Consent Form dated 5/26/26, for the sertraline medication under the Reason for Use of Antidepressant Drug and Benefits section, showed the form did not include the behavior manifestation related to the use of the sertraline medication. Review of Resident 3's MAR for June and July 2026 showed Resident 3 was administered with the sertraline medication on the following dates and time: - 6/4/26 at 0900 hours; - 6/19 to 6/21/26 at 0900 hours; - 6/23 to 6/28/26 at 0900 hours; and - 7/1/26 at 0900 hours. b. Review of Resident 3's Antidepressant Drug Informed Consent Form dated 5/26/26, for the mirtazapine medication under the Reason for Use of Antidepressant Drug and Benefits section, showed the form did not include the behavior manifestation related to the use of the mirtazapine medication. Review of Resident 3's MAR for June and July 2026 showed Resident 3 was administered with the mirtazapine medication on the following dates and time: - 6/1/26 at 2100 hours; - 6/5/26 at 2100 hours; - 6/7/26 at 2100 hours; - 6/20 to 6/21/26 at 2100 hours; - 6/25 to 6/28/26 at 2100 hours; and - 6/30/26 at 2100 hours. c. Review of Resident 3's Psychotherapeutic Medication Informed Consent Form dated 1/16/26, for the Ativan medication under the Target Symptoms/Behaviors section, showed a handwritten note anxiety m/b inability to relax. In addition, the form did not show the duration for the Ativan medication. Review of Resident 3's MAR for June 2026 showed Resident 3 was administered with the Ativan medication on the following dates and time: - 6/14/26 at 1900 hours; - 6/15/26 at 1500 hours; and - 6/16/26 at 1500 hours. d. Review of Resident 3's Psychotherapeutic Medication Informed Consent Form dated 6/19/26, for the ABH medication under the Reason for Use of Psychotherapeutic Drug and Benefits section, showed the form did not include the behavior manifestation related to the use of the ABH medication. Review of Resident 3's MAR for June and July 2026 showed Resident 3 was administered with the ABH medication on the following dates and time: - 6/20 to 6/30/26 at 1400 hours; and - 7/1/26 at 1400 hours. 2. Medical record review for Resident 6 was initiated on 7/1/26. Resident 6 was readmitted to the facility on [DATE]. Review of Resident 6's H&P examination dated 9/24/25, showed Resident 6 had no capacity to understand and make decisions. Review of Resident 6's Order Summary Report showed the following physician's orders: - dated 3/14/26, to administer bupropion hydrochloride (antidepressant medication) 100 mg one tablet by mouth three times a day for depression as manifested by verbalization of sadness; - dated 3/14/26, to administer hydroxyzine hydrochloride (antidepressant medication) 25 mg one tablet by mouth two times a day for anxiety as manifested by restlessness; and - dated 3/14/26, to administer sertraline hydrochloride (antidepressant medication) 100 mg two tablets by mouth one time a day for depression as manifested by tearfulness. a. Review of Resident 6's Antidepressant Drug Informed Consent Form dated 3/14/26, for the bupropion medication under the Reason for Use of Antidepressant Drug and Benefits section, showed the form did not include the behavior manifestation related to the use of bupropion medication. Review of Resident 6's MAR for June and July 2026 showed Resident 6 was administered with the bupropion medication on the following dates and time: - 6/1, 6/3, 6/5, 6/7, 6/8, 6/10, 6/12, 6/13, 6/14, 6/15, 6/17, 6/18, 6/19, 6/21, 6/24, 6/26, 6/28, and 6/29/26 at 0900 hours and 1300 hours; - 6/1 to 6/30/26 at 1700 hours; and - 7/1/26 at 0900 hours and 1300 hours. b. Review of Resident 6's Psychotherapeutic Medication Informed Consent Form dated 3/14/26, for the hydroxyzine medication under the Reason for Use of Psychotherapeutic Drug and Benefits section, showed the form did not include the behavior manifestation related to the use of hydroxyzine medication. Review of Resident 6's MAR for June and July 2026 showed Resident 6 was administered with hydroxyzine medication on the following dates and time: - 6/1, 6/3, 6/6, 6/7, 6/8, 6/10, 6/12, 6/13, 6/14, 6/15, 6/17, 6/18, 6/19, 6/21, 6/24, 6/26, 6/28, and 6/29/26 at 0900 hours; - 6/1 to 6/30/26 at 1700 hours; and - 7/1/26 at 0900 hours. c. Review of Resident 6's Antidepressant Drug Informed Consent Form dated 3/14/26, for the sertraline medication under the Reason for Use of Antidepressant Drug and Benefits section, showed the form did not include the behavior manifestation related to the use of the sertraline medication. Review of Resident 6's MAR for June and July 2026 showed Resident 6 was administered with sertraline medication on the following dates and time: - 6/1, 6/3, 6/6, 6/7, 6/8, 6/10, 6/12, 6/13, 6/14, 6/15, 6/17, 6/18, 6/19, 6/21, 6/24, 6/26, 6/28, and 6/29/26 at 0900 hours; and - 7/1/26 at 0900 hours. 3. Medical record review for Resident 69 was initiated on 7/1/26. Resident 69 was readmitted to the facility on [DATE]. Review of Resident 69's H&P examination dated 6/5/25, showed Resident 69 had the capacity to make decisions. Review of Resident 69's Order Summary Report showed a physician's order dated 5/30/26, to administer alprazolam (antianxiety medication) 0.5 mg one tablet by mouth every eight hours as needed for anxiety as manifested by inability to relax for 90 days. Review of Resident 69's Psychotherapeutic Medication Informed Consent Form dated 4/7/26, for the alprazolam medication under the Reason for Use of Psychotherapeutic Drug and Benefits section, showed the form did not include the behavior manifestation related to the use of alprazolam medication. Review of Resident 69's MAR for June and July 2026 showed Resident 69 was administered with the alprazolam medication on the following dates and time: - 6/2 to 6/4/26 at 2000 hours; - 6/8 to 6/12/26 at 2000 hours; - 6/13/26 at 1520 hours; - 6/14 to 6/17/26 at 2000 hours; - 6/22 to 6/23/26 at 2000 hours; - 6/25/26 at 2030 hours; - 6/26 to 6/28/26 at 2000 hours; and - 6/29/26 at 2007 hours 4. Medical record review for Resident 231 was initiated on 7/1/26. Resident 231 was admitted to the facility on [DATE]. Review of Resident 231's MDS assessment dated [DATE], showed Resident 231 was cognitively intact. Review of Resident 231's Order Summary Report showed a physician's order dated 6/24/26, to administer fluoxetine hydrochloride (antidepressant medication) 20 mg one capsule by mouth one time a day for depression as manifested by tearfulness. Review of Resident 231's Antidepressant Drug Informed Consent Form dated 6/24/26, for the fluoxetine medication under the Reason for Use of Antidepressant Drug and Benefits section, showed the form did not include the behavior manifestation related to the use of fluoxetine medication. Review of Resident 231's MAR for June and July 2026 showed Resident 231 was administered with the fluoxetine medication on 6/25 to 6/29/26 at 0900 hours, and 7/1/26 at 0900 hours. On 7/2/26 at 1000 hours, an interview and concurrent medical record review for Residents 3, 6, 69, and 231 was conducted with the ADON. The ADON verified the above findings for Residents 3, 6, 69, and 231. The ADON stated the informed consent for the psychotropic medication should include the indications, frequency, and the duration for the use of the medication as per the physician's order. On 7/2/26 at 1339 hours, an interview was conducted with the DON. The DON stated the informed consent for the psychotropic medication should show the complete indications for the prescribed medication as per the physician's order. The DON was informed and acknowledged the above findings for Residents 3, 6, 69, and 231. 5. Medical record review for Resident 9 was initiated on 6/29/26. Resident 9 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 9's MDS assessment dated [DATE], showed Resident 9 had severely impaired cognition. Review of Resident 9's Order Summary Report dated 7/1/26, showed a physician's order dated 8/28/25, to administer olanzapine (antipsychotic medication) 2.5 mg one tablet by mouth at bedtime for psychotic disorder (severe mental illnesses characterized by disruptions in thought and perception that cause individuals to lose touch with reality) manifested by disorganized thinking. Review of Resident 9's Psychotherapeutic Drug Informed Consent Form dated 3/26/26, for the olanzapine medication under the Reason for Use of Psychotherapeutic Drug and Benefits section, showed Psychosis was selected. The form did not include the specific behavior manifestation of disorganized thinking related to the use of the olanzapine medication. On 7/1/26 at 1119 hours, an interview and concurrent medical record review for Resident 9 was conducted with LVN 7. LVN 7 verified Resident 9's informed consent form for the olanzapine medication did not show the behavior manifestation related to the use of the olanzapine medication. On 7/2/26 at 0955 hours, an interview was conducted with the DON. The DON stated the informed consent for the use of psychotropic medication should include: the psychotropic medication, class, ordered dose, route, frequency, duration, and the indication of use. When asked if the specific manifested behavior should be included in the informed consent for each resident, the DON stated the consent did not show to document the manifested behavior. When asked if the manifested behavior should be included in the informed consent as part of the indications, or reason for the use of the psychotropic medication, the DON did not answer. On 7/2/26 at 1420 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary services on the formulation of an advance directive was provided for four of seven final sampled residents (Residents 41, 225, 231, and 232) reviewed for advance directive. * The facility failed to follow up the advance directive status after providing the educational materials to Residents 41, 231, and 232 and/or the residents' representative. In addition, the facility failed to ensure assistance in the formulation of an advance directive was offered to Residents 41, 231, and 232. * The facility failed to provide Resident 225's representative with the written information regarding the rights to formulate an advance directive. These failures posed a risk for not providing the care and services based on the residents wishes. Findings: Review of the facility's P&P titled Advance Directive revised on 1/2026 showed the residents have the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. The facility informs residents in writing of their right to formulate an advanced directive and the facility's policies on advance directives. 1. Medical record review for Resident 41 was initiated on 6/29/26. Resident 41was admitted to the facility on [DATE]. Review of Resident 41's POLST dated 6/15/26, showed Resident 41 had no advanced directive. Review of Resident 41's Social Services Evaluation – Initial dated 6/16/26, showed the advanced directive was not offered. Review of Resident 41's MDS assessment dated [DATE], showed Resident 41's BIMS score was 9, indicating the resident's cognition was moderately impaired. Review of Resident 41's Progress Note dated 6/26/26, showed Resident 4 had fluctuating capacity to understand and make decision. On 6/30/26 at 1431 hours, an interview and concurrent medical record review for Residents 41 was conducted with Social Services Coordinator 3. Social Services Coordinator 3 verified the above findings and was unable to show documentation indicating the assistance was offered in formulating an advanced directive to the resident's representative. Social Services Coordinator 3 further stated he provided the educational materials; however, he was not able to follow up as to whether Resident 41 had accepted or declined. On 7/2/26 at 1019 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 2. Medical record review for Resident 231 was initiated on 6/29/26. Resident 231 was admitted to the facility on [DATE]. Review of Resident 231's POLST dated 6/24/26, showed Resident 231 had no advanced directive. Review of Resident 231's Social Services Evaluation – Initial dated 6/25/26, showed the advanced directive was not offered. Review of Resident 231's Progress Note dated 6/26/26, showed Resident 231's baseline cognition was good. Review of Resident 231's MDS assessment dated [DATE], showed Resident 231's BIMS score was 14, indicating the resident's cognition was intact. On 6/30/26 at 1425 hours, an interview was conducted with Resident 231. Resident 231 stated she did not recall whether she had been offered assistance in formulating an advanced directive. On 6/30/26 at 1436 hours, an interview and concurrent medical record review for Resident 231 was conducted with Social Services Coordinator 3. Social Services Coordinator 3 verified the above findings and was unable to show documentation that assistance was offered in formulating an advanced directive to Resident 231. Social Services Coordinator 3 further stated he provided the educational materials; however, he was not able to follow up as to whether Resident 231 had accepted or declined. On 7/2/26 at 1054 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 3. Medical record review for Resident 232 was initiated on 6/30/26. Resident 232 was admitted to the facility on [DATE]. Review of Resident 232's Progress Notes dated 6/29/26, showed Resident 232 had the capacity to make decision. Review of Resident 232's Social Services Evaluation – Initial dated 6/29/26, showed advanced directive was not offered. Further review of Resident 232's medical record failed to show documentation assistance in formulating an advance directive was offered to Resident 232. On 6/30/26 at 1436 hours, an interview and concurrent medical record review for Resident 232 was conducted with Social Services Coordinator 3. Social Services Coordinator 3 verified the above findings and was unable to show documentation that assistance was offered in formulating an advance directive to Resident 232. Social Services Coordinator 3 further stated he provided the educational materials; however, he was not able to follow up as to whether Resident 232 accepted or declined. On 7/2/26 at 1006 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 4. Medical record review for Resident 225 was initiated on 6/29/26. Resident 225 was admitted to the facility on [DATE]. Review of Resident 225's H&P examination dated 6/29/26, showed Resident 225 had no capacity to understand and make decisions. Review of Resident 225's medical record failed to show documented evidence if the information for the advance directive was provided to Resident 225's representative. In addition, there were no documented assessment and evaluation for the advance directive. On 7/1/26 at 1002 hours, an interview and concurrent medical record review for Resident 225 was conducted with the SSD. The SSD stated he was responsible to ask for a copy of the advance directive of the resident upon admission, provide the advance directive form and coordinate with the Ombudsman for assistance for the formulation of the advance directive. The SSD stated he scheduled to meet with Resident 225's family member. The SSD stated he spoke with Resident 225's family member and asked for the AD information the day after the resident was admitted to the facility. When asked if he documented the conversation with Resident 225's family member, the SSD verified and acknowledged he did not document the conversation with Resident 225's family member about the AD of the resident. The SSD verified and acknowledged the POLST and AD were not completed. On 7/2/26 at 1416 hours, an interview and concurrent medical record review for Resident 225 was conducted with the DON. The DON stated she expected the AD to be completed when the resident was admitted to the facility to know the code status of the resident. The DON was informed and verified the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the residents were free from unnecessary psychotropic drugs for one of 34 final sampled residents (Resident 226) and four of five residents (Residents 3, 6, 9, and 69) reviewed for unnecessary medications. * The facility failed to ensure nonpharmacological interventions were provided prior to the use of Ativan (antianxiety), mirtazapine (antidepressant), and sertraline (antidepressant) medications for Resident 3. The facility failed to ensure Resident 3 was monitored for side effects related to the use of the mirtazapine medication. In addition, the facility failed to ensure the behavior related to the use of the sertraline medication was monitored for Resident 3. * The facility failed to ensure nonpharmacological interventions were provided prior to the use bupropion (antidepressant), hydroxyzine (antidepressant), and sertraline (antidepressant) medications for Resident 6. * The facility failed to ensure Resident 9's orthostatic blood pressure were accurately monitored as ordered by the physician for the use olanzapine (antipsychotic) medication. * The facility failed to ensure nonpharmacological interventions were provided prior to the use of alprazolam (antianxiety) medication for Resident 69. * The facility failed to ensure Resident 226's orthostatic blood pressure was accurately monitored as ordered by the physician for the use of the olanzapine (antipsychotic) medication. These failures had the potential for the residents to experience adverse effects from the psychotropic medications, not providing the correct data to the prescriber to adjust the dosage of the medications and to negatively impact the residents' well-being. Findings: Review of the facility's P&P titled Dignity and Respect Psychoactive Medications dated 1/2025 showed the following: - The resident has a right to be treated with respect and dignity including the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms; - The practitioner shall determine that the medication(s) is appropriate to treat a resident's specific, diagnosed, and documented condition and the medication(s) is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s); - The facility staff shall monitor for, and address, symptoms consistent with prolonged sedation from the use of psychotropic medications (e.g., excessive sleeping, drowsiness, withdrawal, decreased participation in activities); - Facility staff will monitor for adverse side effects associated with the use of psychotropic medications, including but not limited to, sedation, such as sleeping during hours that he/she would not ordinarily sleep; withdrawal from activities and socializing; loss of autonomy and dignity; confusion, cognitive decline, and depression; weight loss, decline in skin integrity, or continence level; and/or decline in physical functioning including an increased dependence in activities of daily living; - These effects may result in convenience for the staff, as the resident may require staff to exert less effort than previously. Even if a medication was initially administered for a medical symptom, the continued administration of a medication in the absence of such symptom, which sedates a resident or otherwise makes it easier to care for them, would be deemed a chemical restraint; - The use of non-pharmacological approaches shall be attempted, unless clinically contraindicated, to minimize the need for psychotropic medications, use the lowest possible dose, or discontinue the medications; - The facility shall ensure documentation in the resident's medical record that the facility has attempted behavioral (nonpharmacological) interventions, and that these interventions have been deemed clinically contraindicated when the resident is prescribed psychotropic medications, regardless of whether the medication is approved for the resident's condition; and - The facility's medication management process focuses on recognition or identification of the resident's problem, completion of the assessment, diagnosis, attempted root cause identification, management, and treatment through non-pharmacological interventions when possible, monitoring, and revising interventions to improve the resident's quality of life. 1. Medical record review for Resident 3 was initiated on 7/1/26. Resident 3 was readmitted to the facility on [DATE]. Review of Resident 3's H&P examination dated 2/13/26, showed Resident 3 had no capacity to understand and make decisions. Review of Resident 3's Order Summary Report showed the following physician's orders: - dated 6/24/22, for sertraline: monitor episodes of depression as manifested by verbalization of sadness, every shift; - dated 11/13/23, to administer sertraline hydrochloride 75 mg one tablet by mouth one time a day for depression as manifested by verbalization of sadness; - dated 12/26/23, for mirtazapine: nonpharmacological approach attempted prior to administration of anti-depression: (1) Encourage to verbalize feelings(needs/concern); (2) Encourage family to participate in care; (3) Encourage to attend daily activities; (4) Provide a quiet & calm environment with diversion like listening to music/watching TV; (5) Teach resident relaxation techniques or deep breathing exercises; (6) Redirect & provide gentle reality orientation; (7) Other; every shift; - dated 12/26/23, for sertraline: Nonpharmacological approach attempted prior to administration of anti-depression: (1) Encourage to verbalize feelings(needs/concern); (2) Encourage family to participate in care; (3) Encourage to attend daily activities; (4) Provide a quiet & calm environment with diversion like listening to music/watching TV; (5) Teach resident relaxation techniques or deep breathing exercises; (6) Redirect & provide gentle reality orientation; (7) Other; every shift; - dated 10/16/25, to administer mirtazapine 15 mg 0.5 tablet by mouth at bedtime for depression as manifested by poor intake, less than 50%; - dated 11/24/25, for mirtazapine/sertraline: monitor side effects of anti-depressant agent every shift. Chart 0 for none or use first letters hdtas h= headache; d= dizziness; t= tremors; d= dry mouth; a= anorexia; d= diarrhea; s= sweating; every shift; - dated 12/19/25, for Ativan: Nonpharmacological approach attempted prior to administration of anti-anxiety medication: (1) Encourage to verbalize feelings(needs/concern); (2) Encourage family to participate in care; (3) Encourage to attend daily activities; (4) Provide a quiet & calm environment with diversion like listening to music/watching TV; (5) Teach resident relaxation techniques or deep breathing exercises; (6) Redirect & provide gentle reality orientation; (7) Other; every shift; and - dated 6/14/26, to administer Ativan 0.5 mg one tablet by mouth one tablet every eight hours as needed for anxiety as manifested by verbalization of anxious for 30 days. Review of Resident 3's MAR for June and July 2026 showed the following: a. Resident 3 was administered with the Ativan medication on the following dates and times: - 6/14/26 at 1900 hours; - 6/15/26 at 1500 hours; and - 6/16/26 at 1500 hours. Further review of Resident 3's medical records failed to show documented evidence the nonpharmacological interventions were provided prior to the administration of the Ativan medication on the dates and time above. b. Resident 3 was administered mirtazapine medication on 6/5, 6/20, 6/25, 6/26, 6/27, 6/28, and 6/30/26 at 2100 hours. Further review of Resident 3's medical records failed to show documented evidence the nonpharmacological interventions were provided prior to the administration of mirtazapine medication on the dates and times above. In addition, the resident was not monitored for the side effects of the mirtazapine medication on 6/30/26, in the evening shift. c. Resident 3 was administered with sertraline medication on 6/19, 6/20, 6/21, and 6/23 to 6/28/26 at 0900 hours, and on 7/1/26 at 0900 hours. Further review of Resident 3's medical records failed to show documented evidence the nonpharmacological interventions were provided prior to the administration of sertraline medication on the dates and times above. In addition, the resident was not monitored for the behavior related to the use of sertraline medication on 6/30/26, in the evening shift. 2. Medical record review for Resident 6 was initiated on 7/1/26. Resident 6 was readmitted to the facility on [DATE]. Review of Resident 6's H&P examination dated 9/24/25, showed Resident 6 had no capacity to understand and make decisions. Review of Resident 6's Order Summary Report showed the following physician's orders: - dated 3/14/26, to administer bupropion hydrochloride 100 mg one tablet by mouth three times a day for depression as manifested by verbalization of sadness; - dated 3/14/26, to administer hydroxyzine hydrochloride 25 mg one tablet by mouth two times a day for anxiety as manifested by restlessness; - dated 3/14/26, to administer sertraline hydrochloride 100 mg two tablets by mouth one time a day for depression as manifested by tearfulness; - dated 3/14/26, for sertraline/bupropion: Nonpharmacological approach attempted prior to administration of anti-depression medication: (1) Encourage to verbalize feelings(needs/concern); (2) Encourage family to participate in care; (3) Encourage to attend daily activities; (4) Provide a quiet & calm environment with diversion like listening to music/watching TV; (5) Teach resident relaxation techniques or deep breathing exercises; (6) Redirect & provide gentle reality orientation; (7) Other; every shift; and - dated 3/14/26, for hydroxyzine: Non-pharmacological approach attempted prior to administration of anti-anxiety medication: (1) Encourage to verbalize feelings(needs/concern); (2) Encourage family to participate in care; (3) Encourage to attend daily activities; (4) Provide a quiet & calm environment with diversion like listening to music/watching TV; (5) Teach resident relaxation techniques or deep breathing exercises; (6) Redirect & provide gentle reality orientation; (7) Other; every shift; Review of Resident 6's MAR for June and July 2026 showed the following: a. Resident 6 was administered with bupropion medication as ordered on the following dates and times: - 6/3, 6/5, 6/7, 6/12, 6/13, 6/14, 6/15, 6/17, 6/18, 6/19, 6/24, 6/26, and 6/29/26 at 0900 hours; - 6/3, 6/5, 6/7, 6/12, 6/13, 6/14, 6/15, 6/17, 6/18, 6/19, 6/24, 6/25, 6/26, 6/29, and 6/30/26 at 1300 hours; - 6/2, 6/3, 6/4, 6/5, 6/6, 6/7, 6/9, 6/12, 6/13, 6/14, 6/15, 6/16, 6/17, 6/18, 6/19, 6/20, 6/23, 6/24, 6/25, 6/26, 6/27, 6/29, and 6/30/26 at 1700 hours; and - 7/1/26 at 0900 hours, 1300 hours and 1700 hours. Further review of Resident 6's medical records failed to show documented evidence the nonpharmacological interventions were provided prior to the administration of bupropion medication on the dates and times above. b. Resident 6 was administered with hydroxyzine medication as ordered on the following dates and time: - 6/3, 6/7, 6/12, 6/13, 6/15, 6/17, 6/18, 6/19, 6/21, 6/24, 6/26, and 6/29/26 at 0900 hours; - 6/2, 6/3, 6/7, 6/12, 6/13, 6/15, 6/17, 6/18, 6/19, 6/20, 6/23, 6/24, 6/26, 6/27, and 6/30/26 at 1700 hours; and - 7/1/26 at 0900 hours and 1700 hours. Further review of Resident 6's medical records failed to show documented evidence the nonpharmacological interventions were provided prior to the administration of hydroxyzine medication on the dates and times above. c. Resident 6 was administered with sertraline medication as ordered on the following dates and time: - 6/3, 6/5, 6/7, 6/12, 6/13, 6/14, 6/15, 6/17, 6/18, 6/19, 6/24, 6/26, and 6/29/26 at 0900 hours; and - 7/1/26 at 0900 hours. Further review of Resident 6's medical records failed to show documented evidence the nonpharmacological interventions were provided prior to the administration of sertraline medication on the dates and times above. 3. Medical record review for Resident 69 was initiated on 7/1/26. Resident 69 was readmitted to the facility on [DATE]. Review of Resident 69's H&P examination dated 6/5/25, showed Resident 69 had the capacity to make decisions. Review of Resident 69's Order Summary Report showed the following physician's orders: - dated 12/13/23, for alprazolam: Nonpharmacological approach attempted prior to administration of anti-anxiety medication: (1) Encourage to verbalize feelings(needs/concern); (2) Encourage family to participate in care; (3) Encourage to attend daily activities; (4) Provide a quiet & calm environment with diversion like listening to music/watching TV; (5) Teach resident relaxation techniques or deep breathing exercises; (6) Redirect & provide gentle reality orientation; (7) Other; every shift; and - dated 5/30/26, to administer alprazolam (antianxiety medication) 0.5 mg one tablet by mouth every eight hours as needed for anxiety as manifested by inability to relax for 90 days. Review of Resident 69's MAR for June 2026 showed Resident 69 was administered with alprazolam medication on the following dates and time: - 6/2 to 6/3/26 at 2000 hours; - 6/8 to 6/11/26 at 2000 hours; - 6/14 to 6/17/26 at 2000 hours; - 6/22 to 6/23/26 at 2000 hours; - 6/25/26 at 2030 hours; - 6/26 to 6/28/26 at 2000 hours; and - 6/29/26 at 2007 hours. Further review of Resident 69's medical records failed to show documented evidence the nonpharmacological interventions were provided prior to the administration of alprazolam medication on the dates and times above. On 7/2/26 at 1000 hours, an interview and concurrent medical record review for Residents 3, 6, and 69 was conducted with the ADON. The ADON verified the above findings for Residents 3, 6, and 69. The ADON stated the manifested behaviors and side effects of the psychotropic medications ordered for the resident should be accurately documented to determine if the resident was getting better or worse and it would also assist in determining whether the medication should be continued or not. The ADON further stated providing nonpharmacological interventions prior to administration of the medications should be initiated to determine if it would help the resident and limit the use of pharmacological interventions. On 7/2/26 at 1339 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings for Residents 3, 6, and 69. 4. Medical record review for Resident 9 was initiated on 6/29/26. Resident 9 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 9's MDS assessment dated [DATE], showed Resident 9 had severely impaired cognition. Review of Resident 9's Order Summary Report dated 7/1/26, showed the following physician's orders: - dated 8/28/25, to administer olanzapine (antipsychotic medication) 2.5 mg one tablet by mouth at bedtime for psychotic disorder manifested by disorganized thinking; - dated 6/15/26, for the use of the olanzapine medication, to monitor Resident 9 for orthostatic hypotension - blood pressure in the sitting position, every seven days, during the day shift; and - dated 6/15/26, for the use of the olanzapine medication, to monitor Resident 9 for orthostatic hypotension -blood pressure in the lying position, every seven days, during the day shift. Review of Resident 9's MAR for June 2026 showed Resident 9 was administered with olanzapine 2.5 mg medication at 2100 hours the from 6/1 to 6/30/26. Further review of Resident 9's MAR showed the following: - dated 6/22/26, the BP readings were 142/70 mmHg for the sitting and lying position; and - dated 6/29/26, the BP readings were 138/67 mmHg for the sitting and lying positions. On 7/1/26 at 1105 hours, an interview and concurrent medical record review for Resident 9 was conducted with LVN 6. LVN 6 stated the orthostatic BP was monitored weekly by obtaining the BP readings in the lying and then sitting positions. LVN 6 verified the orthostatic BP reading for the lying and sitting positions were the same for the above dates. On 7/2/26 at 0955 hours, an interview was conducted with the DON. The DON stated for the residents who were administered the antipsychotic medication, the orthostatic BP was being monitored weekly. The BP readings should be obtained in the different positions, sitting and lying and the BP readings were compared. The DON stated the BP readings for the different positions should not be the same. On 7/2/26 at 1420 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. 5. Medical record review for Resident 226 was initiated on 6/30/26. Resident 226 was admitted to the facility on [DATE]. Review of Resident 9's Order Summary Report dated 7/1/26, showed the following physician's orders dated 6/25/26: - to administer olanzapine (antipsychotic medication) 0.5 mg by mouth at bedtime for psychosis manifested by disorganized thinking;- to monitor for orthostatic hypotension everyday shift, for BP in lying position for 10 days; and- to monitor for orthostatic hypotension everyday shift, for BP in sitting position for 10 days. Review of Resident 226's MARs for June 2026 showed the orthostatic blood pressures (sitting and lying) were scheduled to be monitored every day for 10 days. However, the blood pressure readings for both positions (lying and sitting) were the same as follows:- dated 6/26/26 , the blood pressure readings were 106/63 mmHg for sitting and lying positions;- dated 6/27/26, the blood pressure readings were 126/70 mmHg for sitting and lying positions; and- dated 6/28/26, the blood pressure readings were 138/70 mmHg for sitting and lying positions. On 7/1/26 at 1428 hours, an interview and concurrent medical record review for Resident 226 was conducted with the ADON. The ADON verified the physician's order for the use of olanzapine medication was to monitor the orthostatic hypotension for Resident 226. The ADON stated the monitoring of the orthostatic hypotension was due to the side effects of the psychotropic medication use. The ADON verified and stated the orthostatic hypotension monitoring for Resident 226 were inaccurate. On 7/2/26 at 1416 hours, an interview and concurrent medical record review for Resident 226 was conducted with the DON. The DON was informed and verified the above findings.

Based on interview, medical record review, and facility P&P review the facility failed to timely notify and accurately sent the Notification of Proposed Transfer/Discharge to the Office of the State Long-Term Care (LTC) Ombudsman, notified the resident's representative in writing of the reason for transfer and/or bed hold for two of 34 final sampled residents (Residents 49 and 98) and three of three sampled residents (Residents 221, 222, and 223) reviewed for closed records.* The facility failed to ensure the notification of proposed transfer was sent to the Ombudsman for Residents 49, 221, 222, and 223.* The facility failed to ensure Resident 98's family member was notified in writing of reason of transfer to the acute care hospital and bed hold; and the copy of transfer was sent to the Ombudsman. These failures had the potential for the Ombudsman and resident's representative to not be aware of the resident's discharge and advocate for the resident's rights from inappropriate transfer and discharge. Findings: Review of facility's P&P titled Transfer and Discharge revised 1/2026 showed the facility transfers or discharges residents in a safe manner that ensure the discharge meets the resident's needs, provides needed support and resources, and meets the resident's preferences, and permits residents to return to the facility following hospitalization or therapeutic leave. The Transfer and Discharge Requirements – Facility Requirements section showed: 5. The name, address (mailing and email), and phone number of the representative of the Office of the State Long-Term Care ombudsman. The Documentation section showed: 9. The facility documents the resident's transfer or discharge in the medical record and communicates appropriate information to the receiving health care institution or provider when a resident is transferred from the facility; and 10. When a resident's transfer or discharge is necessary to meet the resident's welfare and the resident's needs cannot be met in the facility, the resident's physician or extender shall document: a. The basis for the resident's transfer; b. The specific needs which cannot be met; c. The facility attempts to meet the needs; and d. The services available at the receiving facility to meet the resident's needs. The Permitting Residents to Return to Facility section showed: 16. The facility permits residents to return to the facility after they are hospitalized or placed on therapeutic leave; and 17. The facility provides written notice of bed-hold rights to the resident and/or resident representative at the time of admission and prior to any transfer to a hospital or therapeutic leave. 1. Closed medical record review for Resident 49 was initiated on [DATE]. Resident 49 was readmitted to the facility on [DATE], and transferred to the acute care hospital on 5/1 and [DATE]. Review of Resident 49's Order Summary Report showed the following physician's orders: - dated [DATE], may transfer resident to Acute Care Hospital 1 ER for abdominal CT scan related to abdominal distention with tenderness; and - dated [DATE], may send Resident 49 out to the acute care hospital for further evaluation. Review of Resident 49's Notice of Proposed Transfer and Discharge – 1102 – V2 dated 5/1 and [DATE], failed to show the forms were sent to the Ombudsman. Further review of the medical record did not show any documentation the Ombudsman was notified of Resident 49's transfer to the acute care hospital on 5/1 and [DATE]. On [DATE] at 0919 hours, an interview and concurrent medical record review for Resident 49 was conducted with the ADON. The ADON verified the Notification of Proposed Transfer and Discharge was not sent to the Ombudsman when Resident 49 was transferred to the acute care hospital on 5/1 and [DATE]. 2. Closed medical record review for Resident 221 was initiated on [DATE]. Resident 221 was admitted to the facility on [DATE], and transferred to the acute care hospital on [DATE]. Review of Resident 221's Order Summary Report showed a physician's order dated [DATE], ok to transfer to Acute Care Hospital 2 ED for evaluation and bed hold for seven days if admitted . Review of Resident 221's Notice of Proposed Transfer and Discharge – 1102 – V2 dated [DATE], failed to show the form was sent to the Ombudsman. Further review of the medical record did not show any documentation the Ombudsman was notified of Resident 221's transfer to the acute care hospital on [DATE]. On [DATE] at 0912 hours, an interview and concurrent medical record review for Resident 221 was conducted with the ADON. The ADON verified the Notification of Proposed Transfer and Discharge was not sent to the Ombudsman when Resident 221 was transferred to the acute care hospital on [DATE]. 3. Closed medical record review for Resident 222 was initiated on [DATE]. Resident 222 was readmitted to the facility on [DATE], and discharged due to death on [DATE]. Review of Resident 222's Order Summary Report showed a physician's order dated [DATE], may release the body to Mortuary Provider 1. Further medical record review for Resident 222 failed to show documented evidence the Ombudsman was notified of Resident 222's death on [DATE]. On [DATE] at 0827 hours, an interview and concurrent medical record review for Resident 222 was conducted with the ADON. The ADON verified the Ombudsman was not notified for Resident 222's death on [DATE]. The ADON stated the Ombudsman should be notified of the resident's discharge from the facility whether it was discharge to home, acute care hospital, or other health facility, AMA, or death. 4. Closed medical record review for Resident 223 was initiated on [DATE]. Resident 223 was admitted to the facility on [DATE], and discharged on [DATE]. Review of Resident 223's Order Summary Report showed a physician's order dated [DATE], may discharge home AMA with responsible party. Further review of Resident 223 medical record failed to show documented evidence the Ombudsman was notified of Resident 223's discharge on [DATE]. On [DATE] at 0909 hours, an interview and concurrent medical record review for Resident 223 was conducted with the ADON. The ADON verified the Ombudsman was not notified for Resident 223's discharge to home AMA on [DATE]. On [DATE] at 1339 hours, an interview was conducted with the DON. The DON stated the Ombudsman should be notified of all the discharges of the residents which included discharge to home or other health facilities, AMA, and death. The DON stated the discharging nurse would fax the Notification of Proposed Transfer and Discharge to the Ombudsman and the fax transmittal receipt should be given to the medical record department for filing in the PCC. The DON further stated the expectation was for the nurses to fax it to the Ombudsman as soon as possible or before the end of their shift. The DON was informed and acknowledged the above findings for Residents 49, 221, 222, and 223. 5. Medical record review for Resident 98 was initiated on [DATE]. Resident 98 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 98's H&P examination dated [DATE], showed Resident 98 had no capacity to understand and to make decisions. Review of Resident 98's Order Summary Report showed a physician's order dated [DATE], for may transfer Resident 98 to the acute care hospital and bed hold for seven days if admitted . Further review of Resident 98's medical record failed to show if Resident 98's representative was provided with a written documentation of the reason of the transfer to the acute care hospital and the bed hold, and any documentation if the Ombudsman was notified of Resident 98's transfer to the acute care hospital. On [DATE] at 0739 hours, an interview was conducted with the MRD. The MRD stated the written notification of the transfer and bed hold was not being done since the facility had changed to electronic medical records. On [DATE] at 1037 hours, an interview and concurrent record review for Resident 98 was conducted with the DON. The DON verified the resident's medical record failed to show the notification in writing regarding Resident 98's transfer and bed hold for when the resident was transferred on [DATE]. The DON stated the Ombudsman should have been notified by the licensed nurses through fax. The DON verified no documentation of notification of the Ombudsman was completed for Resident 98.

Based on interview, medical record review, facility record review, and facility P&P review, the facility failed to provide the necessary services to attain or maintain the highest practicable well-being for six of 34 final sampled residents (Residents 6, 7, 9, 201, 222, and 230). * The facility failed to ensure the insulin administration sites were rotated as ordered by the physician for Residents 6, 7, 9, and 230. This failure had the potential to result in ineffective treatment, altered medication effectiveness/absorption, and tissue damage. * The facility failed to ensure Resident 201's Lovenox (anticoagulant medication) and insulin injection sites were rotated as ordered by the physician. This failure had the potential to result in ineffective treatment, altered medication effectiveness/absorption, and tissue damage. * The facility failed to ensure Resident 222 was assessed when the resident was readmitted to the facility. This failure had the potential for the resident to not receive the necessary care and services as the assessments were not completed and may negatively affect the resident's well-being. Findings: Review of the facility's P&P titled Insulin Administration revised 1/2025 showed insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. The injection sites should be rotated to reduce the risk of damaging the skin tissue. According to Taylor's Clinical Nursing Skills, seventh edition, the various sites used for subcutaneous injections are the outer aspect of the upper arm, the abdomen (from below the costal margin to the iliac crest), the anterior aspect of the thigh, the upper back, and the upper ventral (upper front) or dorsogluteal area (buttocks). It is necessary to rotate sites or areas for injections to prevent buildup of fibrous tissue and permit complete absorption of the medication. 1. Medical record review for Resident 6 was initiated on [DATE]. Resident 6 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 6's H&P examination dated [DATE], showed Resident 6 had no capacity to understand and make decisions. Review of Resident 6's Order Summary Report dated [DATE], showed the following physician's orders dated [DATE]: - to administer regular insulin (a short-acting insulin designed to manage high blood sugar levels) 100 unit/ml as per sliding scale (amount of insulin to be administered based on the blood sugar results) subcutaneously before meals and at bedtime and to rotate the site of administration, and - to administer insulin glargine (a long-acting insulin designed to manage blood sugar levels) six units subcutaneously at bedtime and to rotate the site of administration. Review of Resident 6's Location of Administration Report for [DATE] showed the insulin glargine and regular insulin were administered consecutively at the same injection site on the following dates and times: - dated [DATE] at 2046 hours, insulin glargine was administered to the LLQ (left lower quadrant) of the abdomen; - dated [DATE] at 2038 hours, insulin glargine was administered to the LLQ (left lower quadrant) of the abdomen; - dated [DATE] at 2044 hours, insulin glargine was administered to the LLQ (left lower quadrant) of the abdomen; - dated [DATE] at 2109 hours, regular insulin was administered to the LLQ (left lower quadrant) of the abdomen; and at 2111 hours, insulin glargine was administered to the LLQ (left lower quadrant) of the abdomen; - dated [DATE] at 2053 hours, insulin glargine was administered to the LLQ (left lower quadrant) of the abdomen; and - dated [DATE] at 2035 hours, insulin glargine was administered to the LLQ (left lower quadrant) of the abdomen. On [DATE] at 1500 hours, an interview and concurrent medical record review for Resident 6 was conducted with LVN 4. LVN 4 verified the physician's orders for the insulin injection for the routine and sliding scale insulin coverage. LVN 4 stated prior to administering the insulin injection the licensed nurse should check the MAR to see the last administration site. LVN 4 further stated the insulin injection sites should be rotated to prevent complications of the skin from repeated injections at same site. LVN 4 reviewed Resident 6's MAR for [DATE] and verified the above findings when the insulin administration sites were not rotated. 2. Medical record review for Resident 7 was initiated on [DATE]. Resident 7 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 7's H&P examination dated [DATE], showed Resident 7 had the capacity to understand and make decisions. Review of Resident 7's Order Summary Report dated [DATE], showed a physician's order dated [DATE], to administer insulin glargine (a long-acting insulin designed to manage blood sugar levels) 22 units subcutaneously at bedtime and to rotate the site of administration. Review of Resident 7's Location of Administration Report for [DATE] showed the insulin glargine were administered consecutively at the same injection sites on the following dates and times: - dated [DATE] at 2130 hours, insulin glargine was administered to the left arm; - dated [DATE] at 2205 hours, insulin glargine was administered to the left arm; - dated [DATE] at 2201 hours, insulin glargine was administered to the left arm; - dated [DATE] at 2111 hours, insulin glargine was administered to the left arm; - dated [DATE] at 2142 hours, insulin glargine was administered to the left arm; - dated [DATE] at 2112 hours, insulin glargine was administered to the left arm; - dated [DATE] at 2114 hours, insulin glargine was administered to the left arm; - dated [DATE] at 2223 hours, insulin glargine was administered to the left arm; - dated [DATE] at 2033 hours, insulin glargine was administered to the left arm; - dated [DATE] at 2042 hours, insulin glargine was administered to the left arm; - dated [DATE] at 2118 hours, insulin glargine was administered to the left arm; - dated [DATE] at 2146 hours, insulin glargine was administered to the left arm; - dated [DATE] at 2150 hours, insulin glargine was administered to the left arm; and - dated [DATE] at 2135 hours, insulin glargine was administered to the left arm. On [DATE] at 1033 hours, an interview and concurrent medical record review for Resident 7 was conducted with LVN 4. LVN 4 verified the physician's orders for the insulin injection for the routine glargine insulin. LVN 4 reviewed Resident 7's s MAR for [DATE] and verified the above findings when the insulin administration sites were not rotated. LVN 4 stated the insulin injection sites should be rotated as per the physician's order. 3. Medical record review for Resident 9 was initiated on [DATE]. Resident 9 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 9's MDS assessment dated [DATE], showed Resident 9 had severely impaired cognition. Review of Resident 9's Order Summary Report dated [DATE], showed a physician's order dated [DATE], to administer Humulin R insulin (a short-acting insulin designed to manage high blood sugar levels ) 100 unit/ml as per sliding scale (amount of insulin to be administered based on the blood sugar results) subcutaneously before meals and at bedtime and to rotate the site of administration. Review of Resident 9's Location of Administration Report for [DATE] showed the Humulin R insulin was administered consecutively at the same injection site on the following dates and times: - dated [DATE] at 1806 and 2051 hours, Humulin R insulin was administered to the LLQ of the abdomen; - dated [DATE] at 0650 hours, Humulin R insulin was administered to the LLQ of the abdomen; - dated [DATE] at 1543 and 2045 hours, Humulin R insulin was administered to the LLQ of the abdomen; - dated [DATE] at 1547 and 2138 hours, Humulin R insulin was administered to the LLQ of the abdomen; and - dated [DATE] at 1216, 1748 and 2048 hours, Humulin R insulin was administered to the LLQ of the abdomen. On [DATE] at 1119 hours, an interview and concurrent medical record review for Resident 9 was conducted with LVN 7. LVN 7 verified the physician's orders for the Humulin R insulin as per the sliding scale. LVN 4 reviewed Resident 9's MAR for [DATE] and verified the above findings when the insulin administration sites were not rotated. LVN 4 stated the insulin injection sites should be rotated. On [DATE] at 0955 hours, an interview was conducted with the DON. The DON stated prior to the administration of the insulin injections, the licensed nurse should review the resident's MAR to see the location of the previous insulin injection site. The DON stated the insulin injection sites should be rotated to prevent skin complications due to repeated injections at the same site and it may affect the absorption of the insulin. On [DATE] at 1420 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. 4. Medical record Review for Resident 230 was initiated on [DATE]. Resident was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 230's Order Summary Report dated [DATE], showed the following physician's orders: - dated [DATE], to administer Humulin regular insulin (a short-acting insulin) subcutaneously before meals and at bedtime, as per sliding scale; - dated [DATE], to inject 30 units, NPH insulin (an intermediate-acting insulin) subcutaneously at bedtime, rotate injection site of administration; and - dated [DATE], inject 55 units, NPH insulin subcutaneously in the morning, rotate injection site of administration. Review of Resident 230's Location of Administration Report for [DATE] showed the Humulin regular insulin and NPH insulin was administered consecutively on the same injection sites on the following dates and times: - dated [DATE] at 1719 hours, Humulin regular insulin was administered to LLQ of the abdomen; - dated [DATE] at 2137 hours, Humulin regular insulin was administered to LLQ of the abdomen; - dated [DATE] at 1210 hours, Humulin regular insulin was administered to LUQ of the abdomen; - dated [DATE] at 2019 hours, NPH insulin was administered to LUQ of the abdomen; - dated [DATE] at 0808 hours, NPH insulin was administered to LUQ of the abdomen; - dated [DATE] at 1726 hours, Humulin regular insulin was administered to LUQ of the abdomen; - dated [DATE] at 2149 hours, NPH insulin was administered to LUQ of the abdomen; - dated [DATE] at 2148 hours, Humulin regular insulin was administered to LUQ of the abdomen; and - dated [DATE] at 1058 hours, NPH insulin was administered to LUQ of the abdomen; On [DATE] at 1358 hours, an interview and concurrent medical record review for Resident 230 was conducted with LVN 12. LVN 12 verified the above findings and stated the injection site should be rotated with each insulin administration. On [DATE] at 1014 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 5. Medical record review for Resident 201 was initiated on [DATE]. Resident 201 was admitted to the facility on [DATE]. Review of Resident 201's H&P examination dated [DATE], showed Resident 201 had the capacity to make medical decisions. Review of Resident 201's Order Summary Report dated [DATE], showed the following physician's order: -dated [DATE], to administer Lovenox injection 40 mg subcutaneously in the morning, and -dated [DATE], to administer Lispro insulin (a short-acting insulin designed to manage high blood sugar levels) as per sliding scale subcutaneously before meals and at bedtime and to rotate injection sites. Review of Resident 201's Location of Administration Report for [DATE] showed the Lovenox medication was administered consecutively on the same injection sites on the following dates and times: - dated [DATE] at 0813 hours and [DATE] at 0907 hours, the Lovenox medication was administered subcutaneously in the abdomen LUQ (left upper quadrant); and - dated [DATE] at 0916 hours and [DATE] at 0925 hours, the Lovenox medication was administered subcutaneously in the abdomen LLQ (left lower quadrant). Review of Resident 201's Location of Administration Report for [DATE] showed the lispro insulin (used for diabetic) was administered consecutively on the same injection sites on the following dates and times: - dated [DATE] at 0642 hours and at 1216 hours, the lispro insulin was administered subcutaneously in the abdomen LLQ (left lower quadrant); - dated [DATE] at 2123 hours and [DATE] at 1159 hours, the lispro insulin was administered subcutaneously in the abdomen RUQ (right upper quadrant); - dated [DATE] at 2040 hours and [DATE] at 0628 hours, the lispro insulin was administered subcutaneously in the abdomen LUQ (left upper quadrant); and - dated [DATE] at 1215 hours, 1548 hours and 2035 hours, the lispro insulin was administered subcutaneously in the abdomen RLQ (right lower quadrant). On [DATE] at 0850 hours, an interview and concurrent medical record review for Resident 201 was conducted with the ADON. The ADON verified the physician's order for the administration of anticoagulant and insulin medication for Resident 201. The ADON verified and acknowledged injection sites for the anticoagulant medication and insulin were not rotated for the above dates and times. The ADON stated the injection sites should have been rotated to prevent any complication on the injection sites. On [DATE] at 1416 hours, an interview and concurrent medical record review for Resident 201 was conducted with the DON. The DON stated she expected the licensed nurses to rotate the injection sites for the administration of the injectable medications. The DON was informed and acknowledged the above findings. 6. Closed medical record review for Resident 222 was initiated on [DATE]. Resident 222 was readmitted to the facility on [DATE], and discharged due to death on [DATE]. Review of Resident 222's H&P examination dated [DATE], showed Resident 222 had no capacity to understand and make decisions. Review of Resident 222's POLST dated [DATE], showed Resident 222 was a DNR status. Review of Resident 222's Order Summary Report showed a physician's order dated [DATE], for DNR, selective treatment, trial period of artificial nutrition including feeding tubes. Review of Resident 222's Progress Notes showed the following: - dated [DATE] at 1843 hours, Resident 222 came back from the acute care hospital accompanied by a family member, via stretcher ambulance. Resident 222 was awake and alert but with weakness, no signs and symptoms of pain, no shortness of breath noted. Resident 222 would be on intravenous ceftriaxone (antibiotic) medication for pneumonia; - dated [DATE] at 2145 hours, CNA notified the charge nurse Resident 222 appeared to be in distress and breathing abnormally. The charge nurse immediately assessed Resident 222. Resident 222 was noted to be unresponsive. The vital signs were attempted. The pulse rate was noted to be decreasing and unable to obtain. The RN supervisor was immediately notified and responded to bedside. Resident 222 was assessed by two licensed nurses. No pulse rate was detected and no respiration was observed. Resident 222's chart was reviewed and DNR status was confirmed. In accordance with Resident 222's DNR order, no resuscitative measures were initiated; and - dated [DATE] at 2150 hours, Resident 222 was pronounced deceased by the RN supervisor. The time of death called was at 2150 hours. The physician, family, and appropriate facility personnel were notified as per the facility's protocol. Postmortem care initiated as per the facility's policy. Further review of Resident 222 medical record failed to show documented evidence of the assessment and vital signs readings when Resident 222 was admitted to the facility, three hours prior to the change of condition. On [DATE] at 0827 hours, an interview and concurrent medical record review for Resident 222 was conducted with the ADON. The ADON stated upon the resident's admission the licensed nurse would use the Admit/Readmit Evaluation which included the demographics/orientation, neurological, respiratory, cardiovascular, sleep, skin integrity and additional information as basis for the complete assessment and should take the initial vital signs as soon as possible. Review of Resident 222's Weight and Vitals Summary showed the last recorded vital signs was on [DATE] at 1352 hours. The ADON verified Resident 222's vital signs were not assessed and the completed assessment was not performed when Resident 222 was readmitted on [DATE]. When asked if the Admit/Readmit Evaluation should have been completed for Resident 222 upon admission on [DATE], the ADON stated she was not sure if the Admit/Readmit Evaluation assessment should have been done. The ADON further stated Resident 222 was in and out of the acute care hospital and there was a plan for the resident to be placed in either hospice or palliative care. On [DATE] at 1339 hours, an interview and concurrent medical record review for Resident 222 was conducted with the DON. The DON stated no matter what the resident type was, either skilled or long-term resident and initial or readmission, the licensed nurse should do a thorough assessment of the resident and utilize the Admit/Readmit Evaluation in the PCC for the assessment of the resident. The DON stated either the CNA or licensed nurse should check or get the initial vital signs upon admission of the resident as soon as possible. The DON was informed and acknowledged the above findings for Resident 222.

Based on observation, interview, medical record review, and P&P review, the facility failed to provide the necessary care and services related to GT enteral feeding for four of 34 final sampled residents (Residents 12, 49, 117, and 148) reviewed for tube feedings. * The facility failed to ensure the GT enteral feeding formula was labeled with the start time for Resident 12. * The facility failed to ensure Resident 49 was administered with the complete dose of the GT enteral feeding as per the physician's order. In addition, the facility failed to label Resident 49's enteral feeding formula with the start time. * The facility failed to ensure Resident 117 was administered with the complete dose of the GT enteral feeding as per the physician's order. * The facility failed to ensure Resident 148's enteral feed syringe was changed daily. These failures had the potential for the residents to have complications related to the use of GT and/or to put the residents risk for weight loss and/or dehydration. Findings: Review of the facility's P&P titled Enteral Feeding- Safety Precautions revised 1/2025 showed enteral formulas shall be administered at full strength or in accordance with the physician order. The nurse shall verify the enteral nutrition label against the order before administration. To ensure: a. Resident name, ID and room number; b. Type of formula; c. Date and time formula were prepared; d. Route of delivery; e. Access site; f. Method (pump, gravity, syringe); g. Rate of administration (mL/hour); and h. The formula label contains the initials, date and time the formula was hung/administered. 1. Medical record review for Resident 12 was initiated on 6/29/26. Resident 12 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 12's H&P examination dated 4/22/26, showed Resident 12 had no capacity to understand and make decisions. Review of Resident 12's Order Summary Report for June 2026 showed a physician's order dated 4/20/26, to administer Glucerna 1.2 (enteral feeding formula) or equivalent at 45 ml/hr for 20 hours, to provide 900 ml (1080 calories) and to start the infusion at 1200 hours and continue for 20 hours or until the total volume is complete. On 6/29/26 at 1454 hours, an observation was conducted for Resident 12. Resident 12 was observed lying in bed with the GT feeding of Glucerna 1.2 running at 45 ml/hr via the GT. The enteral feeding formula bottle was not observed labeled with the start time. On 6/29/26 at 1502 hours, an interview and concurrent observation was conducted with LVN 4. LVN 4 stated when hanging a new enteral feeding formula, the bottle should be labeled with the resident's name, ordered rate, and date and time the feeding was started. LVN 4 stated the enteral feeding formulas should be discarded after 24 hours. LVN 4 further stated the start time should be labeled, to determine when the enteral feeding formula should be discarded. LVN 4 verified the above findings. LVN 4 stated she should have labeled the feeding formula bottle so the next shift would know when it should be discarded. 2. Medical record review for Resident 49 was initiated on 6/29/26. Resident 49 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 49's H&P examination dated 6/12/25, showed Resident 49 had no capacity to make decisions. a. Review of Resident 49's Order Summary Report for June 2026 showed a physician's order dated 6/25/26, to administer Glucerna 1.5 (enteral feeding formula) at 90 ml/hr for 12 hours, to provide 1080 ml and to start the infusion at 1800 hours and off at 0600 hours, or until the dose is met. On 6/29/26 at 1013 hours, during the initial tour of the facility, Resident 49 was observed lying in bed with the GT enteral feeding of Glucerna 1.5 running at 90 ml/hr via the GT. The enteral formula bottle was not observed labeled with the start time. On 6/29/26 at 1033 hours, an observation for Resident 49 and concurrent interview was conducted with LVN 6. LVN 6 stated when hanging the GT enteral feeding formula, the bottle should be labeled with the resident's name, date and time the feeding started, the ordered rate and volume. LVN 6 verified Resident 49's enteral formula bottle was not labeled with the start time b. Review of Resident 49's Order Summary Report for June 2026, showed a physician's orders dated 6/30/26, to administer Glucerna 1.5 at 75 ml/hr for 15 hours, to provide 1125 ml and to start the infusion at 1800 hours and off at 0900 hours, or until the dose is met. On 7/1/26 at 0819 hours, an observation was conducted for Resident 49. Resident 49 was observed lying in bed. The GT enteral feeding was not connected. However, the GT enteral feeding bottle of Glucerna 1.5 was hanging on the pole and was labeled with the date of 7/1/26 at 0530 hours and the rate showed 90 ml/hr for 12 hours. On 7/1/26 at 1413 hours, an observation for Resident 49 and concurrent interview and record review was conducted with LVN 7. LVN 7 stated Resident 49 was currently receiving the GT enteral feeding Glucerna 1.5 at 90 ml/hr for 12 hours. LVN 7 further stated during the shift change in morning, Resident 49 was connected to the GT at the rate of 90 ml/hr. LVN 7 was asked to check Resident 49's feeding pump. The GT feeding pump history showed the current enteral feeding formula rate was 90 ml/hr and 1080 ml fed. LVN 7 reviewed Resident 49's medical records and verified the new physician's order dated 6/30/26, for the GT enteral feeding rate of 75 ml/hr for 15 hours, for a total volume of 1125 ml. LVN 7 stated the new rate and duration of the enteral feedings should have been changed yesterday. c. On 7/2/26 at 0830 hours, a follow-up observation was conducted for Resident 49. Resident 49 was observed lying in bed with the GT feeding of Glucerna 1.5 running at 75 ml/hr via the GT. The enteral feeding formula bottle was not observed labeled with the start time. On 7/2/26 at 0851 hours, an observation for Resident 49 and concurrent interview was conducted with LVN 7. LVN 7 verified the enteral feeding formula bottle was not labeled with the start time. On 7/2/26 at 0955 hours, an interview was conducted with the DON. The DON stated the enteral feeding formula should be administered as per the physician's order and the enteral feeding bottles should be labeled with the resident' name, date and time the formula was started, and the rate and duration. The DON stated the enteral feeding formulas were good for 24 hours, and the labeling of the time would let the licensed nurses know when the enteral feeding formula should be discarded. The DON further stated if the resident did not receive the enteral feedings at the ordered rate and duration, there may be a protentional for weight loss. On 7/2/26 at 1420 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. 3. Medical record review for Resident 117 was initiated on 6/29/26. Resident 117 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 117's H&P examination dated 6/22/26, showed Resident 117 did not have decision-making capacity. Review of Resident 117's MDS 5-day PPS assessment dated [DATE], showed Resident 117 had a feeding tube and had a medical diagnosis of dysphagia (difficulty swallowing). Review of Resident 117's Order Summary Report showed a physician's order dated 6/22/26, to administer Glucerna 1.2 at 65 ml/hr for 20 hours (on at 1200 hours, off at 0800 hours or when dose met) to provide 1300 ml/1560 kcal. On 6/29/26 at 1113 hours, an observation for Resident 117 and concurrent interview was conducted with LVN 2. Resident 117 was observed in bed with no GT enteral feeding hanging. LVN 2 verified Resident 117 was not connected with GT enteral feeding. When LVN 2 was asked to check Resident 117's GT feeding pump, the feeding pump showed feeding incomplete. The GT feeding pump history showed 104 ml left. LVN 2 verified Resident 117 did not receive the prescribed dose of 1300 ml of enteral feeding. On 7/2/26 at 0825 hours, a follow-up observation for Resident 117 and concurrent interview was conducted for Resident 117 with the ADON. Resident 117 was observed lying in bed with no GT enteral feeding hanging. When ADON was asked to check Resident 117's GT feeding pump, the feeding pump showed feeding incomplete. The GT feeding pump history showed 275 ml left. The ADON verified Resident 117 did not receive the prescribed dose of 1300ml of enteral feeding. 4. Review of the facility's P&P titled Enteral Feeding - Syringe revised 3/2023 showed the purpose of this procedure is to guide the proper sanitizing of reusable enteral feeding syringes. Enteral feeding syringes are replaced every 24 hours. Medical record review for Resident 148 was initiated on 6/29/26. Resident 148 was admitted to the facility on [DATE]. Review of Resident 148's H&P examination dated 5/14/26, showed Resident 148 had limited decision making capacity. Review of Resident 148's MDS 5 day PPS assessment dated [DATE], showed Resident 148 had a feeding tube and had a medical diagnosis of dysphagia (difficulty swallowing). Review of Resident 148's Order Summary Report showed the following physician's order dated 5/14/26, to change the enteral feed syringe every day shift daily. On 6/29/26 at 1043 hours, an observation for Resident 148 and concurrent interview was conducted with LVN 2. Resident 148 was observed lying in bed. Resident 148 was observed with enteral feeding syringe at bedside labeled 6/26/26. LVN 2 verified the findings. LVN 2 stated the enteral feeding syringe were changed every day. On 7/2/26 at 0837 hours, an interview was conducted with the DON. The DON stated the residents who were on GT enteral feeding need to have new enteral feeding syringes every day for infection prevention. The DON further stated the licensed nurses were expected to make sure the residents who were on the GT enteral feeding will receive the full amount of the enteral feeding as prescribed by the physician. On 7/2/26 at 1416 hours, an interview was conducted with the Administrator and Assistant Administrator. The Administrator and Assistant Administrator were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary respiratory care and services were provided for 10 of 34 final sampled residents (Residents 3, 5, 10, 68, 106, 164, 224, 225, 227, and 231) and one nonsampled resident (Resident 236). * The facility failed to ensure Resident 3's oxygen tubing and storage bag were changed every seven days. * The facility failed to ensure Resident 5's oxygen tubing and nebulizer tubing were changed every seven days. In addition, the facility failed to ensure the nebulizer tubing was inside a storage bag when not in use. * The facility failed to ensure Resident 10 was administered with the oxygen therapy as ordered by the physician. * The facility failed to ensure Resident 68 was administered with the oxygen therapy as ordered by the physician. In addition, the facility failed to ensure Resident 68's nasal cannula tubing was dated and labeled. * The facility failed to obtain a physician's order for Resident 106's CPAP machine settings. In addition, the facility failed to follow the care and maintenance of Resident 106's CPAP machine as per the manufacturer's guidelines. * The facility failed to ensure Resident 164's oxygen tubing and storage bag were changed every seven days. * The facility failed to ensure a physician's order was obtained for Resident 224's use of oxygen therapy. In addition, the facility failed to ensure the oxygen tubing was dated and labeled and inside a storage bag when not in use. * The facility failed to ensure a physician's order was obtained for Resident 225's use of oxygen therapy. In addition, the facility failed to ensure Resident 225's oxygen tubing was not touching the floor, the humidifier was dated and labeled and a sign to show oxygen in use was posted outside Resident 225's room. * The facility failed to ensure Resident 227's oxygen tubing was inside a storage bag when not in use. * The facility failed to ensure Resident 231's oxygen humidifier, nasal canula and storage bag were dated and labeled. * The facility failed to ensure Resident 236's oxygen humidifier was dated and labeled. These failures had the potential for the residents to not receive the appropriate respiratory care and services and may negatively impact the residents' medical conditions. Findings: Review of the facility's P&P titled Storage Maintenance and Handling of Oxygen revised 1/2026 showed the following oxygen safety guidelines have been established to provide safety to staff and residents. Use plugs, caps and plastic bags to protect equipment not in use from dust and dirt. Review of the facility's P&P titled Respiratory/Tracheostomy Care and Suctioning revised 1/2026 showed a physician's order shall be maintained in the medical record including parameters of oxygen administration and indication for use. 1. On 6/29/26 at 0812 hours, during the initial tour of the facility, an observation was conducted for Resident 224. Resident 224 was observed lying in bed. An oxygen concentrator was observed at bedside with oxygen tubing attached. The oxygen tubing was hanging on the IV pole with no date and label and was not inside a storage bag. Medical record review for Resident 224 was initiated on 6/29/26. Resident 224 was admitted to the facility on [DATE]. Review of Resident 224's H&P examination dated 6/25/26, showed Resident 224 had limited decision-making capacity. Review of Resident 224's Order Summary Report failed to show a physician's order for Resident 224's use of oxygen. On 6/29/26 at 0828 hours, an observation for Resident 224 and concurrent interview was conducted with the DSD. The DSD verified the oxygen tubing was hanging on the IV pole, had no date and label, and was not inside a storage bag. The DSD stated the nasal cannula should have been changed every seven days, for infection control. The DSD further stated when the oxygen was not in use, the oxygen tubing needed to be inside a storage bag for sanitary purposes. On 6/29/26 at 1518 hours, a follow-up observation, interview, and concurrent medical record review for Resident 224 was conducted with LVN 1. Resident 224 was observed lying in bed with oxygen at a rate of two liters per minute via nasal cannula. LVN 1 verified Resident 224 was receiving oxygen at two liters per minute and stated there was no order for Resident 224's oxygen use. 2. On 6/29/26 at 0831 hours, during the initial tour of the facility, Resident 3 was observed lying in bed receiving oxygen therapy at a rate of three liters per minute via nasal canula. A nasal canula dated 6/21/26, was connected to the oxygen concentrator and a nebulizer tubing was observed inside a storage bag with label dated 6/21/26. Medial record review for Resident 3 was initiated on 6/29/26. Resident 3 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 3's H&P examination dated 4/12/26, showed Resident 3 had no capacity to understand and make decisions. Review of Resident 3's Order Summary Report dated 7/1/26, showed the following physician's orders: - dated 6/13/25, to administer oxygen at three liters per minute via nasal cannula, as needed for low oxygen saturation. - dated 6/18/25, to administer ipratropium- albuterol ( bronchodilator used to control and prevent breathing difficulties) solution 3 ml via nebulizer every six hours as needed for wheezing or shortness of breath. On 6/29/26 at 0835 hours, an observation for Resident 3 and concurrent interview was conducted with LVN 3. LVN 3 verified the oxygen and nebulizer tubing was dated 6/21/26. LVN 3 stated the oxygen and nebulizer tubing need to be changed every week for infection and sanitary purposes. 3. On 6/29/26 at 0841 hours, an observation was conducted for Resident 5. Resident 5 was observed sitting in bed and receiving oxygen at a rate of two liters per minute via nasal cannula. Resident 5 nebulizer tubing was observed on top of the bedside table dated 6/21/26, and was not inside the storage bag. Medical record review for Resident 5 was initiated on 6/29/26. Resident 5 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 5's H&P examination dated 6/1/26, showed Resident 5 had the capacity to understand and make decisions. Review of Resident 5's Order Summary Report dated 7/1/26, showed the following physician's orders: - dated 5/31/26, to administer oxygen at a rate of one-two liters per minute via nasal cannula, as needed for acute hypoxic respiratory failure, - dated 6/11/26, to administer ipratropium- albuterol solution 3 ml via nebulizer every six hours as needed for wheezing or shortness of breath, and - dated 6/11/26, to administer ipratropium- albuterol solution 3 ml via nebulizer three times a day for wheezing or shortness of breath. On 6/29/26 at 0853 hours, an observation for Resident 5 and concurrent interview was conducted with LVN 3. LVN 3 verified the above findings. LVN 3 stated the nasal cannula, and nebulizer tubing should have been changed every week, and the nebulizer tubing should have been inside a storage bag when not in use for infection control. 4. On 6/29/26 at 0929 hours, an observation was conducted for Resident 164. Resident 164 was observed lying in bed receiving oxygen at a rate of five liters per minute via nasal cannula. The oxygen tubing and storage bag was dated 6/21/26. Medical record review for Resident 164 was initiated on 6/29/26. Resident 164 was admitted to the facility on [DATE]. Review of Resident 164's H&P examination dated 3/21/26, showed Resident 164 had the capacity to understand and make decisions. Review of Resident 164's Order Summary Report showed a physician's order dated 3/20/25, to administer oxygen at a rate of five liters per minute via nasal cannula as needed for low oxygen saturation. On 6/29/26 at 0944 hours, an observation for Resident 164 and concurrent interview was conducted with LVN 3. LVN 3 verified the above findings and stated the nasal cannula tubing need to be changed every week, for infection control. 5. On 6/29/26 at 1029 hours, during the initial tour of the facility, an observation was conducted for Resident 227. Resident 227 was observed lying in bed and receiving oxygen at a rate of three liters per minute via nasal cannula. Medical record review for Resident 227 was initiated on 6/29/26. Resident 227 was admitted to the facility on [DATE]. Review of Resident 227's H&P examination dated 6/29/26, showed Resident 227 had a decision-making capacity. Review of Resident 227's Order Summary Report showed a physician's order dated 6/27/26, to administer oxygen at a rate of three liters per minute via nasal cannula as needed for acute respiratory failure. On 6/29/26 at 1157 hours, a follow-up observation for Resident 227 and concurrent interview was conducted with LVN 1. An oxygen tubing was observed attached to the oxygen cylinder tank in the wheelchair was coiled and was not inside a storage bag. LVN 1 verified the findings. LVN 1 stated the oxygen tubing if not in use needed to be inside a storage bag for infection control. On 7/2/26 at 0837 hours, an interview was conducted with the DON. The DON was asked about the process when a resident was on oxygen therapy. The DON stated an order needs to be placed before starting oxygen therapy for the residents, and care plan. The licensed nurses need to label the oxygen/nebulizer tubing and storage bag with the date when it was changed. The oxygen and nebulizer tubing needs to be changed every week for infection control and sanitary purposes. The DON stated when the oxygen and nebulizer tubing was not in use, it was expected for the licensed nurses to store the tubing inside the storage bag. On 7/2/26 at 1416 hours, an interview was conducted with the Administrator and Assistant Administrator. The Administrator and Assistant Administrator were informed and acknowledged the above findings. 6. On 6/29/26 at 0936 hours, during the initial tour of the facility, Resident 68 was observed sitting in the wheelchair in her room. Resident 68 was observed receiving continuous oxygen via the nasal canula at a rate of three liters per minute. Resident 68's nasal cannula was not observed labeled with the date and the storage bag hanging on the oxygen cannister behind Resident 68's wheelchair, was labeled with the date of 6/7/26. When asked, Resident 68 stated she was receiving four liters per minute of oxygen. Medical record review for Resident 68 was initiated on 6/29/26. Resident 68 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 68's H&P examination dated 5/7/26, showed Resident 68 had the capacity to understand and make decisions. Review of Resident 68's Order Summary Report for June 2026 showed a physician's order dated 6/27/26, to administer oxygen at a rate of four liters per minute via nasal cannula as needed or continuous for the diagnosis of chronic obstructive pulmonary disease (COPD, a progressive, inflammatory lung disease that blocks airflow and causes severe breathing difficulty). On 6/29/26 at 0952 hours, an observation for Resident 68 and concurrent interview and medical record review was conducted with LVN 5. LVN 5 stated the oxygen tubing should be changed weekly. LVN 5 stated both the oxygen tubing as well as the set-up bag should be labeled and dated. LVN 5 verified Resident 68 was receiving oxygen at a rate of three liter per minute. LVN 5 stated the oxygen therapy should be administered as ordered at a rate of four liters per minute. 7. On 6/29/26 at 1017 hours, during the initial tour of the facility, Resident 10 was observed sleeping in bed with the nasal cannula on the bed. The nasal canula was connected to the oxygen concentrator and set at a rate of three liters per minute. Medical record review for Resident 10 was initiated on 6/29/26. Resident 10 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 10's H&P examination dated 9/12/25, showed Resident 10 had the capacity to understand and make decisions. Review of Resident 10's Order Summary Report for June 2026 showed a physician's order dated 4/10/26, to administer oxygen therapy at a rate of two liters per minute via nasal cannula as needed for comfort and management of shortness of breath. On 6/29/26 at 1038 hours, an observation for Resident 10, and concurrent interview and medical record review was conducted with LVN 6. LVN 6 verified Resident 10 was receiving oxygen therapy at a rate of three liters per minute. However, review of the physician's order for oxygen administration showed to administer oxygen therapy at a rate of two liters per minute via nasal cannula. LVN 6 stated the oxygen therapy should be administered as per the physician's order. On 7/2/26 at 0955 hours, an interview was conducted with the DON. The DON stated continuous oxygen therapy should be administered as per the physician's order and should be checked by the licensed nurses. The DON stated the tubing should be kept in the bag when not in use. The DON stated the oxygen tubing should be labeled with the date when it was changed every week. On 7/2/26 at 1420 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. 8. Review of facility's P&P titled Storage Maintenance and Handling of Oxygen dated January 2026 showed the facility's general rules included the No Smoking signs shall be visible where oxygen is stored or being administered. On 6/29/26 at 0949 hours, an observation was conducted for Resident 225. Resident 225 was observed in bed receiving oxygen at a rate of 1.5 liters per minute via nasal cannula connected to the humidifier from the concentrator oxygen machine. The oxygen tubing was observed touching the floor and the humidifier was undated. In addition, there was no posted signage of No Smoking outside Resident 225's room. Medical record review for Resident 225 was initiated on 6/29/26. Resident 225 was admitted to the facility on [DATE]. Review of Resident 225's H&P examination dated 6/29/26, showed Resident 225 had no capacity to understand and make decisions. Review of Resident 225's Order Summary Report dated 7/1/26, failed to show documented evidence a physician order was obtained for the use of oxygen therapy. On 6/29/26 at 1500 hours, an observation, concurrent interview and medical record review for Resident 225 was conducted with LVN 15. LVN 15 was asked at Resident 225's bedside. LVN 15 verified and acknowledged the oxygen tubing was touching the floor, the humidifier was undated, and there was no posted signage for no smoking outside the room of Resident 225. In addition, LVN 15 was asked about the physician's order for Resident 225's use of oxygen therapy. LVN 15 verified there was no physician's order for Resident 225's use of the oxygen. Cross reference F655. 9. Review of the facility's P&P titled BiPAP and CPAP Therapy dated January 2026showed the facility's guidelines to review the physician's order to determine the oxygen concentration, duration, flow, and the PEEP pressure (CPAP) for the machine. Review and follow the manufacturer's instructions for the CPAP machine setup and oxygen delivery. Medical record review for Resident 106 was initiated on 6/29/26. Resident 106 was admitted to the facility on [DATE]. Review of Resident 106's H&P examination dated 6/22/26, showed Resident 106 had the capacity to understand and make decisions. On 6/29/26 at 1225 hours, an observation and concurrent interview was conducted with Resident 106. Resident 106 was observed awake in bed and the CPAP machine on top of the bedside drawer. Resident 106 stated the CPAP machine was brought from home and her husband would help her to put on the CPAP mask at night and the nurses helped her take it off in the morning. When asked if she had seen the nurses clean the mask and tubing of her CPAP mask, Resident 106 did not answer. Review of Resident 106's Order Summary Report dated 7/1/26, showed a physician's order dated 6/25/26, for CPAP settings: Hours of use: Continuous at NOC and PRN. Further review of the Order Summary Report failed to show a physician's order for the oxygen concentration, duration, flow, and the PEEP pressure (CPAP) for the machine as per the manufacturer's instruction. On 7/1/26 at 0826 hours, an interview for Resident 106 was conducted with LVN 16. LVN 16 verified Resident 106 was using the CPAP machine. LVN 16 stated the RT does the setting of the machine and the licensed nurses were responsible for turning on and off for the resident. LVN 16 stated the charge nurses were responsible for cleaning and maintaining the CPAP machine. On 7/1/26 at 0843 hours, an interview and concurrent medical record review for Resident 106 and 225 was conducted with the ADON. The ADON was informed of the findings and stated the oxygen humidifier should have been labeled and dated, the oxygen tubing should not be touching the floor and there should be a posted signage of No Smoking on the doorway. The ADON verified and acknowledged there was no order for Resident 225's oxygen use. The ADON verified Resident 106's CPAP machine physician's order had no specific setting order as per the manufacturer's instruction. On 7/2/26 at 1416 hours, an interview and concurrent medical record review for Resident 106 and 225 was conducted with the DON. The DON was informed and verified the above findings. Cross reference F 656, example # 2. 10. Medical record Review for Resident 231 was initiated on 6/29/26. Resident was admitted to the facility on [DATE]. Review of Resident 231's Order Summary Report dated 6/30/26 showed a physician's order dated 6/24/26, to administer oxygen at a rate of 2-3 liters per minute via nasal cannula continuously. a. On 6/29/26 at 1012 hours, during the initial tour, Resident 231's oxygen concentrator with a humidifier attached was at bedside. The humidifier was observed not labeled with a date. On 6/29/26 at 1516 hours, an observation Resident 231's oxygen concentrator and concurrent interview was conducted with LVN 12. LVN 12 verified the humidifier was observed not labeled with date. b. On 7/1/26 at 0836 hours, a follow-up observation of Resident 231 was conducted. Resident 231 was in the room, lying in bed. An oxygen with attached nasal cannula was observed on a wheelchair by the foot of Resident 231's bed. The nasal cannula and plastic bag was observed not labeled with a date. Resident 231 stated the wheelchair and the oxygen belonged to her. Resident 231 further stated she did not know when the nasal cannula was changed. On 7/1/26 at 0836 hours, an observation of Resident 231 and concurrent interview was conducted with LVN 8. LVN 8 verified Resident 231's oxygen nasal cannula was not labeled with a date. LVN 8 stated the nasal cannula should be labeled with a date. On 7/2/26 at 1023 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 11. Medical record review for Resident 236 was initiated on 6/29/26. Resident 236 was admitted to the facility on [DATE], and readmitted on [DATE]. On 6/29/26 at 1006 hours, during the initial tour of the facility, Resident 236 was observed in the resident's room with oxygen at the rate of two liters per minute via nasal cannula. The humidifier was observed not labeled with date. On 6/29/26 at 1518 hours, an observation of Resident 236's oxygen nasal cannula and concurrent interview was conducted with LVN 12. LVN 12 verified the resident's humidifier was observed not labeled with a date. On 7/2/26 at 1023 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate dialysis care was provided for four of 34 final sampled residents (Residents 6, 201, 227 and 228) reviewed for dialysis services. * The facility failed to ensure Resident 6's left upper arm dialysis shunt was being monitored for bruit and thrill. Additionally, the facility failed to ensure Resident 6's hemodialysis communication records were complete, and failed to ensure Resident 6's intake and output were accurately monitored. * The facility failed to ensure Resident 201 and 228's's fluid restriction was accurately monitored per physician's order. * The facility failed to ensure the emergency dialysis kit was kept at Resident 227's bedside. These failures had the potential for the residents not to receive the necessary and/or immediate interventions to manage the dialysis care, access site, and prevent possible medical complications. Findings: Review of the facility's P&P titled Dialysis Management revised 3/2023 showed to provide the residents who require dialysis care, services consistent with professional standards of practice, a comprehensive person-centered care plan which meets the residents' goals and preferences. 1. Medical record review for Resident 227 was initiated on 6/29/26. Resident 227 was admitted to the facility on [DATE]. Review of Resident 227's H&P examination dated 6/29/26, showed Resident 227 had a decision-making capacity. Review of Resident 227's admission Record showed Resident 227 had a diagnosis of ESRD (End Stage Renal Disease) and was dependent on renal dialysis. Review of Resident 227's Order Summary Report showed a physician's order dated 6/27/26, for hemodialysis every Monday, Wednesday, and Friday at the dialysis center. On 6/29/26 at 1029 hours, during the initial tour of the facility, an observation and concurrent interview was conducted for Resident 227. Resident 227 was observed lying in bed. Resident 227 was observed with left upper chest perma-catheter and a left upper arm AV fistula. Resident stated that she went to dialysis every Monday, Wednesday, and Friday. No emergency dialysis kit was observed at bedside. On 6/29/26 at 1157 hours, an observation and concurrent interview for Resident 227 was conducted with LVN 1. LVN 1 verified there was no emergency dialysis kit at Resident 227's bedside. LVN 1 stated the residents who received dialysis needed to have an emergency dialysis at bedside, and residents were at risks for bleeding. 2. Medical record review for Resident 228 was initiated on 6/29/26. Resident 228 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 228's H&P examination dated 6/23/26, showed Resident 228 had a decision-making capacity. Review of Resident 228's admission Record showed Resident 228 had a diagnosis of ESRD and was dependent on renal dialysis. Review of Resident 228's Order Summary Report dated 7/1/26, showed the following physician's orders: - dated 6/22/26, for hemodialysis every Monday, Wednesday, and Friday at the dialysis facility; - dated 6/22/26, for 1500 ml fluid restriction (nursing-780 ml, and dietary-720 ml); and - dated 6/22/26, to monitor intake and output every shift. Review of Resident 228's MAR for the month of 6/2026 showed 1500 ml fluid restriction monitoring by the licensed nurses. Resident 228's monitoring of fluid restrictions on each shift by the licensed nurses showed a check mark on each entry. There was no specific amount of fluid consumed on each shift every day. On 6/30/26 at 1015 hours, an observation was conducted for Resident 228. Resident 228 was observed sitting in a wheelchair with 500 ml water pitcher at the bedside table. On 7/1/26 at 0936 hours, an interview and concurrent medical record review for Resident 228 was conducted with the ADON. The ADON verified the above findings. The ADON stated the monitoring of the fluid restriction was inaccurate when the licensed nurses placed only check marks on each shift in the MAR. On 7/2/26 at 0837 hours, an interview was conducted with DON. The DON was informed and verified the above findings. On 7/2/26 at 1416 hours, an interview was conducted with the Administrator and Assistant Administrator. The Administrator and Assistant Administrator were informed and acknowledged the above findings. 3. Review of the facility's P&P titled Dialysis Management revised 3/2023 showed the licensed nurses assess, manage, and report changes in bruit or thrill, bleeding, infections, hypertension or hypotension, hyperkalemia, etc. Medical record review for Resident 6 was initiated on 6/29/26. Resident 6 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 6's H&P examination dated 9/24/25, showed Resident 6 had no capacity to understand and make decisions. Review of Resident 6's Order Summary Report dated 6/30/26, showed a physician's order dated 3/14/26, for Resident 6's hemodialysis schedule three times a week, every Tuesday, Thursday, and Saturdays with Dialysis Center A. The pick-up time was 0850 hours. a. Review of Resident 6's Dialysis Communication Record showed the following incomplete documentation: - dated 6/18/26, the type of access was AV shunt/AV fistula; however, the location of the access site was blank, - dated 6/25/26, the type of access was AV shunt/AV fistula; however, the location of the access site was blank, - dated 6/27/26, the type of access was AV shunt/AV fistula; however, the location of the access site was blank, and - dated 6/30/26, the type of access was AV shunt/AV fistula; however, the location of the access site was blank. b. Review of Resident 6's Order Summary Report dated 6/30/26, showed the following physician's orders: - dated 3/14/26, to monitor Resident 6's hemodialysis site for redness, swelling, drainage and pain, every shift. - dated 4/22/26, no BP, IV and blood draw to Resident 6's left arm. - dated 5/29/26, okay to use needles on Resident 6's left arm fistula as tolerated. Further review of the Resident 6's Order Summary Report dated 6/30/26, failed to show a physician's order for the monitoring of Resident 6's left upper arm hemodialysis access for bruit and thrill. Review of Resident 6's medical record failed to show the licensed nurses' documentation for the monitoring of Resident 6's hemodialysis access site for bruit and thrill on the days Resident 6 did not have the hemodialysis treatments. On 6/30/26 at 1430 hours, an interview and concurrent medical record review for Resident 6 was conducted with LVN 4. LVN 4 stated Resident 6 received hemodialysis treatments on Tuesdays, Thursday, and Saturdays. LVN 4 stated Resident 6's hemodialysis access was in the left upper arm and the licensed nurses were responsible for checking the resident's hemodialysis access site for bruit and thrill, and documented the assessments in the pre- and post- dialysis communication record. LVN 4 stated the dialysis communication record was used as a form of communication between the facility and the dialysis center and all the sections on the form should be completed. LVN 4 reviewed the dialysis communication records for the above dates and verified the above findings. When asked about the monitoring of Resident 6's left arm hemodialysis access for bruit and thrill on the days Resident 6 did not have hemodialysis treatments, LVN 4 reviewed Resident 6's medical record and stated Resident 6 did not have a physician's order for the monitoring of bruit and thrill. LVN 4 verified there was no documentation of the assessment and monitoring of Resident 6's hemodialysis access site for bruit and thrill on the days Resident 6 did not have the hemodialysis treatments. c. Review of Resident 6's Order Summary Report dated 6/30/26, showed the following physician's orders dated 3/14/26: - to monitor Resident 6's daily intake and output, every shift. - to monitor Resident 6's daily intake in 24 hours, every evening shift. Review of Resident 6's MAR for 6/2026 showed inconsistent monitoring of Resident 6's intake. For example: For the monitoring of Resident 6's intake every shift, the licensed nurses documented: - on 6/1/26: 500 ml for the day shift, 250 ml for the evening shift, and 80 ml for the night shift; - on 6/2/26: 200 ml for the day shift, 240 ml for the evening shift, and 80 ml for the night shift; - on 6/3/26: 240 ml for the day shift, 240 ml for the evening shift, and 80 ml for the night shift; - on 6/4/26: 100 ml for the day shift, 300 ml for the evening shift, and 80 ml for the night shift; - on 6/5/26: 200 ml for the day shift, 300 ml for the evening shift, and 80 ml for the night shift; - on 6/6/26: 100 ml for the day shift, 240 ml for the evening shift, and 80 ml for the night shift; and - on 6/10/26, 200 ml for the day shift, 320 ml for the evening shift, and 80 ml for the night shift. However, further review of Resident 6's MAR for 6/2026 showed for the monitoring of Resident 6's 24-hour intake, the licensed nurses documented the following: - on 6/1: x2 (times two), - on 6/2: x2, - on 6/3: x2, - on 6/4: 300 ml, - on 6/5: 300 ml, - on 6/6: 420 ml, and - on 6/10/26: x6. On 6/30/26 at 1450 hours, an interview and concurrent medical record review for Resident 6 was conducted with LVN 6. LVN 6 stated Resident 6 was not on fluid restrictions; however, there was a physician's order to monitor the resident's intake and output every shift, and daily. LVN 6 stated the licensed nurses were responsible for the monitoring of intake and output, and documented the amount in the MAR. LVN 6 reviewed Resident 6's MAR for 6/2026 and verified the above findings. On 7/2/26 at 0948 hours, an interview and concurrent medical record review for Resident 6 was conducted with the DON. The DON stated the licensed nurses were responsible for the monitoring of the resident's hemodialysis access and assessing for bruit and thrill, every shift, to ensure the hemodialysis access site was working properly. The DON stated the licensed nurses were responsible for completing the pre- and post- dialysis assessments and the licensed nurses should document the dialysis type and location in the dialysis communication record. The DON stated for the residents with monitoring of the intake and output, the intake should be documented by the licensed nurses in the MAR, and the documentation should be accurate. The DON reviewed Resident 6's MAR for the monitoring of intake and output and verified the above findings. On 7/2/26 at 1420 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. 4. Review of the facility's P&P titled Dialysis-Care Planning dated December 2025 showed the comprehensive care plan will be developed for residents receiving dialysis includes the monitoring of vital signs, weights, nutritional and fluid needs, or any restrictions. Fluid restrictions and interventions when indicated. Medical record review for Resident 201 was initiated on 6/29/26. Resident 201 was admitted to the facility on [DATE], with diagnosis of acute kidney failure and chronic kidney disease. Review of Resident 201's H&P examination dated 5/22/26, showed Resident 201 had the capacity to make medical decisions. Review of Resident 201's Order Summary Report dated 7/1/26, showed a physician's order dated 5/25/26, for the fluid restriction of 1500 ml: Nursing - 780 ml and Dietary - 720 ml. Another physician's order dated 5/22/26, showed to monitor intake and output every shift. Review of Resident 201's Plan of Care dated 5/26/26, showed a care plan problem addressing Resident 201 needed dialysis related to the diagnoses. The interventions included the fluid restriction of 1500 ml per day. Review of Resident 201's Documentation Survey Report dated 7/1/26, showed the amount of fluid intake on each meal per day. Review of Resident 201's MAR for the month of 6/2026 showed the 1500 ml fluid restriction monitoring by the licensed nurses. However, the monitoring of the fluid restriction on each shift by the licensed nurses showed a check mark on each entry. There was no documentation of the specific amount of fluid Resident 201 consumed on each shift everyday. On 6/30/26 at 1421 hours, an interview for Resident 201 was conducted with CNA 3. CNA 3 verified Resident 201 was on fluid restriction. CNA 3 stated the amount of fluids from the food tray was recorded on each meal on the fluid intake log. CNA 3 verified she recorded only the fluids taken from the resident food tray on each meal and not the fluids on the resident's water pitcher at bedside. On 7/1/26 at 0850 hours, an interview and concurrent medical record review for Resident 201 was conducted with the ADON. The ADON verified Resident 201 was on dialysis every Monday, Wednesday, and Friday morning. The ADON was asked about the fluid restriction of the resident. The ADON verified the physician's order for fluid restriction of 1500 ml per day with a breakdown of amount of fluids for nursing and dietary, The ADON was informed of the findings. The ADON verified the monitoring of the fluid restriction was inaccurate monitoring because the licensed nurses placed only check mark each shift on the MAR. On 7/2/26 at 1416 hours, an interview and concurrent medical record review for Resident 201 was conducted with the DON. The DON was informed and verified the above findings.

Based on observations, interview, facility records review, and facility P&P review, the facility failed to ensure the medications were properly stored for one of 34 final sampled residents (Resident 12), one nonsampled resident (Resident 81), and in two of two medication rooms (Medication Rooms A and B). * The facility failed to ensure the medications were stored according to the manufacturer label in Medication Rooms A and B. * The facility failed to ensure the Anasept (an antimicrobial skin and wound cleanser) was not left on top of Resident 81's television stand in Room A. * The facility failed to ensure the medicine cup containing a white color cream and packet of Calma Plex (anorectal paste - provides soothing relief and external protection for irritated, inflamed perianal skin) were not left in Resident 12's room. These failures had the potential to compromise medication's stability, potency, and effectiveness and medication access of unauthorized persons. Findings: Review of the facility's P&P titled Labeling and Storage of Drugs revised 1/2025 showed the drugs shall be stored in an orderly manner in cabinets, drawers, or carts of sufficient size to prevent crowding. Review of the facility's P&P titled Pharmaceutical Service – Labeling and Storage of Drugs revised 1/2025 showed the drugs shall be stored at appropriate temperatures. 1. Review of the facility's document titled Medication Room Temperature Log for Medication Room A for April 2026 showed the temperature was 78 degrees Fahrenheit for the following dates and shifts: - dated 4/3/26 at PM shift; - dated 4/5/26 at PM shift; - dated 4/6/26 at PM shift; - dated 4/12/26 at AM shift; - dated 4/13/26 at AM and PM shift; - dated 4/16/26 at AM and PM shift; - dated 4/21/26 at AM shift; - dated 4/24/26 at AM shift; and - dated 4/27/26 at PM shift; Review of the facility's document titled Medication Room Temperature Log for Medication Room A for May 2026 showed the temperature was 78 degrees Fahrenheit for the following dates and shifts: - dated 5/3/26 AM and PM shift; - dated 5/5/26 AM shift; - dated 5/11/26 AM shift; - dated 5/18/26 AM shift; - dated 5/23/26 AM shift; - dated 5/25/26 AM and PM shift; - dated 5/26/26 AM shift; and - dated 5/27/26 AM and PM shift; Review of the facility's document titled Medication Room Temperature Log for Medication Room A for June 2026 showed the temperature was 78 degrees Fahrenheit for the following dates and shifts: - dated 6/2/26 at AM shift; - dated 6/3/26 at AM shift; - dated 6/4/26 at AM and PM shift; - dated 6/8/26 at AM and PM shift; - dated 6/11/26 at AM and PM shift; - dated 6/14/26 at AM and PM shift; - dated 6/19/26 at AM and PM shift; - dated 6/20/26 at AM shift; - dated 6/23/26 at AM and PM shift; - dated 6/26/26 at AM shift; - dated 6/28/26 at AM and PM shift; and - dated 6/30/26 at AM shift; On 6/30/26 at 1035 hours, an observation of Medication Room A and concurrent interview was conducted with the ADON. The ADON checked the thermometer in Medication Room A and stated Medication Room A temperature was 78 degrees Fahrenheit. Medication Room A was observed stored with medications and intravenous emergency kit medications. On 6/30/26 at 1429 hours, another observation of Medication Room A and concurrent interview was conducted with the ADON. The ADON stated the temperature in Medication Room A was still 78 degrees Fahrenheit. Medication Room A was observed with an intravenous emergency kit medications. The ADON opened the intravenous emergency kit. The intravenous emergency kit contained the following: - one carton of 50% injectable dextrose (immediate treatment of low blood sugar), the product label showed to store at 68 to 77 degrees Fahrenheit; and - three bags of injectable metronidazole (antibiotic), the product label showed to store at 68 to 77 degrees Fahrenheit. The ADON verified the product labeling of dextrose and metronidazole medications. On 7/1/26 at 1352 hours, a follow-up observation and concurrent interview were conducted with the ADON. Medication Room A was observed with the following medications: - three bottles of acetaminophen (pain reliever and fever reducer) 500 mg, the product label showed to store at 68 to 77 degrees Fahrenheit; - three bottles of acetaminophen 325 mg, the product label showed to store at 68 to 77 degrees Fahrenheit; and - two cartons of loperamide (antidiarrheal) caplets 2 m, the product label showed to store at 68 to 77 degrees Fahrenheit. The ADON verified the product labeling of the above medications. 2. Review of the facility's document titled Temperature Log for Medication Room B for April 2026 showed the temperature was 78 degrees Fahrenheit during PM shift on 4/2, 4/7, 4/10, 4/11, 4/13, 4/14, and 4/23/26. The temperature log further showed the temperature range was 68 to 77 degrees Fahrenheit with instructions of any deviation outside the set temperature range must be immediately reported to the DON/Administrator and reported to the pharmacy. Review of the facility's document titled Temperature Log for Medication Room B for June 2026 showed the temperature was 78 degrees Fahrenheit during AM shift on 6/30/26. On 6/30/26 at 1054 hours, an observation of Medication Room B and concurrent interview was conducted with the ADON. The ADON checked the thermometer in Medication Room B and stated Medication Room B temperature was 78 degrees Fahrenheit. The ADON further stated Medication Room B was warm. Medication Room B was observed stored with medications and intravenous emergency kit medications. On 6/30/26 at 1413 hours, another observation of Medication Room B and concurrent interview was conducted with the ADON. The ADON stated the temperature in Medication Room B was still 78 degrees Fahrenheit. Medication Room B was observed with an intravenous emergency kit medication. The ADON opened the intravenous emergency kit. The intravenous emergency kit contained the following medications: - one carton of 50% injectable dextrose, the product label showed to store at 68 to 77 degrees Fahrenheit; and - three bags of injectable metronidazole, the product label showed to store at 68 to 77 degrees Fahrenheit. The ADON verified the product labeling of dextrose and metronidazole medications. On 7/1/26 at 1403 hours, a follow-up observation and concurrent interview was conducted with the ADON. Medication Room B was observed with the following medications: - two bottles of docusate sodium sulfate (stool softener) 100 mg, the product label showed to store at 59 to 77 degrees Fahrenheit; - two cartons of bisacodyl (antidiarrheal) suppositories 10 mg, the product label showed to store below 77 degrees Fahrenheit; - one carton of acetaminophen suppositories 650 mg, the product label showed to store at 68 to 77 degrees Fahrenheit; and - one carton of hemorrhoidal suppositories, the product label showed to store at 68 to 77 degrees Fahrenheit. The ADON verified the product labeling of the medications above. On 7/2/26 at 1104 hours, an interview was conducted with the DON. The DON was informed and acknowledged the temperature in Medication Room A and Medication Room B were above 77 degrees Fahrenheit. The DON acknowledged inside Medication Rooms A and B contained drugs with product labeling to store at 68 to 77 degrees Fahrenheit. The DON stated storing the medications at a proper temperature was important to maintain the potency of the medications. 3. On 6/29/26 at 0948 hours, during initial tour of the facility, a white spray bottle of Anasept was observed on top of Resident 81's television stand. Medical record review for Resident 81 was initiated on 6/29/26. Resident 81 was admitted to the facility on [DATE]. Review of Resident 81's Progress Note dated 6/9/26, showed Resident 81 had no capacity to make decision. On 6/29/26 at 1521 hours, an observation and concurrent interview was conducted with LVN 12. LVN 12 verified the Anasept spray bottle was left on Resident 81's television stand. LVN 12 stated the Anasept spray bottle should not have been left in the resident's room. On 6/30/26 at 0908 hours, an interview was conducted with LVN 8. LVN 8 stated the Anasept spray bottle did not belong to Resident 81. LVN 8 further stated it must have been left in Resident 81's room by mistake. On 7/2/26 at 1007 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. Review of the facility's P&P titled Labeling and Storage of Drugs revised 1/2025 showed drugs shall be stored in an orderly manner in cabinets, drawers, or carts of sufficient size to prevent crowding. 4. On 6/29/26 at 0933 hours, during the initial tour of the facility, Resident 12 was observed in bed. A medication cup containing a white cream and tongue depressor and a packet of Calma Plex was observed on Resident 12's bedside drawer. Resident 12 shared the room with two other residents. Medical record review for Resident 12 was initiated on 6/29/26. Resident 12 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 12's H&P examination dated 4/22/26, showed Resident 12 had no capacity to understand and make decisions. Review of Resident 12's Self Administration of Medication assessment dated [DATE], showed the documentation Resident 12 was not mentally or physically able to administer her own medication. On 6/29/26 at 0953 hours, an observation and concurrent interview was conducted with LVN 5. LVN 5 stated Resident 12's treatments were provided by the treatment nurses. LVN 5 stated the treatment nurse would prepare the topical creams and the remainder cream should be discarded and not left at the bedside. LVN 5 verified the above findings. LVN 5 stated the topical cream should have been discarded and the packet of Calma Plex should be kept in the treatment cart. On 7/2/26 at 0955 hours, an interview and concurrent medical record review for Resident 1 was conducted with the DON. The DON stated if the residents had no capacity, the resident should not self-administer the medication. The DON further stated for those residents had no capacity, the medications should not be left at the bedside. On 7/2/26 at 1420 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen. * The facility failed to ensure the proper labeling of food and beverages in the kitchen. * The facility failed to ensure the items in the refrigerator was discarded after the use-by date. * The facility failed to ensure the kitchen utensils and equipment were stored or kept in sanitary conditions. * The facility failed to ensure the kitchen utensils and equipment were in good condition. *The facility failed to properly air dry the kitchen equipment. *The facility failed to ensure the temperature monitoring of the food kept in the emergency food supply room. * The facility failed to ensure Dietary Aide 1 performed hand hygiene after wearing disposable gloves in the kitchen and before donning new disposable gloves. * The facility failed to ensure the refrigerator fans were clean. These failures had the potential for exposure to food-borne illnesses for a medical vulnerable population of 168 residents who received food prepared in the kitchen.Findings:Review of the facility's document titled Diet Roster Rollup dated 6/29/26, showed 168 of 172 residents in the facility received food prepared in the kitchen. 1. According to USDA Food Code 2022, Section 3-501.17, Ready-To-Eat, Time/Temperature Control for Safety Food, Date Marking (undated), showed date marking requirements apply to containers of processed food that have been opened and to food prepared, if held for more than 24 hours, shall be clearly marked to indicate the date or day by which the food shall be consumed on the premise, sold, or discarded. Review of the facility's P&P titled Food Receiving and Storage revised 1/2026, showed when food, food products or beverages are delivered to the nursing home, the facility staff must ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all foods stored in the refrigerator or freezer as indicated. Practices to maintain safe refrigerated storage include: c. labeling dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable) or discarded.Review of the facility's P&P titled Refrigerators and Freezers revised 1/2026, showed all foods shall be appropriately dated to ensure proper rotation by expiration dates. Use-by dates will be complete with expiration dates on all prepared food in the refrigerators. Expiration dates on unopened food will be observed and use-by dates indicated once food is opened.On 6/29/26 at 0800 hours, an initial tour of the kitchen was conducted with the DSS. The following was observed:- two opened bags of chicken breasts inside Freezer A were not labeled with the opened or use-by dates; - a box of grape juice and a box of black and white tea were connected to the juice dispenser. The juice boxes were not labeled with the opened date. The label on the juice boxes showed to use the product 45 days after connecting; and- a box of prune juice was connected to the juice dispenser. The box was labeled with the date 3/10/26. The DSS stated she did not know if that was the received or opened date.The DSS verified the above findings and stated she did not know when the above items were opened. 2. Review of the facility's P&P titled Refrigerators and Freezers revised 1/2026, showed all foods shall be appropriately dated to ensure proper rotation by expiration dates. Use-by dates will be complete with expiration dates on all prepared food in the refrigerators. Expiration dates on unopened food will be observed and use-by dates indicated once food is opened.On 6/29/26 at 0800 hours, an initial tour of the kitchen was conducted with the DSS. The following was observed:- a tray containing multiple small plastic cups of Italian dressing (inside Refrigerator C) was labeled with the use-by date of 6/27/26;- a container of jelly (inside Refrigerator D) was labeled with the use-by date of 6/27/26;- a container of ham slices (inside Refrigerator D) was labeled with the use-by date of 6/28/26; and- a bowl of yogurt and two bowls of pudding (inside Refrigerator C) was labeled with the use-by date of 6/28/26.The DSS verified the above findings. 3. According to the USDA Food Code 2022, Section 4-601.11, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils:(A) Equipment food-contact surfaces and utensils shall be clean to sight and touch.(B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations.(C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to USDA Food Code 2022, 4-602.13, Non-Food Contact Surfaces (undated) showed the presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests.Review of the facility's P&P titled Safe Food Preparation revised 1/2025, showed cross-contamination can occur when harmful substances, i.e., chemical or disease-causing microorganisms are transferred to food by hands (including gloved hands), food contact surfaces, sponges, cloth towels, or utensils that are not adequately cleaned. Examples of ways to reduce cross-contamination include but are not limited to: clean and sanitize work surfaces, including cutting boards and food-contact equipment (e.g., food processors, blenders, preparation tables, knife blades, can openers, and slicers), between uses and consistent with applicable code.Review of the facility's P&P titled Cleaning and Disinfection of Utensils revised 1/2026, showed all food-contact items and surfaces shall be maintained in a sanitary condition and good repair to protect patients from contamination and foodborne illness. Utensils, counters, shelves, and equipment shall be kept clean, disinfected/sanitized as appropriate, and in good repair. Clean and disinfected utensils shall be air dried and stored to prevent contamination. a. On 6/29/26 at 0800 hours, an initial tour of the kitchen was conducted with the DSS. The following were observed:- multiple plastic container lids stored inside a clear plastic bin. The clear plastic bin was observed with debris and food particles at the bottom of the bin;- multiple stacked small white bowls stored inside a clear plastic bin. The clear plastic bin was observed with debris and food particles at the bottom of the bin;- a food mixer observed with a dry brown stain and multiple dry brown particles inside the bowl. A paper towel was used to wipe the mixer bowl and multiple dry particles or debris were observed on the paper towel; - a meat slicer was observed with multiple dry food residue and food particles on multiple parts of the machine;- the drawer storing the kitchen utensils was observed with one black glove, a wet-white substance, and multiple dry black-brown particles;- a pizza slicer observed with dry food particles; and- a yellow cutting board observed stained. The DSS verified the above findings. The DSS stated the bins and kitchen equipment should be clean. b. On 6/30/26 at 1005 hours, a puree preparation observation was conducted of Dietary Aide 1. Dietary Aide 1 was observed preparing the black bean puree. The blender was observed with white colored food residue. Dietary Aide 1 verified the above findings and was observed removing the blender to be washed. 4. According to the USDA Food Code 2022, Section 4-101.11, Multiuse, Characteristics (undated) showed for materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be safe, durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition.Review of the facility's P&P titled Cleaning and Disinfection of Utensils revised 1/2026, showed all food-contact items and surfaces shall be maintained in a sanitary condition and good repair to protect patients from contamination and foodborne illness. Utensils, counters, shelves, and equipment shall be kept clean, disinfected/sanitized as appropriate, and in good repair. Surfaces shall be free from breaks, corrosion, open seams, cracks, and chipped areas which preclude cleaning and sanitizing. On 6/29/26 at 0800 hours, an initial tour of the kitchen was conducted with the DSS. The following were observed:- two chipped spatulas;- one melted green plastic container lid;- one cracked blue plastic container lid; and- one white cutting board observed stained, discolored, and heavily marred on both sides.The DSS verified the above findings. 5. According to the USDA Food Code 2022, 4-901.11, Equipment and Utensils, Air-Drying Required (undated), after cleaning and sanitizing, equipment, and utensils shall be air-dried or used after adequate draining before getting in contact with food.Review of the facility's P&P titled Cleaning and Disinfection of Utensils revised 1/2026, showed all food-contact items and surfaces shall be maintained in a sanitary condition and good repair to protect patients from contamination and foodborne illness. Clean and disinfected utensils shall be air dried and stored to prevent contamination. Air dry: Allow items to air dry completely; do not towel dry. Store in a clean, protected area. On 6/29/26 at 0800 hours, an initial tour of the kitchen was conducted with the DSS. The following were observed:- six water pitchers for the resident use, stored upside down with the lid on and visibly wet;- multiple clear plastic cups stored upside down and visibly wet;- two clear plastic bins stacked and visibly wet;- two trays of plastic bowls stored upside down and visibly wet; and- two scoopers (dishers) stored in the drawer wet.The DSS verified the above findings. The DSS stated the items should be completely dried before placing them on the rack or drawer and ready for use. 6. Review of the facility's P&P titled Food Receiving and Storage revised 1/2026, showed dry storage may be in a room or area designated for the storage of dry goods, such as single service items, canned goods, and packaged or containerized bulk food that is not Potentially Hazardous Foods. Controlling temperature, humidity, and rodent and insect infestation helps prevent deterioration or contamination of the food. On 6/29/26 at 0800 hours, an initial tour of the kitchen was conducted with the DSS. The emergency food supply was observed inside a room labeled Emergency Food Storage. Inspection of the room failed to show a thermometer inside the room. The DSS verified the above findings. The DSS was asked about the monitoring of the temperature inside the emergency food supply room and the DSS stated the emergency food supply was moved to the new dry storage location a week ago. The DSS stated the temperature inside the room was not being monitored. 7. According to the USDA Food Code 2022, 3-304.15 Gloves, Use Limitation, showed hands must be washed before donning gloves.Review of the facility's P&P titled Hand Hygiene revised 2/2025, showed hand hygiene is always the final step after removing and disposing of personal protective equipment.On 6/30/26 at 1005 hours, during the puree food preparation observation with Dietary Aide 1, the following were observed:- Dietary Aide 1 was observed wearing gloves while preparing the tamale pie puree. Dietary Aide 1 was observed removing the gloves and donning a new pair of gloves. Dietary Aide 1 was not observed washing his hands prior to donning the new pair of gloves; and- Dietary Aide 1 was observed wearing gloves while preparing the pureed carrots. Dietary Aide 1 was observed flipping through the recipe book, removing the glove in his right hand, scooping thickener powder from the bin, donning a new glove, and adding thickener to the pureed carrots. Dietary Aide 1 was not observed washing his hands prior to donning the new glove.On 6/30/26 at 1105 hours, an interview was conducted with Dietary Aide 1. Dietary Aide 1 stated after the removal of the gloves and prior to donning a new pair of gloves, the hands should be washed. Dietary Aide 1 verified he did not wash his hands in between glove use and prior to donning a new pair of gloves during puree preparation. 8. Review of the facility's P&P titled Refrigerators and Freezers revised 1/2026, showed the Supervisors or maintenance staff will inspect the refrigerators and freezers monthly for gasket condition, fan condition, presence of rust, excess condensation, and any other damage or maintenance needs. The refrigerators and freezers will be kept clean, free of debris, and mopped with a sanitizing solution on a scheduled basis and more often as necessary. On 6/29/26 at 0800 hours, an initial tour of the kitchen was conducted with the DSS. The following were observed:- the fan inside of refrigerator A was observed with blackish, fussy substances. A paper towel was used to wipe the fan and blackish-brown residue was observed on the paper towel, and- the fans inside Refrigerator B were observed with blackish-grey substances. A paper towel was used to wipe the fan and blackish-grey fuzzy residue were observed on the paper towel.The DSS verified the above findings. The DSS stated the refrigerators should be clean and the cleaning of the fans inside the refrigerators should be part of the cleaning schedule. On 7/2/26 at 1330 hours, an interview was conducted with the Administrator, RD, and DSS. The Administrator, RD, and DSS were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive person-centered care plan was revised to reflect the residents' current care needs and interventions for two of 34 final sampled residents (Residents 3 and 154). * The facility failed to ensure Resident 3's care plan interventions for the use of the pain medications was revised to include the nonpharmacological interventions as per physician's order. * The facility failed to ensure Resident 154's care plan for the risk for fall was revised to include the use of the pad alarm in bed as per the physician's order. These failures posed the risk for the residents to not receive individualized and person centered care in accordance with their assessed needs. Findings: Review of the facility's P&P titled Develop-Implement Comprehensive Care Plans revised 1/2026 showed the care plans must be person-centered and reflect the resident's goals for admission and desired outcomes, interventions that reflect the resident's cultural preferences, values, and practices. The interdisciplinary team, including the physician, a registered nurse, the resident or the resident's representative and other staff determined by the resident's needs will develop the care plan with corresponding interventions for care that are in accordance with professional standards of practice and accounting for residents' experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident. 1. Medical record review for Resident 3 was initiated on 7/1/26. Resident 3 was readmitted to the facility on [DATE]. Review of Resident 3's H&P examination dated 2/13/26, showed Resident 3 had capacity to understand and make decisions. Review of Resident 3's Order Summary Report showed the following physician's orders: - dated 12/20/23, acetaminophen (pain reliever): nonpharmacological approach attempted prior to administration of pain medication- (1) repositioning; (2) dim light/quiet environment; (3) hot/cold application; (4) relaxation techniques; (5) distraction; (6) music; (7) other every shift; - dated 12/20/23, hydrocodone-acetaminophen (pain reliever): nonpharmacological approach attempted prior to administration of pain medication- (1) repositioning; (2) dim light/quiet environment; (3) hot/cold application; (4) relaxation techniques; (5) distraction; (6) music; (7) other every shift; - dated 12/29/25, morphine sulfate (pain reliever): nonpharmacological approach attempted prior to administration of pain medication- (1) repositioning; (2) dim light/quiet environment; (3) hot/cold application; (4) relaxation techniques; (5) distraction; (6) music; (7) other every shift; and - dated 12/20/23, tramadol(pain reliever): nonpharmacological approach attempted prior to administration of pain medication- (1) repositioning; (2) dim light/quiet environment; (3) hot/cold application; (4) relaxation techniques; (5) distraction; (6) music; (7) other every shift; Review of Resident 3's care plan showed the care plan problem to address the following: - the resident's use of Norco (hydrocodone) medication for pain management revised on 8/4/25, did not include the physician's ordered nonpharmacological approach as interventions; - resident's risk for pain related to fibromyalgia revised on 8/4/25, included to administer analgesia as per orders but did not include the physician ordered nonpharmacological approach as interventions; and - the resident's use of the morphine sulfate medication for pain management revised on 2/6/26, did not include the physician's ordered nonpharmacological approach as interventions. On 7/1/26 at 1455 hours, an interview and concurrent medical record review for Resident 3 was conducted with the ADON. The ADON verified the above findings for Residents 3. The ADON stated the care plans should reflect all the interventions including the nonpharmacological interventions being provided to the resident per the physician's order. On 7/2/26 at 1339 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings for Resident 3. 2. On 6/29/26 at 1304 hours, during the initial tour of the facility, Resident 154 was observed in bed with the pad alarm in placed in bed. Medical record review for Resident 154 was initiated on 6/29/26. Resident 154 was admitted to the facility on [DATE]. Review of Resident 154's H&P examination dated 6/3/26, showed Resident 154 had no capacity to understand and make decision. Review of Resident 154's Fall Risk Evaluation dated 6/1/26, showed Resident 154 was high risk for falls. Review of Resident 154's Order Summary Report dated 7/1/26, showed a physician's order dated 6/6/26, for a pad alarm when in bed to alert the staff when the resident attempts to get up from the bed unassisted, poor safety awareness, and increase fall risk. Review of Resident 154's plan of care showed a care plan problem dated 6/2/26, addressing Resident 154's risk for fall. However, the care plan interventions failed to show the use of pad alarm in bed as ordered was included. On 6/30/26 at 1429 hours, an observation and concurrent interview with CNA 3 at Resident 154's bedside. CNA 3 was asked about Resident 154's pad alarm placed in bed. CNA 3 verified Resident 154's use of the bed alarm because the resident getting up unassisted from the bed. On 7/1/26 at 1423 hours, an interview and concurrent medical record review for Resident 154 was conducted with the ADON. The ADON verified the physician order for the pad alarm in bed for unassisted getting out of bed and for safety. The ADON verified Resident 154 was a high risk for fall. The ADON was asked for the care plan for fall and was able to show the care plan for fall dated 6/2/26. The ADON verified the pad alarm was not included on the interventions for fall. On 7/2/26 at 1416 hours, an interview and concurrent medical record review for Resident 154 was conducted with the DON. The DON was informed and verified the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 34 final sampled resident (Resident 5) and one nonsampled resident (Resident 108) was assessed for safe self-administration of medications. * The facility failed to ensure Resident 5 was safe to administer the saline nasal spray (medication to relieve nasal congestion) medication found at bedside. * The facility failed to ensure Resident 108 was safe to administer the Salonpas Lidocaine Plus (a topical anesthetic to temporarily numb localized muscle, joint and nerve pain) roll on medication and maximum strength Neuropathy (manage tingling, burning and sharp nerve discomfort in your hands, feet and legs) cream found at bedside. These failures had the potential for Residents 5 and 108 to administer the medication inaccurately and negatively impact the health and safety of the residents.Findings: Review of the facility's P&P titled Self-Administration of Medication revised 1/2026 showed the interdisciplinary team supports the right of each resident to self-administer medications when this practice is clinically appropriate. A resident may only self-administer medication after the IDT has determined which medication may be self-administer. Medications self-administered by the resident and which the resident has been determined safe to be maintained at bedside, shall be stored in a locked container to maintain safety. 1. Medical record review for Resident 5 was initiated on 6/29/26. Resident 5 was admitted to the facility on [DATE], and readmitted on [DATE]. On 6/29/26 at 0841 hours, during the initial tour of the facility, an observation and concurrent interview was conducted with Resident 5. Resident 5 was observed sitting in bed, and a bottle of saline nasal spray medication was observed on the resident's overbed table. Resident 5 stated the saline nasal spray was her medication and she would use the medication to spray her nose. Review of Resident 5's H&P examination dated 6/1/26, showed Resident 5 had the capacity to understand and make decisions. Review of Resident 5's Order Summary Report for 7/1/26, did not show a physician's order for the saline nasal spray. Further review of Resident 5's medical record failed to show a physician's order for Resident 5 to self-administer medications, and there was no documentation of an assessment for Resident 5 to safely self-administer the saline nasal spray. On 6/29/26 at 0851 hours, an observation, interview, and concurrent medical record review for Resident 5 was conducted with LVN 3. LVN 3 verified the saline nasal spay at Resident 5's overbed table. LVN 3 stated Resident 5 should have no medication at bedside, and other residents can get the saline nasal spray and can use the spray. LVN 3 further stated there was no physician's order for the nasal spray and for Resident 5 to self-administer the medication. 2. Medical record review for Resident 108 was initiated on 6/29/26. Resident 108 was admitted to the facility on [DATE]. On 6/29/26 at 0956 hours, during the initial tour of the facility, an observation and concurrent interview was conducted with Resident 108. Resident 108 was observed sitting in her bed, a Salonpas Lidocaine Plus roll on medication and a jar of maximum strength Neuropathy cream was observed on the resident's overbed table. Resident 108 stated the Salonpas Lidocaine Plus roll on and maximum strength Neuropathy was her medication. Resident 108 further stated she would use the Salonpas and Neuropathy medications when she had pain. Review of Resident 108's H&P examination dated 6/12/26, showed Resident 108 had the capacity to understand and make decisions. Review of Resident 108's Order Summary Report did not show a physician's order for the Salonpas Lidocaine Plus roll on medication and maximum strength Neuropathy cream. Review of Resident 108's Plan of Care with the printed date of 7/1/26, did not show a care plan problem to address Resident 108's safe self-administration of the medications. Further review of Resident 108's medical record failed to show a physician's order for Resident 108 to self-administer the Salonpas Lidocaine Plus roll on medication and a jar of maximum strength Neuropathy cream, and there was no documentation of an assessment for Resident 108 to safely self-administer medications. On 6/29/26 at 1010 hours, an observation, interview, and concurrent medical record review was conducted for Resident 108 with the DSD. The DSD verified the medication at bedside. The DSD stated Resident 108 should have no medication at the bedside, and other residents can get the medication and can use the medication. The DSD verified there was no physician's order for the Salonpas Lidocaine Plus roll on and maximum strength Neuropathy cream. The DSD verified there were no self-administration assessment and no care plan for the use of Salonpas Lidocaine Plus roll on and maximum strength Neuropathy medications. On 7/2/26 at 0837 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated an IDT needs to do a self-administration assessment for all the residents and the residents would need to demonstrate they were capable to self- administer their own medications. The DON verified Residents 5 and 108 had no physician's order, assessment, and care plan for the self-administration of any medications. On 7/2/26 at 1416 hours, an interview was conducted with the Administrator and Assistant administrator. The Administrator and Assistant Administrator were informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the physician was informed of a change of condition for one or five final sampled residents (Resident 13 ) reviewed for nutrition. * The facility failed to notify Resident 13's physician and the resident's responsible party of the 9 lbs. (12.2%) weight loss from 2/3/26 to 3/4/26. This failure had the potential for Resident 13 to not receive the necessary care and treatment to manage the resident's weight loss and the resident's responsible party to not be aware of the resident's current condition.Findings: Review of the facility's P&P titled Notification of Changes revised 1/2026 showed the facility shall immediately or as soon as practicable, inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident representative(s) when there is:a. An accident involving the resident which results in injury and has the potential for requiring physician intervention.b. A significant change in the resident's physical, mental, or psychosocial status.c. A need to alter treatment significantly; andd. A decision to transfer or discharge the resident from the facility.The licensed personnel will provide timely, accurate, and standardized communication with the physician or licensed practitioner when a resident experiences a significant change in condition, using the SBAR (Situation-Background-Assessment-Recommendation) communication tool or documented equivalent in the nursing progress notes. Medical record review for Resident 13 was conducted on 6/28/26. Resident 13 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 13's MDS assessment dated [DATE], showed Resident 13 had severe impaired cognition. Review of Resident 13's Weights and Vitals Summary from 2/3/26 through 4/4/26, showed the following weights and comparisons:- dated 2/3/26, weight = 74 lbs.; - dated 3/4/26, weight = 65 lbs. (-9 lbs., a 12.2% severe weight loss in one month since 2/3/26); and- dated 4/4/26, weight = 62 lbs. Review of Resident 13's medical record failed to show documentation Resident 13's physician or responsible party were informed of Resident 13's current weight of 65 lbs. and weight loss of 9 lbs. On 7/1/26 at 1006 hours, an interview and concurrent medical record review for Resident 13 was conducted with LVN 4. LVN 4 stated for the weight variance of five pounds weight loss in a week or 5% weight loss in a month, the physician would be informed, an SBAR would be initiated to address the change in resident's condition, and the resident would be monitored. When asked about Resident 13's documented weight loss on 3/4/26, LVN 4 reviewed Resident 13's medical record and stated there was no documentation if the resident's physician or responsible party were informed of the 9 lbs. (12.2%) weight loss from 2/3/26 to 3/4/26. On 7/2/26 at 0913 hours, an interview was conducted with the DON. The DON stated a weight loss of more than 10% in one month was considered a severe weight loss. The DON stated the licensed nurse should compare the most recent weight with the previous weight to determine if there was a significant weight variance and if there was a weight variance noted, the nurse should inform the physician and family and initiate an SBAR for monitoring. On 7/2/26 at 1420 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. Cross Reference to F692.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive care plan was developed to reflect the individual care needs for two of 34 final sampled residents (Residents 106 and 144). * The facility failed to ensure care plan was developed for Resident 106's use of the CPAP machine. * The facility failed to ensure a care plan was developed to address Resident 144's difficulty in hearing. These failures posed the risk of not providing the residents with the appropriate, consistent, and individualized care. Findings: Review of the facility P&P titled Develop-implement Comprehensive Care Plans revised 1/2026 showed the facility develops a person-centered comprehensive care plan that is culturally competent and trauma-informed, developed and implemented to meet each resident's preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs. Each resident will have a person-centered comprehensive care plan developed and implemented to meet his or her preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs with seven days after the completion of the comprehensive assessment. 1. On 6/29/26 at 0825 hours, during the initial tour, Resident 144 was observed in bed. Resident 144 was spoken to and unable to hear. Resident 144 was spoken to by talking close to the resident's ear. Resident 144 stated she lost her hearing aid in the facility. Medical record review for Resident 144 was initiated on 6/29/26. Resident 144 was admitted to the facility on [DATE]. Review of Resident 144's MDS assessment dated [DATE], showed Resident 144's hearing was adequate with the use of the hearing aid. Resident 144's BIMS score was 14 which indicated the resident was cognitively intact. Review of Resident 144's Care Plan Report failed to show a care plan was developed to address Resident 144's difficulty in hearing or the use and care of Resident 144's hearing aid. On 7/1/26 at 0900 hours, a follow-up observation and concurrent interview was conducted with Resident 144. Resident 144 was in the room lying in bed. Resident 144 had difficulty in communicating. Words were repeated to Resident 144 three to four times and was spoken to very close to the resident's ear. Resident 144 had no alternative means of communication in the room. Resident 144 stated she felt frustrated because she lost her hearing aid and was not able to hear. On 7/1/26 at 0904 hours, an interview was conducted with CNA 2. CNA 2 stated Resident 144 was admitted with hearing aid and was able to communicate well with the use of the hearing aid. CNA 2 stated Resident 144 had hard time hearing now because she had lost her hearing aide. CNA 2 further stated you would need to talk close to her ears. On 7/1/26 at 0914 hours, an interview was conducted with Social Services Coordinator 3. Social Services Coordinator 3 stated Resident 144's hearing aid was lost between 6/14/26 – 6/16/26. Social Services Coordinator 3 verified there was no plan of care developed on how to communicate with Resident 144 effectively. On 7/1/26 at 1436 hours, an interview and concurrent record review for Resident 144 was conducted with LVN 13. LVN 13 verified Resident 144 had difficulty with hearing. LVN 13 verified Resident 144's Care Plan Report failed to show a care plan was developed to address the use and care of resident's hearing aid, or difficulty in hearing without the use of hearing aid. On 7/2/26 at 1039 hours, an interview was conducted with the DON. The DON was informed and acknowledged the findings as above. Cross reference to F685. 2. Medical record review for Resident 106 was initiated on 6/30/25. Resident 106 was admitted to the facility on [DATE]. Review of Resident 106's H&P examination dated 6/22/26, showed Resident 106 had the capacity to understand and make decisions. Review of Resident 106's Order Summary Report showed a physician's order dated 6/25/26, for CPAP continuously at NOC (bedtime) and PRN for respiratory distress. Review of Resident 106's Care Plan Report did not show if the care plan problem and interventions were developed to address Resident 106's use of the CPAP machine. On 7/1/26 at 0830 hours, an interview and concurrent medical record review for Resident 106 was conducted with the ADON. The ADON was asked about the care plan for Resident 106's use of the CPAP machine. The ADON verified there was no care plan for the use of Resident 106's CPAP machine. On 7/2/26 at 1416 hours, an interview and concurrent medical record review for Resident 106 was conducted with the DON. The DON was informed and verified the above findings. Cross reference to F 695, example # 9.

Based on observation, interview, and medical record review, the facility failed to provide the necessary care and services to maintain the IV accesses for two of two final sampled resident (Residents 37 and 224) reviewed for IV therapy consistent with professional standards of practice. * The facility failed to ensure Resident 37's PICC line was monitored accurately when the facility failed to measure IV line on insertion site and arm circumference as ordered.* The facility failed to ensure Resident 224's peripheral IV was correctly labeled and dated.These failures posed the risk for Resident 37 and 224 to develop complications related to the IV therapy. Findings: 1. On 6/29/26 at 1035 hours, during the initial tour, Resident 37 was observed with PICC line catheter inserted on her left upper arm with a dressing dated 6/25/26. Medical record review for Resident 37 was initiated on 6/29/26. Resident 37 was admitted to the facility on [DATE]. Review of Resident 37's PICC insertion record showed the PICC line was inserted on 6/17/26. Review of Resident 37's Order Summary Report showed the following physician's orders dated: -6/17/26, for measurement if IV lines from insertion site on admission/after dressing change, and arm circumference (in inches) every night shift every 7 days. Review of Resident 37's IV MARs for June 2026 showed no documented evidence of the nurse' initials on 6/23/26, evening shift for Resident 37's IV line from insertion site and arm circumference. Further review of Resident 37's medical record failed to show any documentation of measurement resident's IV line from insertion site and arm circumference on 6/23/26 was completed. On 6/30/26 at 1419 hours, an interview and concurrent record review for Resident 37 was conducted with RN 2. RN 2 verified the physician's order and MAR as above. RN 2 stated the IV PICC line should have been measured on 6/23/26, to make sure the IV site was in place. RN 2 verified the resident's medical record failed to show a measurement was completed on 6/23/26. On 7/2/26 at 1016 hours, an interview was conducted with the DON. The DON stated the expectation was for the assigned RN to complete the measurement of the central line and document weekly. 2. During the initial tour of the facility on 6/29/26 at 0812 hours, an observation was conducted for Resident 224. Resident 224 was lying in bed, and observed left hand with peripheral IV with no date and label when it was inserted. Medical record review for Resident 224 was initiated on 6/29/26. Resident 224 was admitted to the facility on [DATE]. Review of Resident 224's H&P examination dated 6/25/26, showed Resident 224 has limited decision-making capacity. Review of Resident 224's Order Summary Report failed to show a physician's order for use of peripheral IV. On 6/29/26 at 0828 hours, an observation and interview for Resident 224 was conducted with DSD. The DSD verified the above findings. The DSD stated the licensed nurse who inserted the IV needed to label the dressing with the date and initial. The DSD further stated when the peripheral IV was no longer needed, then to discontinue the peripheral IV to prevent infection. On 7/2/26 at 0837 hours, an interview was conducted with the DON. The DON verified the above findings. The DON stated that licensed nurse who inserted the peripheral line was expected to label the dressing with the date and initial. On 7/2/26 at 1416 hours, an interview was conducted with the Administrator and Assistant Administrator. The Administrator and Assistant Administrator were informed and acknowledged the above findings.

Based on observation, interview, medical record review, facility document review, and P&P review, the facility failed to ensure one of five final sampled residents (Resident 13), reviewed for nutrition, received the appropriate services needed to maintain acceptable parameters of nutritional status. * The facility failed to ensure an effective monitoring of acceptable parameters of nutritional status were implemented through systematic approach when Resident 13 experienced severe weight loss. The severe weight loss of nine lbs. in one month was not assessed and monitored timely as per the facility's P&P. In addition, the facility failed to ensure the physician was notified of Resident 13's severe weight loss and poor PO (per orem or by mouth) intake and failed to ensure Resident 13 received the hashbrowns for her morning breakfast meal. These failures had the potential for adverse nutritional outcomes and to negatively affect Resident 13's well-being.Findings: A professional reference review of the National Library of Medicine titled, An approach to the management of unintentional weight loss in elderly people dated 3/15/05, showed in part, Unintentional weight loss, or the involuntary decline in total body weight over time, is common among elderly people who live at home. Weight loss in elderly people can have a deleterious effect on the ability to function and on quality of life and is associated with an increase in mortality over a 12-month period .Unintentional weight loss is the involuntary decline in total body weight over time. In clinical practice, it is encountered in up to 8% of all adult outpatients and 27% of frail people 65 years and older. Weight loss is an important risk factor in elderly patients. It is associated with increased mortality, which can range from 9% to as high as 38% within 1 to 2.5 years after weight loss has occurred .Weight loss of 4%-5% or more of body weight within 1 year, or 10% or more over 5-10 years or longer, is associated with increased mortality or morbidity or both. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC552892/ Review of the facility's P&P titled Weight Management revised 1/2026 showed the facility strives to maintain acceptable parameters of nutritional status unless the resident's clinical condition demonstrates that this is not possible; to provide a therapeutic diet for residents with nutritional problems. The weights will be recorded monthly unless ordered more or less frequently by the physician or upon the discretion of the IDT. The weight management committee will meet weekly and residents with nutritional and/or weight concerns are evaluated during the meeting. The criteria for a resident to be reviewed may include, but is not limited to:- Residents who have a sudden change in nutritional intake and are at risk for significant weight loss or exhibit gradual weight loss/gain.- Residents who have lost or gained five lbs. since the last recorded weight.- Residents who have lost or gained >5% of their body weight in the last month.The committee shall document in the clinical record the review and subsequent recommendations. Review of the facility's P&P titled Notification of Changes revised 1/2026 showed the facility shall immediately or as soon as practicable, inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident representative(s) when there is:- An accident involving the resident which results in injury and has the potential for requiring physician intervention.- A significant change in the resident's physical, mental, or psychosocial status.- A need to alter treatment significantly; and- A decision to transfer or discharge the resident from the facility.The licensed personnel will provide timely, accurate, and standardized communication with the physician or licensed practitioner when a resident experiences a significant change in condition, using the SBAR (Situation-Background-Assessment-Recommendation) communication tool or documented equivalent in the nursing progress notes. Medical record review for Resident 13 was conducted on 6/28/26. Resident 13 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 13's MDS assessment dated [DATE], showed Resident 13 had severely impaired cognition. a. Review of Resident 13's Weights and Vitals Summary from 2/3/26 through 4/4/26, showed the following weights comparisons for Resident 13:- On 9/3/25, weighed 77 lbs.;- On 12/5/25, weighed 75 lbs.;- On 2/3/26, weighed 74 lbs.; and- On 3/4/26, weighed 65 lbs., a weight loss of nine lbs., a 12.2% severe weight loss in one month since 2/3/26; a weight loss of 10 lbs., a 13.3% severe weight loss in three months since 12/5/25, and a weight loss of 12 lbs., a 15.6% weight loss in six months since 9/3/25. Review of Resident 13's medical records failed to show documentation of the physician and Resident 13's responsible party being informed of Resident 13's weight of 65 lbs. and the resident's weight loss of nine lbs., 12.2% in one month, 13.3% weight loss in three months, and 15.6% weight loss in six months. Additionally, Resident 13's medical record failed to show documentation the weight management committee meeting to discuss Resident 13's weight loss until 4/13/26. On 7/1/26 at 0902 hours, an interview was conducted with RNA 1. RNA 1 stated the RNAs were responsible for obtaining the residents' weights for new admissions, weekly weights, and monthly weights. RNA 1 stated the weights were entered into PCC (Point Click Care, an electronic health record system). RNA 1 stated for any weight loss or gain of five lbs. in one week or month, the RNA should report to the licensed nurse. On 7/1/26 at 1006 hours, an interview and concurrent medical record review for Resident 13 was conducted with LVN 4. LVN 4 stated for the weight variance of five- pounds weight loss in a week or 5% weight loss in a month, the physician would be informed, an SBAR (Situation/Background/Assessment/Recommendation, a communication tool) would be initiated to address the change in condition and the resident would be monitored. When asked about Resident 13's documented weight loss on 3/4/26, LVN 4 reviewed Resident 13's medical record and stated there was no documentation the physician or responsible party were informed of Resident 13's nine lbs. or 12.2% weight loss from 2/3/26 to 3/4/26. b. Review of Resident 13's Documentation Survey Report for February 2026, showed the following documentation of Resident 13's meal intake and amount:- Dated 2/26/26, for the lunch meal: Resident 13 ate 26-50% of the meal, an alternative meal was not offered,- Dated 2/26/26, for the dinner meal: Resident 13 ate 26-50% of the meal, an alternative meal was offered,- Dated 2/27/26, for the breakfast meal: Resident 13 ate 26-50% of the meal, an alternative meal was not offered, and- Dated 2/27/26, for the lunch meal: Resident 13 ate 0-25% of the meal, an alternative meal was not offered. Review of Resident 13's Licensed Nurse Weekly Summary dated 3/4/26, showed the licensed nurse documented no nutritional concerns within the last week (from 2/25/26 to 3/4/26). Further review of Resident 13's medical records failed to show any documentation to address Resident 13's poor PO intake of 50% or less for the above dates and failed to show the documentation of the physician and Resident 13's responsible party being informed of Resident 13's poor PO intake. On 6/30/26 at 1416 hours, an interview was conducted with CNA 1. CNA 1 stated Resident 13 tried to feed herself; however, the resident required staff assistance when eating. CNA 1 stated if Resident 13 ate less than 50% of the meal, the resident would be offered alternatives or substitutes and to notify the licensed nurse. On 7/1/26 at 1335 hours, an interview was conducted with LVN 4. LVN 4 stated when a resident had poor PO intake, the resident would be encouraged to eat more and offered snacks and alternatives as tolerated. LVN 4 stated if the resident had frequent episodes of poor PO intake of 50% or less, for three meals, the physician would be informed and a Change in Condition evaluation would be completed to monitor the resident. On 7/2/26 at 1415 hours, an interview and concurrent medical record review for Resident 13 was conducted with the DON. The DON stated if the resident had poor PO intake of less than 50%, for three consecutive meals, the licensed nurse should inform the physician and initiate an SBAR so the resident could be monitored. The DON reviewed Resident 13's medical record and verified the above findings. c. Review of Resident 13's Nutritional Assessment/Evaluation by the RD dated 3/2/26, showed the following documentation:- Resident 13 weighed 74 lbs. on 2/3/26, with the usual body weight (UBW) of 73 to 78 lbs. (over 1.5 years), the goal weight was 75 to 80 lbs.;- No significant weight change;- The nutritional goals showed to maintain weight more than or equal to 74 lbs. with the possible gain to 80 lbs.;- The nutritional interventions showed the RD spoke with the physician with orders to add multivitamins and minerals and change the diet to fortified- no added salt. The RD documented will continue to monitor: monthly weights for changes, laboratories as available, and skin. Review of Resident 13's Dietary/Nutritional Progress Notes dated 3/27/26, showed the following documentation by the RD:- Resident 13's current weight of 65 lbs. as of 3/4/26, with a nine lbs (12%) weight loss in a month and 12 lbs. (16%) weight loss in six months.- Resident 13's intake was 25 to 100%, often 50-75%, and fed by staff.- Resident 13 was on Remeron (antidepressant medication) to stimulate appetite, on medication for hypertension (high blood pressure) which can cause diuresis (process in which the kidneys filter excess fluid from the blood to produce extra urine).- Resident 13 had a urinary tract infection with antibiotic treatment on 2/2026 may have impacted appetite.- Will try offering Boost VHC (very high calorie) again and monitor acceptance. Also recommended to have laboratories checked and to assess status and weekly weights for four weeks. Review of Resident 13's IDT Progress Notes-Weight Variance and Nutritional condition dated 4/13/26, showed documentation by the IDT having met to discuss Resident 13's weight variance. On 7/1/26 at 1345 hours, an interview and concurrent medical record review for Resident 13 was conducted with the RD. The RD stated at the beginning of each month she printed the monthly weights to identify the residents with weight variances in one-, three-, and six-month intervals. The RD stated upon review of the weights and the identification of the residents with weight variances, she would conduct a nutritional assessment/evaluation for the identified residents. The RD further stated if there was a physician's order for an RD evaluation, she would assess the resident within one to two days. The RD reviewed Resident 13's medical record and stated she had identified Resident 13's with nine lbs. (12%) weight loss when she printed the monthly weights at the beginning of March and had placed the resident on her list of residents to review. The RD verified she did not assess/evaluate Resident 13 until 3/27/26 and requested for an IDT meeting to discuss the resident's weight variance but was not done until 4/13/26. When asked, the RD agreed the residents with significant weight variances should be assessed and evaluated as soon as possible to address the weight loss and determine the appropriate interventions to prevent further weight loss. The RD further stated if there was a physician's order for an RD evaluation, she would have prioritized the resident's nutritional evaluation sooner. On 7/2/26 at 0913 hours, an interview was conducted with the DON. The DON stated a weight loss of more than 10% in one month was considered a severe weight loss. The DON stated the RD was responsible for reviewing the resident's monthly weights and checking for any weight variances. Additionally, the DON stated the licensed nurses when completing the licensed nurses' weekly summary, should review the residents' weights to determine if there were any weight variances. The DON stated the licensed nurse should compare the most recent weight with the previous weight to determine if there was a significant weight variance. The DON stated if there was a weight variance noted, the nurse should inform the physician and resident representative and initiate an SBAR for monitoring. d. Review of Resident 13's Order Summary Report dated 7/1/26, showed a physician's order dated 3/2/26, to provide Resident 13 with a fortified, no added salt (NAS), soft and bite-sized texture diet. Resident 13 was approved for regular bread and dessert. On 7/1/26 at 0829 hours, a breakfast meal observation and concurrent interview was conducted with CNA 1. Resident 13 was observed in bed with the head of bed elevated. CNA 1 was observed assisting Resident 13 with her breakfast meal. Resident 13 was observed with the following items on her breakfast tray: two slices of bread, scrambled eggs, a bowl of oatmeal cereal, a cup of milk, a cup of cranberry juice, and a carton of Boost (nutritional supplement). Review of Resident 13's breakfast meal ticket showed the following items listed for Resident 13's breakfast meal: cranberry juice, super cereal, breakfast sandwich, hashbrowns, whole milk, coffee, and Boost. However, Resident 13's tray did not include hashbrowns. CNA 1 verified Resident 13's breakfast tray did not have the hashbrowns. On 7/1/26 at 0833 hours, an interview and concurrent observation was conducted with LVN 14. LVN 14 reviewed Resident 13's meal ticket and breakfast tray and verified the above findings and stated he would inform the kitchen. LVN 14 stated the resident should have the hashbrown on her tray for breakfast. On 7/2/26 at 1420 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. Cross reference to F580.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care was provided to prevent the development of pressure injuries for one of two final sampled residents (Resident 231) reviewed for pressure ulcer/ injury. * The facility failed to ensure the LVN (LVN 8) assessed Resident 231's pain prior providing the wound care treatment. This failure had the potential for not providing the necessary care and services and effectively managing the resident's needs.Findings: 1. Review of the facility's P&P titled Treatment Services to Prevent/ Heal Pressure Ulcers dated January 2025 showed the assessment and treatment of a resident's pain are integral components of pressure ulcer or pressure injury prevention and management. Pain that interferes with movement and/or affects mood may contribute to immobility and contribute to the potential for developing or for delayed healing or non-healing of an already existing pressure ulcer or pressure injury. Medical record review for Resident 231 was initiated on 6/29/26. Resident 231 was admitted to the facility on [DATE]. Review of Resident 231's Order Summary Report dated 6/30/26, showed the following physician's orders dated 6/25/26:- To assess pain for treatment process: First- Pretreatment; Second- During treatment; and Third- After treatment every day shift. - To cleanse left buttock extended to left ischium, and to the left posterior leg deep tissue injury with normal saline, pat dry, apply skin prep and leave open to air every day. - To cleanse left buttock Stage 3 pressure injury with normal saline, pat dry, apply skin prep to wound perimeter, apply calcium alginate to wound bed, and cover with 4X4 foam boarder dressing every day shift. - To cleanse right buttock Stage 3 pressure injury with normal saline, pat dry, apply skin prep to wound perimeter, apply calcium alginate to wound bed, and cover with 4X4 foam boarder dressing every day shift. - To cleanse right buttock extended to right ischium and to right posterior leg deep tissue injury with normal saline, pat dry, apply skin prep and leave open to air every day. Review of Resident 231's Care Plan Report dated 6/26/26, showed a care problem for deep tissue injury on left ischium and right inner buttock with an intervention for pain management/medication as ordered. On 7/1/26 at 1122 hours, a wound care treatment observation was conducted for Resident 231 with LVN 8. LVN 8 failed to assess Resident 231 for pain prior initiating the wound care treatment. In the middle of wound care, Resident 231 complained of pain. LVN 8 assessed for pain level, and Resident 231 responded the pain was at scale of 7 (0:no pain, 1-3 mild as noticeable but manageable; 4-6 moderate as harder to ignore; and 7-10 severe or dominates one's attention). On 7/1/26 at 1215 hours, an interview was conducted with LVN 8. LVN 8 verified she failed to assess Resident 231's pain prior to initiating the wound care treatment. LVN 8 verified she should have assessed Resident 231's pain prior wound care treatment to medicate the resident if needed for comfort. On 7/2/26 at 1006 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, and record review the facility failed to ensure one of 34 final sampled resident (Resident 144) was provided with proper care to maintain resident's ability to hear. * The facility failed to ensure Resident 144's had no difficulty in communication when the hearing aide got lost in the facility. This failure had caused the resident difficulty in communication and potentially cause not to meet her needs and psychosocial harm. Findings: 1. On 6/29/26 at 0825 hours, during the initial tour, Resident 144 was observed in bed. Resident was observed unable to hear. Resident was spoken to by talking close to the resident's ear. Resident stated she had lost her hearing aid in the facility. Medical record review for Resident 144 was initiated on 6/29/26. Resident 144 was admitted to the facility on [DATE]. Review of Resident 144's MDS assessment dated [DATE], showed the resident's hearing was adequate with the use of the hearing aid. Resident's BIMS score was 14, which indicates resident was cognitively intact and functioning normally. Review of Resident 144's Care Plan Report failed to show a care plan was developed to address the resident's difficulty in hearing or use and care of the resident's hearing aid. On 7/1/26 at 0900 hours, an observation and a concurrent interview was conducted with Resident 144. Resident was in the room lying in bed. Resident had difficulty in communicating. Words were repeated to the resident three to four times and was spoken to very close to the resident's ear. Resident had no alternative communication in the room. Resident 144 stated she felt frustrated because she had lost her hearing aid and was not able to hear. On 7/1/26 at 0904 hours, an interview was conducted with CNA 2. CNA 2 stated Resident 144 was admitted with hearing aid and was able to communicate well with the use of the hearing aid. CNA 2 stated the resident had hard time hearing now because she had lost her hearing aide, and need to talk close to her ears. On 7/1/26 at 0914 hours, an interview was conducted with Social Services Coordinator 3. Social Services Coordinator 3 stated the resident's hearing aid was lost between 6/14/26 - 6/16/26. Social Services Coordinator 3 verified there was no plan of care developed to communicate with the resident effectively. Social Services Coordinator 3 stated he spoke with the resident's representative and was informed the facility will reimburse the resident with the lost of the hearing aid on 6/30/26. On 7/1/26 at 1436 hours, a concurrent record review for Resident 144 and an interview was conducted with LVN 13. LVN 13 verified resident had difficulty with hearing. On 7/2/26 at 1039 hours, an interview was conducted with the DON. The DON was informed and acknowledged the findings as above. Cross reference F656.

Based on interview and medical record review, the facility failed to identify and inform the physician of a decline in one of two sampled residents (Resident 2) neurological condition after a fall. In addition, the facility failed to ensure the abductor pillow was applied as ordered for Resident 2. * Resident 2 sustained a unwitnessed fall on [DATE] at 0210 hours, and a change in her neurological status at 0755 hours. Resident 2's physician was not informed of this change. Resident 2 showed a further decline and was transferred to the acute care hospital emergency department via paramedics. A CT scan showed Resident 2 had a large right-sided subdural hemorrhage with a midline shift and obstructive [DIAGNOSES REDACTED] with an enlarged left temporal horn. Resident 2 expired 48 hours later. * Resident 2 had a physician's orders [REDACTED]. This had the potential for the resident to sustain an injury such as a dislocation of the resident's recently surgical repair of a [MEDICAL CONDITION] joint. Findings: Review of Resident 2's closed medical record was initiated on [DATE]. Resident 2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. a. Review of Resident 2's Progress Notes (the licensed nurses' notes) dated [DATE], showed on admission, Resident 2 was alert, verbally responsive, and able to make simple needs known with episodes of forgetfulness secondary to dementia. On [DATE] at 1924 hours, Resident 2 was lying in bed awake, alert, and verbally responsive; and the resident's call light was within her reach. On [DATE] at 0238 hours, [MEDICATION NAME]-[MEDICATION NAME] (a narcotic pain reliever) ,[DATE] mg was administered to the resident for the right leg pain. Review of Resident 2's SBAR Communication for Changes in Condition, Assessment Summary form dated [DATE] at 0322 hours, showed the resident had an unwitnessed fall. According to the documentation Resident 2 was alert and responsive able to answer simple questions after the fall incident with episodes of confusion and forgetfulness. Resident 2 was started on neuro checks (an exam of the resident's level of consciousness, movement, hand grasps, left and right pupil size and reaction, speech, vital signs (blood pressure, pulse, respiratory rate, and temperature), and pain level). Review of Resident 2's Neurological Flow Sheet form dated [DATE], showed the instructions for the licensed nurses to complete this form for any unwitnessed falls for 72 hours following a fall and inform the attending physician if there was a deviation from the resident's normal status. Resident 2's Neurological Flow Sheet dated [DATE], showed the following: - At 0210, 0225, 0240, 0255, 0325, 0355, 0455, 0555, and 0655 hours: Level of Consciousness = 1 (fully conscious - awake, aware, oriented, Movement = 1 (all four extremities) Hand Grasps = 1 (equal and strong) Pupil Reaction left/right = ,[DATE] (brisk) Speech = 1 (clear) - At 0755 hours, Resident 2's neurological exam results showed the following decline: Level of Consciousness = 3 (obtund - very drowsy, responds to touch stimuli) Speech = left blank - At 1155 hours, Resident 2's neurological exam showed further decline: Level of Consciousness = 4 (stupor - responds only to painful stimuli) Movement = 7 (no movement/unusual movement) Hand Grasps = 4 (none) Pupil Reaction = 3 (fixed) Speech marked = N/A Further review of Resident 2's Progress Notes (the licensed nurses' notes) dated [DATE], showed the following: - At 0730 hours, Resident 2 was sleeping comfortably with no facial grimacing indicating pain/discomfort. - At 0743 hours, LVN 6 documented at 0342 hours, the x-ray technician arrived at 0551 hours, the x-ray results were received; at 0600 hours, Resident 2's physician was informed of the x-ray results. - At 0750 hours, Resident 2's daughter was at the bedside assisting the resident with her breakfast. The resident was having a hard time keeping her eyes open. - At 0800 hours, according to the CNA Resident 2 consumed 80% of her breakfast. - At 0805 hours, CNA offered the resident a shower and the resident's daughter suggested to let Resident 2 to rest and nap. - At 0950 hours, the licensed nurse tried to administer Resident 2's medication; however, Resident 2 was asleep; the resident's daughter agreed to give the resident's medications when the resident awakened. - At 1054 hours, LVN 5 spoke with Resident 2's physician and reported the results of the x-ray received from the resident's orthopedic surgeon's office. There was no documented evidence the physician was informed of the resident's decline in the neurological condition of a fall, starting at 0755 hours on [DATE]. - At 1058 hours, Resident 2 was asleep, responsive to verbal and tactile stimuli with no facial grimacing to indicate any discomfort. Again, there was no documented evidence the physician was informed of the resident's decline in the neurological condition of a fall at 0755 hours and a further decline at 1115 hour on [DATE]. - At 1239 hours, CNA 1 notified LVN 5 at approximately 1200 hours Resident 2 was lethargic and the family was concerned. Resident was in bed asleep and not responding to verbal or tactile stimuli. Resident moved both arms in response to a sternal rub. Resident 2 was not able to follow commands or open her eyes, snoring, and not waking up. RN 1 was called to the room and spoke with Resident 2's family who wanted to wait for the resident's attending physician to evaluate the resident. RN 1 and LVN 5 recommended to transfer Resident 2 to the acute care hospital emergency department for evaluation. The family members agreed to the transfer. Staff called 911 and the paramedics arrived at 1210 hours. At 1220 hours, Resident 2's attending physician was called and a message was left for the physician. The paramedics transported Resident 2 to the emergency department at 1224 hours. There was no documentation in Resident 2's medical record to show the physician was informed of the resident's neurological changes documented by LVN 1 on [DATE], starting at 0755 hours. On [DATE] at 1415, an interview was conducted with CNA 1. CNA 1 stated Resident 2 was normally very alert and able to make her needs known. The resident required limited assistance of one person to walk to the bathroom using a walker. CNA 1 was asked to describe the events of [DATE], from the beginning of the day shift until the resident was transferred to the hospital. CNA 1 stated Resident 2 was sleeping during his first rounds at approximately 0720 hours. At approximately 0740 hours, CNA 1 delivered the resident's breakfast tray; the resident was still sleeping and the resident's daughter had set up the tray. When he picked up the resident's tray after approximately 30 minutes, the resident was asleep. There was approximately 30% of the breakfast consumed; however, CNA 1 stated the daughter later told him the resident had eaten one half a slice of toast, and the daughter had eaten the rest of the 30%. The resident usually ate ,[DATE]%; he and the daughter assumed it was because the resident was tired. CNA 1 stated at 1040 hours when he went to offer Resident 2 a shower the resident was asleep and the resident's daughter asked him to wait until tomorrow. CNA 1 stated at approximately 1150 hours, one of the resident's family members asked him to call a licensed nurse. CNA 1 told LVN 5 who went to Resident 2's room. CNA 1 stated he did not follow the LVN into the resident's room. CNA 1 stated he had not seen Resident 2 awake at all since he came on duty that day. On [DATE] at 1515 hours, an interview was conducted with LVN 1. LVN 1 stated Resident 2 was usually awake, alert, oriented, and able to make her needs known without confusion. LVN 1 was asked to describe the events of [DATE], from the beginning of the shift until the resident was transferred to the hospital. LVN 1 stated she saw Resident 2 on [DATE] prior to 0800 hours and stated Resident 2 was sleeping. LVN 1 stated she performed a neurological exam before 0800 hours. LVN 1 stated the Resident 2's pupils reacted equally and quickly; the resident did not respond or grasp at all when LVN 1 had asked the resident to squeeze two of her fingers and did not move her legs at all when asked. LVN 1 stated CNA 1 took the resident's vital signs and they were normal. LVN 1 stated at 0945 hours, she went to administer Resident 2 her medications but was unable to do so because Resident 2 had a hard time waking up. LVN 1 stated the resident could not keep her eyes open which was usually not the case. LVN 1 stated she thought maybe the resident was sleeping due to the events (fall) during the night and the pain pill the resident had taken (at 0238 hours). LVN 1 saw the resident again just before 1100 hours and she was asleep. LVN 1 held Resident 2's hands, and the resident moved but did not open her eyes or speak. LVN 1 stated at approximately 1200 hours, while she was on her lunch break, she heard a code blue announced for Resident 2's room. When LVN 1 arrived to the room, the resident had a pulse and had was breathing. However, the staff could not arouse the resident. LVN 1 stated when a sternal rub was performed on the resident, there was slight movement of her legs and shoulders; however, the resident did not awaken. LVN 1 stated she thought it was from the dose of [MEDICATION NAME] (generic for [MEDICATION NAME]-[MEDICATION NAME] ,[DATE] mg) the resident had received after the fall. LVN 1 stated she had not observe Resident 2 have this type of reaction after the pain medication administration in the past. LVN 1 stated the 911 was called and the paramedics arrived at approximately 1210 hours. When LVN 1 was asked to explain the discrepancy between her documented description of the neurological exam noted above (Resident 2 had no hand grasp and did not move her legs) and what was documented on the Neurological Flow Sheet (hand grasps were equal and strong, moved all four extremities) at 0755 hours, LVN 1 stated she did not have an explanation. On [DATE] at 1540 hours, an interview was conducted with RN 1. RN 1 was asked to describe the events of [DATE]. RN 1 stated Resident 2 was a short-term resident and admitted to the facility for rehabilitation following surgery for [REDACTED]. Resident 2 had been found on the floor, was awake, alert, oriented, and stated she did not hit her head. The night shift nurses had recommended the resident be transferred to the emergency department. However, Resident 2's physician did not order a transfer and ordered for a STAT x-ray. RN 1 stated LVN 5 asked her to assess Resident 2 on [DATE] at approximately 1200 hours, secondary to a change in the resident's condition. RN 1 went to Resident 2's room. The family was at the bedside reported the resident would not wake up. The resident's vital signs were normal and showing no signs of distress; she just would not wake up. LVN 5 performed a sternal rub and Resident 2 shrugged; however, she did not open her eyes or move any other body parts. RN 1 stated the family initially wanted to wait for Resident 2's physician. RN 1 recommended to transfer the resident to the hospital via 911 and the family agreed. The paramedics arrived at approximately 1215 hours. RN 1 stated she was not informed by the charge nurse or the CNA anything unusual for Resident 2 earlier in the shift. On [DATE] at 0840 hours, a telephone interview was conducted with Resident 2's Family Member 1. Family Member 1 stated the facility had informed her Resident 2 fell on [DATE] at approximately 0315 hours. When the family arrived at the facility at approximately 0330 hours, the resident did not look like her usual self; her speech was slurred and she did not answer any questions regarding what had happened. The family member stated the resident fell asleep at approximately 0530 or 0600 hours, after speaking to another family member; it was the last time the resident spoke. The family member stated at 0800 hours, when they delivered Resident 2's breakfast, the resident was asleep. Family Member 1 attempted to feed the resident; however, the resident was very drowsy and could hardly stay awake. The resident kept chewing on the same bite of toast, and did not consume any other food or fluids from the breakfast tray. The resident slept all morning and when the lunch tray was delivered, she (the family member) asked the nurse to check the resident because she was still asleep. Shortly afterwards, the staff called 911 and the resident was then transferred to the acute hospital emergency department. When asked, Family Member 1 stated she did not recall the nursing staff assessing the resident's eyes, hand grasps, or movement during either the night or day shifts. On [DATE] at 0941 hours, a telephone interview was conducted with Family Member 2. Family Member 2 stated the family arrived at 0330 hours on [DATE], after being informed the resident had fallen. Family Member 2 stated the resident did not look like herself; her speech was slurred and her face looked damaged. When asked to explain damaged, Family Member 2 stated the resident's eyes were vertically bigger than normal, as though her eyes were opened too much. Family Member 2 stated the resident remained awake throughout the night until approximately 0600 hours. The family member did not answer when asked what had happened. Staff brought in the resident's breakfast at approximately 0800 hours. Family Member 1 tried to awaken the resident to eat; however, the resident was very drowsy and only ate one bite. After breakfast, the resident just stayed asleep. At 1200 hours, Family Member 1 became concerned and asked the nurse to check the resident. The staff called 911 and the resident was transferred to the acute care hospital emergency department. When asked how often the staff checked Resident 2 during the night, Family Member 2 stated three or four times before breakfast. The family member stated the staff stood by the resident's bed and looked at her; they did not do anything. When asked if they looked in the resident's eyes with a light, asked her questions, or checked her hand grips, Family Member 2 stated no. On [DATE] at 1140 hours, a telephone interview was conducted with LVN 5. LVN 5 was asked to describe the events surrounding Resident 2's transfer to the hospital on [DATE]. LVN 5 stated when she made rounds on Resident 2 at 0830 hours, the resident was sleeping. LVN 5 did not recall if she entered the room or if she spoke to any of the family members. LVN 5 stated she was working as the desk nurse on [DATE]. LVN 5 stated while LVN 1 was on lunch break, Resident 2's CNA asked LVN 5 to check on the resident. When LVN 5 went to Resident 2's room, the family members were very concerned because the resident had been very sleepy since the morning. LVN 5 stated the resident was very lethargic; she checked the resident's blood sugars and vital signs and told the family the resident needed to be sent to the hospital. The family was indecisive about waiting for the resident's physician's versus transferring the resident to the acute care hospital. LVN 5 called RN 1 to Resident 2's room. RN 1 agreed the resident should be sent to the acute care hospital and the family agreed. The paramedics were called and arrived very quickly to transport the resident to the acute care hospital emergency department. LVN 5 was asked how the resident was assessed. LVN 5 stated the resident's vital signs, blood sugars, and oxygen saturation levels were assessed. LVN 5 stated she shook the resident's shoulder to arouse her and the resident did not respond. LVN 5 and RN 1 both did a sternal rub; the resident did not open her eyes but might have moaned and moved a little. RN 1 stated she performed a neurological exam on Resident 2. LVN 5 stated prior to being asked to check, Resident 2 by the CNA, she had not heard about any concerns about the resident's condition other than the resident was being monitored due to a fall. On [DATE] at 1408 hours, a telephone interview was conducted with CNA 3. CNA 3 was asked to describe the events the night of [DATE], and early morning [DATE] for Resident 2. CNA 3 stated she made the initial rounds on Resident 2 at approximately 2300 hours on [DATE]. The resident was awake, alert, and denied any pain or the need to use the bathroom. The call light was within the resident's reach. CNA 3 stated she had not seen the resident again until the charge nurse called for help. When CNA 3 entered Resident 2's room, Resident 2 was laying on the floor near the bathroom with her head towards the door to the room, she was propped up on her elbow holding her head up. The charge nurse asked Resident 2 if she had hit her head and the resident stated no, just her leg hurt. After the nurse assessed the resident, four staff members lifted the resident to the wheelchair and then to the bed with a draw sheet. CNA 3 stated she did not enter the resident's room again until the last rounds because the family was there and the nurse kept going in the room. At last rounds the resident was awake, but quiet; she did not speak. On [DATE] at 1410 hours, a follow-up telephone interview was conducted with LVN 1. LVN 1 was asked to explain her documentation about Resident 2 being still asleep but responsive to verbal and tactile stimuli, written on [DATE] at 1058 hours. LVN 1 stated the resident was asleep, but when she called the resident's name and tapped on her shoulder, the resident did not speak or move, but the resident's eyes moved under her eyelids. When asked, LVN 1 verified she performed the neurological exam on [DATE] at 0755 hours. LVN 1 stated she checked the resident's pupils for size and reaction using a penlight, she asked the resident her squeeze her hand and checked for level of consciousness by checking if the resident was alert. LVN 1 stated she did not recall how she checked the resident for movement. LVN 1 stated the resident was asleep and she tried to awaken the resident. LVN 1 stated the resident responded more to touch than verbal commands or questions, but she did not fully wake up. LVN 1 stated she thought Resident 2 was tired. When asked if she correlated her finding on the neurological exam with a change in the resident's neurological status. LVN 1 stated no, she thought the resident was tired and sleeping. When asked if she had informed Resident 2's physician of the resident's change in level of consciousness. LVN 1 stated no. When LVN 1 was asked if she attempted to awaken the resident at the time she went in to administer the resident's medications at 0945 hours on [DATE]. LVN 1 stated no. LVN 1 stated she never saw the resident's eyes open during her shift. On [DATE] at 1540 hours, a telephone interview was conducted with RN 2. RN 2 was asked how she assessed Resident 2 the early morning of [DATE]. RN 2 stated she asked the resident if she was in pain (the resident pointed to her hip). She stated she if she had hit her head (the resident stated no), and to move her extremities (the resident could move her arms and barely move her left leg). RN 2 stated she performed a neurological exam: the resident's pupils were equal, her hand grasps were equal, and her vital signs were normal. The resident knew her name, where she was, and explained she was trying to go to the bathroom. RN 2 stated she performed a body assessment and Resident 2 did not have any new bruises or skin tears. RN 2 stated she communicated several times with the family who was visiting in Resident 2's room and each time the resident was awake and speaking with the family. RN 2 did not observe anything unusual in how the resident acted or looked. When asked if she had performed the resident's neurological exams, RN 2 stated she had only performed the first one, the charge nurse (RN 2) had performed the rest of them during the shift. On [DATE] at 0942 hours, a telephone interview was conducted with LVN 6 regarding the events surrounding Resident 2's fall. LVN 6 stated she heard Resident 2 calling for help not too long after the start of the shift on [DATE]. LVN 6 stated she found Resident 2 lying on the floor on her side. LVN 6 stated she called for the RN and CNA to help. LVN 6 stated Resident 2 told her she was trying to go to the bathroom. LVN 6 stated Resident 2 denied hitting her head. LVN 6 stated after assessing the resident and transferring her back to bed, LVN 6 called the resident's physician and family. LVN 6 stated three or four family members came to the facility. LVN 6 stated she spoke with Resident 2's family members and recommended to transfer the resident to the hospital for evaluation; however, the family wanted to wait for the physician's recommendations. LVN 6 stated RN 2 was the main nurse communicating with Resident 2's family while she was making phone calls and doing paperwork. LVN 6 stated RN 2 performed all of the neurological assessments. LVN 6 stated she asked the CNA to take Resident 2's vital signs. LVN 6 verified she documented the results of RN 2's assessments on the Neurological Flow Sheet. When asked LVN 6 denied performing the neurological assessments for Resident 2. LVN 6 stated RN 2 performed the neurological exams and then told LVN 6 the information to document on the flow sheet. According to the Mayo Clinic, symptoms and causes of an intracranial hematoma can be life threatening. With time as pressure on the brain increases, some or all of the following signs and symptoms may be produced: increasing headache, drowsiness and progressive loss of consciousness, dizziness, confusion, unequal pupil size and slurred speech. As more blood fills the space between the brain and skull, other signs and symptoms may become apparent, such as: lethargy, [MEDICAL CONDITION], and unconsciousness. Review of Resident 2's acute care hospital emergency department's medical record showed Resident 2 was admitted to the acute care hospital on [DATE], with altered mental status. The emergency department physician's neurological exam showed No speech. Patient is obtunded. She has some movement to bilateral lower extremities and left arm but none noted to the right upper extremity. The resident's eyes showed the right pupil was possibly 1 mm larger than the left. Results of a CT scan (from the acute care hospital) of the brain completed on [DATE] at 1425 hours, showed Resident 2 had a large right-sided subdural hemorrhage with a midline shift and obstructive [DIAGNOSES REDACTED] with an enlarged left temporal horn. Review of Resident 2's Certificate of Death showed the resident expired on [DATE] at 0430 hours. The primary Cause of Death was listed as massive subdural hematoma, non-traumatic. b. Review of Resident 2's physician's orders [REDACTED]. Review of Resident 2's MAR indicated [REDACTED]. The MAR indicated [REDACTED]. On [DATE] at 0840 hours, a telephone interview was conducted with Family Member 1. Family Member 1 stated she visited Resident 2 on [DATE]. Before Family Member 1 left at 2100 hours, she walked the resident to the bathroom using the resident's walker. Family Member 1 stated the resident did not have the abductor pillow between her legs when she got her up. Family Member 1 stated when she arrived back at the facility later at 0330 hours, the abductor pillow was in the chair where it had been when she left the night before. Family Member 1 stated if the abductor pillow had been between the resident's legs the resident could not have gotten out of bed by herself because the abductor pillow was attached to the resident's legs with Velcro straps. On [DATE] at 1408 hours, a telephone interview was conducted with CNA 3 regarding the events the the night Resident 2 fell . CNA 3 stated she made rounds on ,[DATE] at 2300 hours. CNA 3 stated the resident was supposed to have the abductor pillow placed between her legs due to the recent hip surgery. The CNA from the previous shift reported the resident's abductor pillow was not in place. CNA 3 stated she asked the resident, the resident told the CNA she did not want in on yet, so CNA 3 did not put it in place. The CNA stated she did not see the resident again until she was called to the resident's room when the resident fell . On [DATE] at 0942 hours, a telephone interview was conducted with LVN 6. When asked about Resident 2's abductor pillow the night the resident fell , LVN 6 stated she had not noticed it was not in place and had not seen Resident 2 the night pf the resident's fall.

Based on interview, clinical record review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 1) received adequate supervision during a transfer with a mechanical lift, causing Resident 1 to sustain a fall, which resulted in multiple facial bone fractures and required hospitalization . Findings: Review of the facility's P&P titled Total Mechanical Lift dated 7/1/15, showed: a. The nursing staff will be trained to use the mechanical lift. b. The resident will have a physician's orders [REDACTED]. c. At least two people are present while a resident is being transferred with the mechanical lift. Closed clinical record review for Resident 1 was initiated on 12/31/15. Resident 1 was admitted to the facility on [DATE], and discharged to the acute care hospital on [DATE]. Review of Resident 1's MDS dated [DATE], showed Resident 1's cognitive skills were severely impaired and required full staff performance for transfers with two or more persons. Review of Resident 1's Health Status Note dated 11/30/15, showed LVN 1 was summoned by CNA 1 at 1020 hours. The note showed Resident 1 was on the bedroom floor near the bed lying in a supine position. The resident had a laceration to the left side of her forehead, a cut on her left upper lip, and redness to the left eye. Further documentation showed Resident 1 fell out of the mechanical lift while being transferred from the bed to the wheelchair. Review of the facility's fall investigation showed Resident 1 was being transferred by two CNAs from the bed to the wheelchair using a mechanical lift. Resident 1 leaned forward which caused the sling to tilt, and the resident fell on the floor, face first. Resident 1 sustained a laceration on the forehead. The physician was notified and the resident was sent to the acute care hospital. The facility's investigation report showed CHHA 1, an employee working for a hospice agency and coming to the facility to provide care for Resident 1's roommate was alleged to have assisted CNA 1 in transferring Resident 1 from the bed to the wheelchair. Review of the Ambulance Prehospital Care Report dated 11/30/15 at 1145 hours, showed Resident 1 was transported to the acute care hospital's ED for uncontrolled bleeding from her nose. Review of the Emergency Department Provider note dated 11/30/15, showed Resident 1 arrived at the ED at 1158 hours. Resident 1 had a CT scan of the head, maxillofacial, and cervical spine done. The results of the CT scans showed an acute nondepressed fracture of the left frontal bone with involvement of the inner table and left orbital roof (the skull just above the left eye), acute fractures of the bilateral nasal bones, bilateral frontal processes of the maxilla (facial bones), and bilateral maxillary sinus walls. Resident 1 was admitted to the hospital for evaluation due to the fall with traumatic injuries. Resident 1 was readmitted to the facility on [DATE]. On 12/31/15 at 0920 hours, Resident 1 was observed lying in bed. Resident 1 was observed to have a healed scar on the left side of her forehead above the eyebrow. An interview was conducted with LVN 1 on 12/31/15 at 0922 hours. LVN 1 stated on 11/30/15, he heard CNA 1 call for help. LVN 1 stated he entered the resident's room and Resident 1 was on the floor. LVN 1 stated CNA 1 reported Resident 1 was being transferred from the bed to the wheelchair with the mechanical lift; and she suddenly leaned forward and fell to the floor, head first. An interview was conducted with CHHA 1 on 1/8/16 at 1035 hours. CHHA 1 stated he was caring for another resident who shared the room with Resident 1. CHHA 1 stated he was behind the privacy curtain when he heard a loud noise. CHHA 1 stated he opened the privacy curtain and saw Resident 1 lying face down on the floor. CHHA 1 stated he saw CNA 1 behind the mechanical lift control, then she ran to the resident on the floor. CHHA 1 stated he told CNA 1 to call for help and assisted Resident 1 to a supine position and noted blood on the resident's forehead. CHHA 1 was asked if he assisted CNA 1 with the transfer of Resident 1 using the mechanical lift. CHHA 1 stated he did not assist with Resident 1's transfer and was not at the controls of the mechanical lift. An interview was conducted with CNA 1 on 1/8/16 at 1115 hours. CNA 1 stated she was standing next to the resident in the sling of the mechanical lift and CHHA 1 was moving the mechanical lift. CNA 1 stated she asked CHHA 1, who was assisting the roommate of Resident 1, to assist her with the transfer of Resident 1. CNA 1 stated Resident 1 was placed on the sling in the bed, the bed was against the wall, the resident was in a sitting position in the sling. The resident was being backed up to place the resident in a wheelchair. Resident 1 suddenly leaned forward and fell on her face to the floor. CNA 1 stated the fall happened so fast she could not stop the fall. CNA 1 was asked if Resident 1 hit her head on anything during the fall. CNA 1 stated Resident 1's head was next to the left base leg of the lift but thought she probably hit her face on the floor. CNA 1 stated she then called the Charge Nurse with her walkie-talkie. On 1/11/16 at 0920 hours, another interview was conducted with LVN 1. LVN 1 stated he was the first Charge Nurse to respond after Resident 1 fell . LVN 1 stated Resident 1 was in a prone position on the floor when he entered the room. LVN 1 stated the resident was lying in the center between the base legs of the lift.

Based on interview and clinical record review, the facility failed to promptly and thoroughly investigate allegations of abuse for for three of three residents (Resident Q, Resident 13 and Resident D). Resident Q reported an allegation of abuse on 5/24/13, involving CNA 16. However, administration failed to ensure an investigation was conducted regarding the allegation. On 10/25/13, Resident Q and her family member again reported the allegation of abuse from May 2013, to Social Service Assistant (SSA) 1. This time an investigation was done, however, the facility did not interview staff members or other residents as part of their investigation. On 8/31/13 and 10/16/13, Resident 13 reported allegations of abuse involving CNA 16. The allegation of abuse on 8/31/13, was not investigated. In addition, the allegation on 10/16/13, was not thoroughly investigated; the facility did not interview any other residents to determine if there may have been any other allegations of abuse against CNA 16. As a result, CNA 16 continued to work in the facility. On 11/21/13, during an investigation conducted by the California Department of Public Health (CDPH), Licensing & Certification, a third resident (Resident D) verbalized allegations of repeated sexual abuse by CNA 16. Findings: According to the facility's policy and procedure (P&P) titled California Mandatory Reporting dated 7/02, employees are mandated reporters in California, per California law and are required to report all abuse, sexual and physical assaults. a. An interview with Administrator 3 was conducted on 11/13/13 at 1100 hours. He stated he received an allegation of abuse from Resident Q against CNA 16 on 10/29/13. The Administrator was asked to provide all evidence from the investigation into the allegation of abuse regarding Resident Q. The Administrator stated he asked SSA 1 to take Resident Q's statement. He stated Resident Q was interviewed and CNA 16 ' s employment was terminated on or about 10/24/13. When asked if he interviewed any other residents or staff members, the Administrator stated, "No." Clinical record review for Resident Q was initiated on 11/13/13. Review of the Minimum Data Sets (MDS, an assessment tool) dated 8/23/13 and 2/20/13, showed the resident is alert, oriented and can communicate her needs. Review of a Social Service Progress Note dated 10/29/13, showed SSA 1 interviewed Resident Q and her family member on 10/29/13, regarding the resident's allegation against CNA 16. According to the Social Service Note, Resident Q reported in May or June, CNA 16 began to massage her back and proceeded to give her a full body massage. The report showed Resident Q told SSA 1 the CNA got too close to her private area and she felt uncomfortable. Resident Q requested she only receive care from female CNAs. On 11/13/13 at 1515 hours, an interview with Resident Q was initiated. Resident Q stated she was admitted to the facility early in the year, and resided on the first floor for about two months. She stated she was then transferred to the second floor. She stated CNA 16 was assigned to care for her on 5/24/13. She stated, in the middle of the night (on 5/24/13), she had soiled her clothing and CNA 16 helped her to the bathroom, removed her clothing and then put her into bed naked. She stated her back was hurting and CNA 16 began to massage her back, but then began to massage her front. She said that is when CNA 16 went too low towards her private region and she became very uncomfortable. Resident Q was asked how she remembered when the incident occurred. She stated she wrote the date and the name of the CNA in her journal. She stated she also documented the name of the licensed nurse (Assistant Director of Nurses - ADON 2) who she reported the incident to. Resident Q retrieved her journal and showed the entries she had made in her journal verifying CNA 16's and ADON 2's names and the date of the incident. Resident Q stated she told her family member about what happened the next day. The resident was asked if anyone at the facility investigated or asked her any questions about what happened after that. She stated, no. She stated she finally told the Director of Nurses (DON) she did not want any male CNAs caring for her again. An interview was conducted with ADON 2 on 11/13/13 at 1545 hours. ADON 2 stated she was informed of the incident by Resident Q in May 2013 and reported it to Administrator 1. ADON 2 stated she was not aware of any investigation into the incident. On 11/13/13 at 1630 hours, an interview with Resident Q's family member was conducted. The family member stated Resident Q called her and told her what happened with CNA 16 in May 2013. The family member stated she called the Administrator's office, but Administrator 1 did not answer the phone. The family member stated she left a long message about the incident for the Administrator, but never heard back from her. When asked if the family member knew of any investigation or if the resident was interviewed by facility staff regarding her grievance against CNA 16, the family member stated, no; no one interviewed her or the resident. Review of CNA 16's Time Detail report verified he had worked on 5/24/13. b. Clinical record review for Resident 13 was initiated on 10/15/13. The MDS dated [DATE], showed the resident is cognitively intact. Further review showed the resident has no hallucinations (false perception that appears to be real) or [MEDICAL CONDITION] (false belief held despite strong evidence against it). Review of the nurse's note dated 8/31/13 at 0215 hours, showed the resident reported to the nurse a CNA went in her room, hit her legs while the resident was in bed, and left the room. The note further showed the CNA assigned to Resident 13 was changed and the incident was reported to Administrator 1. Review of the Physician's Progress Note dated 9/3/13, showed the resident falsely accused a staff member of touching and hitting her legs. During an interview with Administrator 1 on 10/15/13 at 1500 hours, she was asked if she has any investigations for Resident 13. She replied, no. An interview was conducted with Licensed Vocation Nurse (LVN) 8 on 10/17/13. LVN 8 was asked their policy regarding allegations of abuse. He stated they have to notify the Administrator and the Ombudsman. He further stated an allegation of abuse occurred two months ago involving Resident 13 and CNA 16. The resident had reported CNA 16 had touched her and walked out of the room. He stated he called Administrator 1 to report the incident and was informed to document the incident, initiate behavior monitoring for Resident 13, and Administrator 1 would follow-up in the morning. LVN 8 was asked what happened to CNA 16. He stated, he reassigned the CNA to another area of the facility. LVN 8 was informed the allegation was not investigated. He stated he thought Administrator 1 conducted an investigation because the staff completed their statements. Additional clinical record review showed psychiatrist's notes dated 9/21/13 and 10/9/13, which identified Resident 13 had no hallucinations or [MEDICAL CONDITION]. During an interview with ADON 2 on 10/17/13, she was asked their policy on allegations of abuse. She stated, if the allegation is against a staff member, the staff member has to be sent home. On 10/17/13 at 1415 hours, an interview was conducted with Resident 13. She stated there was a man (CNA 16) who entered her room, touched her shoulder and caressed her legs. She was asked if she told anyone. She stated it happened several times and she had reported him before. She stated they reassigned him to another location in the facility. She was asked if it happened again. She replied, "yes," and stated she was determined to report him. She further stated, just this week, he came in my room again and touched my shoulder, but this time she had a reacher (a tool used to pick up things) and I hit the man on the head. She stated that man is a CNA and stated CNA 16's name. She stated CNA 16 works the 11-7 shift. When asked what day of the week it happened. She stated if today is Thursday, then Tuesday night. She was asked if she reported the incident. She stated she reported it to ADON 2 and SSA 1. She further stated SSA 1 wanted her to move to another room, but she refused. She stated she is not the criminal. She stated CNA 16 was reassigned to another location. Review of the CNA staffing schedule and assignments for 10/15/13 (Tuesday) 11-7 shift showed CNA 16 was working that night and assigned to rooms on the same hallway where Resident 13's room is located. On 10/17/13 at 1540 hours, an interview was initiated with SSA 1. The SSA confirmed Resident 13 had reported being inappropriately touched by CNA 16 on 10/15/13. He stated they called CNA 16 in for questioning. SSA 1 was asked to provide the facility's investigation. He stated the Corporate Consultant Nurse asked him to interview Resident 13 again and asked if she felt violated or unsafe. SSA 1 stated the resident did not feel violated or unsafe, so the facility did not submit a report to the CDPH or the Ombudsman. When he was asked to provide the facility's investigation, he stated he will get it from the Corporate Consultant Nurse. On 10/17/13 at 1615 hours, SSA 1 provided copies of statements from CNA 16 and a brief statement from CNA 17 showing she was assigned to Resident 13. SSA 1's interview with Resident 13 showed Resident 13 stated a CNA went into her room and touched her, but she hit the CNA on the head. The interview did not show if the resident was asked if any other incidents occurred involving CNA 16. There was no documented evidence the facility interviewed the charge nurse, RN supervisor, other CNAs or other residents. Review of the Corporate Consultant Nurse's follow-up notification letter dated 10/17/13, showed the nurse confirmed CNA 16 was working on 10/15/13, but was not assigned to care for Resident 13. The letter showed Resident 13 stated she had hit someone who came into her room with her reacher after she was inappropriately touched, but she could not confirm who it was as it was dark in her room. The resident then got up out of bed and saw CNA 16 walking down the hall holding the back of his head. The Corporate Consultant Nurse identified he had examined CNA 16's head on 10/17/13, but saw no evidence of an injury to support Resident 13's statement. The report showed he called the resident's family member and the resident's psychiatrist to report what happened. The letter further showed CNA 16 would be allowed to return to work. The letter did not show any interviews were conducted with any other residents. During an interview with an anonymous staff member on 10/18/13 at 1000 hours, the staff member stated they were instructed by the Corporate Consultant Nurse not to report or document Resident 13's allegation of abuse on 10/16/13. CNA 16 last day of employment at the facility was 10/28/13. c. On 11/14/13 at 0930 hours, an interview was conducted with Resident D. Resident D was asked if any facility staff member has ever done anything inappropriate or made her uncomfortable while providing care to her. Resident D stated, yes, a male CNA (CNA 16) on the night shift had touched her vaginal area too much and too deep while changing her incontinence briefs. She stated it happened two or three times a few months ago. Resident D stated she was shocked by what happened and did not know what to do. She said she was too embarrassed to tell anyone. Clinical record review for Resident D was initiated on 11/14/13. The MDS dated [DATE], showed she was alert, oriented and has no cognitive problems. The resident wears an incontinence brief at night and requires staff's assistance to change it. On 12/3/13, the facility reported a Manager from CDPH Investigation Section was at the facility and interviewed Resident D regarding her allegations of abuse by CNA 16. Resident D provided specific details as to what CNA 16 did to her. She stated, while he was changing her incontinence brief and cleaning her, CNA 16 put his finger into her vagina. She said it happened on three separate occasions within a one week period. When asked if he said or did anything while he was touching her, she stated," He had a smile on his face and looked at me while it was happening. "She stated she had no idea what was going on and was in shock," I didn't know what to do." She stated, on the third occasion, she rolled over so he would stop. She stated he said to her "You like my work?" When the Manager asked if she had reported it to anyone, she replied, "I was so embarrassed and didn't know what really happened." The resident revealed she had never been sexually active and is a virgin.

Based on resident complaints, interviews with residents and staff and record review, the facility failed to provide sufficient nursing staff and related services to attain and maintain the basic physical and psychosocial needs of each resident. The lack of sufficient staffing was voiced during the resident group interview by all 13 residents representing all three resident care areas in the facility. Clinical record review for 24 sampled residents and 18 nonsampled residents (a total of 42 residents from throughout the facility with a census of 105 residents) showed a lack of appropriate assessments, care and care planning to meet the residents' identified needs for incontinence, pressure ulcers, ADLs, PICC lines, physical/occupational therapy, dental, ophthalmology and audiology deficits, changes of condition, timely physician notification and infection control procedures. The lack of care resulted in continent residents becoming incontinent and skin irritation, development and worsening of pressure ulcers, declining ADL abilities, decreased range of motion, clogging of a PICC line, a dental emergency, a resident without a hearing aid for over one year, and two residents with severely worsening vision without appropriate follow up. Staff interviews revealed RNA and activity services were not routinely provided due to insufficient staffing, but services were charted as if completed. During interviews with CNA staff, the CNAs expressed frustration with the increasing number of assigned residents which had gotten worse in the last five months. Review of the monthly schedule for licensed staff and CNAs given to the survey team shows insufficient staffing to meet the residents needs. During subsequent interviews, surveyors were told the monthly schedule was not accurate; staffing was adjusted on a day to day basis, but neither Administrator 1, DON 1 or DON 2 could verbalize the methodology used to ensure adequacy of staffing. Findings: 1. On 10/13/13, review of the night shift schedule for 10/13/13, was initiated. Review of the third floor census showed a census of 55 residents with 41 of those residents were identified as fully incontinent. There were four CNAs scheduled to work. An interview with Administrator 1, DON 1 and DON 2 was initiated on 10/23/13 at 1300 hours. Administrator 1 and DON 1 were asked if each of the 41 incontinent residents was incontinent of urine, how much time would the CNA need to change each resident. DON 1 stated, if the resident is incontinent of urine, it would take around ten minutes to change the resident if the bed was dry. DON 1 confirmed it would take two CNAs their entire shift to change each resident twice, leaving two CNAs to care for all 55 residents' needs, including answering call lights, assisting and supervising confused residents to ensure their safety, turning residents, assisting residents to get out of bed as needed, give morning care (go to the bathroom, brush their teeth, comb their hair, clean their hands) and passing water for the day. Administrator 1 was asked if she has any system in place to base staffing on the above residents' needs. She stated, no. 2. An interview with CNA 7 was initiated on 10/10/13 at 1130 hours. CNA 7 stated, during the day shift, she used to have nine residents to care for. Now she has 10 or 11 residents daily. Her responsibilities include answering call lights, providing four showers a day, changing everyone's linen daily, incontinence care for six fully incontinent residents, getting everyone up and back to bed at least once per shift and assisting seven residents to eat. She stated she can not complete her work. 3. An interview with CNA 5 was initiated on 10/10/13 at 1530 hours. CNA 5 stated she works during the day and her daily work includes four to five showers, changing linens, incontinence care, answering call lights and assisting with feeding. CNA 5 stated she can not keep up with the work load and has complained to her supervisor. CNA 5 stated, when she gives showers, she knows the other residents are using their call lights, but she can not assist them because she can not leave the residents in the shower to assist others. 4. An interview with CNA 16 was initiated on 10/11/13 at 0640 hours. CNA 16 stated he sometimes has 20 - 21 residents at night to care for. The CNA stated he can not complete all his work with that many residents to care for. 5. An interview with RNA 4 and RNA 5 was initiated on 10/17/13 at 1030 hours. The RNAs stated, on Monday and Tuesday, the weekly weights are being provided, not leaving time for the RNA treatments. On Wednesday, Thursday and Friday, one or two RNAs are scheduled to work, but they are sometimes used to assist the residents in activities. There are not enough RNAs to complete the needed work. RNA 5 stated he just checks the work assignment sheet, documents the work is done even though it is not. 6. An interview with the Activities Director was initiated on 10/17/13 at 1145 hours. The Activities Director stated residents are not getting room visits due to her being the only staff member in the department during the week. She stated the group activities are her priority. 7. An interview with SSA 1 was initiated on 10/16/13 at 1000 hours. SSA 1 stated he has only been working at the facility for two months. He stated he has been trying to catch up on as many resident issues as possible. 8. An interview with ADON 2 was initiated on 10/15/13 at 1530 hours. The ADON stated she never knows how many staff are working on the next shift until a half hour before the previous shift ends. An interview with the DSD was initiated on 10/15/13 at 1600 hours. The DSD stated the published monthly schedule is not the schedule the employees follow. A daily assignment sheet is done and the employees must sign in on this sheet. Review of the monthly schedule and the daily assignment sheet showed neither schedule was correct. The DSD stated the sheets are not correct because she changes them daily and brings a new sheet to the nurses' station. (Cross reference to F224, F248, F250, F309, F311, F312, F314, F318).

Based on observation and interview, the facility failed to provide a food tray in an appropriate period of time to one of 11 sampled residents (Resident 26). Resident 26 waited over half an hour for her lunch tray while her tablemates ate their lunches. This poses the risk of the resident feeling frustrated and ignored. Findings: Lunch observation was conducted on 12/11/13 at 1205 hours, in the second floor dining room. Resident 26 was observed seated at a table with another resident, waiting for her lunch tray while tablemate was eating lunch. Observations at 1215 hours, 1220 hours, 1225 hours and 1230 hours showed Resident 26 had not received her lunch tray. All the other residents in the dining room were eating their lunches. Resident 26 sat at the table looking around. At 1230 hours, an interview was conducted with Resident 26. She was asked if she is hungry. Resident 26 stated she was hungry. At this time, LVN 2 was interviewed. When asked where Resident 26's tray is, LVN 2 stated Resident 26 usually eats in her room. When asked about their system if the resident wishes to eat in the dining room, LVN 2 stated they usually call the dietary department ahead of time to inform them. LVN 2 stated she called the dietary department at 1130 hours to notify them Resident 26 was going to eat in the dining room. On 12/11/13 at 1235 hours, Resident 26 was observed receiving her lunch tray.

Based on interview and clinical record review, the facility failed to provide a comprehensive assessment for one of 11 sampled residents (Resident 5). Resident 5 had a decrease in his red blood cell (hemoglobin) count ([MEDICAL CONDITION]). The facility did not assess the resident for signs or symptoms of the [MEDICAL CONDITION], such as blood in the stools, shortness of breath, or increased fatigue, which could indicate the [MEDICAL CONDITION] was getting worse. The facility did not discuss the [MEDICAL CONDITION] with Resident 5. In addition, the facility did not develop a plan to ensure the resident's blood count did not get worse and follow a physician's orders [REDACTED]. This has the potential for the [MEDICAL CONDITION] to get worse. Findings: According to Medicinenet.com, hemoglobin is the protein molecule in red blood cells that carries oxygen from the lungs to the body's tissues and returns carbon [MEDICATION NAME] from the tissues back to the lungs. A low hemoglobin level is referred to as [MEDICAL CONDITION] or low red blood count. A low hemoglobin level may lead to increased fatigue and more strain on the heart, which could lead to [MEDICAL CONDITION] (the heart muscle is not able to pump enough blood to satisfy the metabolic needs of the tissues). Clinical record review for Resident 5 was initiated on 12/10/13. Review of the Face Sheet dated 10/27/13, showed Resident 5 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Physician 2's Progress Note dated 10/30/13, showed Physician 2 documented Resident 5 has a history of [MEDICAL CONDITION]. The note showed to restart the resident on iron supplements twice a day. There are no further physician progress notes [REDACTED]. Review of the Physician order [REDACTED]. Review of the laboratory reports dated 11/4/13, and 11/11/13, showed Resident 5's hemoglobin was 10 (normal 13.5 - 16.9). Review of the laboratory report dated 11/18/13, showed the hemoglobin dropped to 8. The nurse's note dated 11/18/13, showed the physician was notified of the lab result and ordered a repeat blood test. The laboratory report dated 11/22/13, showed the hemoglobin dropped to 7.7. According to the Nurse's Notes dated 11/22/13, the physician was made aware of the lab result and ordered another blood test. Further review of the Nurse's Notes dated 11/18/13, through 11/25/13, showed no documentation to show the nurses addressed the problem of [MEDICAL CONDITION] or discussed a plan for Resident 5 with the resident's physician. Review of the care plan showed no care plan problem to address the [MEDICAL CONDITION] for Resident 5. Review of the IDT notes dated 11/20/13, and 11/27/13, showed no documentation the IDT discussed Resident 5's [MEDICAL CONDITION] or developed a plan to assess if the resident's [MEDICAL CONDITION] was getting worse. An interview with Resident 5 was initiated on 12/13/13 at 1100 hours. Resident 5 stated he was not aware of the [MEDICAL CONDITION]. The resident stated the physician or the facility staff had not discussed the [MEDICAL CONDITION] with him. An interview with Physician 2 was initiated on 12/13/13 at 1130 hours. Physician 2 stated he was aware of Resident 5's lab results and visits the facility regularly. Physician 2 was asked if the facility had discussed a plan for Resident 5's [MEDICAL CONDITION] with him. The physician stated he was not aware of any plan for the [MEDICAL CONDITION]. An interview with DON 3 was initiated on 12/13/13 at 1500 hours. The DON confirmed there was no care plan or documentation to show a plan for Resident 5's [MEDICAL CONDITION].

Based on interview and clinical record review, the facility failed to promote dignity for three of 24 sampled residents (Residents 2, 5 and 13), five nonsampled residents (Residents F, B, D, E and R) from a resident group interview. Residents stated they were not given there showers on a regular basis, call lights were not answered timely, causing incontinence. This has caused the residents to feel frustrated and ignored. The facility failed to follow Resident 13's physician's orders [REDACTED]. This resulted in psychological anguish to Resident 13. Immediate Jeopardy was identified on 10/11/13 at 0930 hours, regarding the facility's failure to provide services to promote dignity, including answering call lights promptly, providing showers and incontinence care and ensuring residents are assisted out of bed. The Administrator was made aware of the Immediate Jeopardy on 10/11/13 at 1210 hours. The facility provided inservice education to all staff members regarding answering call lights, turning residents, incontinence care and additional CNAs were scheduled to assist with care. On 10/18/13 at 1430 hours, Administrator 2 and DON 2 were informed the Immediate Jeopardy was abated. Findings: 1. An interview with Resident 5 was initiated on 10/10/13 at 0800 hours. Resident 5 stated he had a fall in May 2013 and was left on the floor for over 20 minutes because no one answered his call light and his yells for help. (Cross Reference to F323) Resident 5 stated he is fully continent of his bowels and bladder. The resident stated he can use a urinal without assistance, but he needs assistance when he moves his bowels. Resident 5 stated he has been incontinent in the bed due to long wait times for the call lights. (Cross Reference to F311) Resident 5 stated he does not get his showers on a regular basis. He must insist on getting his showers. 2. An interview with Resident F's family member was initiated on 10/18/13 at 1000 hours. The family member stated she and another family member visit the resident daily at around 1400 hours. The family member stated she usually finds food on the resident's face from lunch. She further stated she frequently found the resident was not cleaned, so she has hired a caregiver to give the resident a bath. 3. An interview with nonsampled Resident B was initiated on 10/17/13 at 1345 hours. Resident B stated his call light is not answered promptly causing him to become incontinent of his bowels three times. He stated, when he complained to the CNAs about the wait times, the CNAs get angry. The resident stated the CNAs have lost their [MEDICATION NAME]. 4. An interview with nonsampled Resident D was initiated on 10/10/13 at 0830 hours. Resident D stated she had an episode of incontinence of her bowels due to over an hour wait time for the call light to be answered last week. The resident stated, if you complain, the CNAs complain right back about being short of staff. The resident stated "I have to be here, they don't." In addition, the resident stated she was supposed to get two showers a week. She stated she usually gets her first shower, but has to insist on the second shower or she will not receive it. 5. An interview with nonsampled Resident E was initiated on 10/10/13 at 0845 hours. Resident E stated, "if I do not like the dinner being served and ask for a substitute, the staff do not want to get it for me. I have to insist." 6. An interview with nonsampled Resident R was initiated on 10/10/13 at 1445 hours. Resident R stated, when she was admitted to the facility, she could walk with a walker. She was told not to walk to the bathroom without assistance. The resident stated the problem is, no one comes to assist her to the bathroom. She will sit in the bed or the wheelchair all day, alone, and she has now become weaker. 7. During initial tour, an interview was conducted with Resident 13. Resident 13 stated, "I can not hear you; let me just get my hearing aide in my drawer." When the resident placed the hearing aide in the right ear, it was a Bluetooth (a hands free wireless device used with a mobile telephone) not a hearing aide device. When asked where is the real hearing aide, Resident 13 stated, "It was broken since last year, and they gave this device to me 6 months ago. When asked how she feels when she is talking to people and can not verbalized her thoughts about the conversation, Resident 13, stated "I can not communicate very well because I can not hear them, especially during our resident council meeting. All the residents were asking for my opinion and I just answered them back with, yes, because I can not hear or understand them. I can drop or forget everything, like my lipstick, hair salon, but not my hearing aide; I really need it." Review of Resident 13's clinical record was initiated on 10/10/13 at 0915 hours. Resident 13 was admitted to the facility on [DATE]. Review of Resident 13's MDS shows she is cognitively intact. Review of SSA progress notes and IDT notes since 2012 to present showed in all documentation the resident did not need referrals or outside resources at this time. No documentation was found regarding a broken or replaced hearing aide. (Cross reference to F250) 8. On 10/15/13, clinical record review was initiated for Resident 2. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Resident 2 is severely cognitively impaired, speaks a foreign language and is totally dependent on staff for bed mobility, transfers, toileting, eating and locomotion off the unit. Resident 2 requires extensive assistance with personal hygiene, bathing and is always incontinent of both bladder and bowel. On 10/22/13 at 1420 hours, an interview was conducted with Resident 2's family member. When asked about Resident 2's general appearance and grooming, Resident 2's family member stated Resident 2 is always in bed and her hair is not done when she visits. Resident 2's family member stated she has seen a decline in the care and services provided by the facility in the last month and a half. Resident 2's family member stated Resident 2 is a quiet person by nature and will not complain, but appears very unhappy. When asked if she had discussed her concerns with the facility, she stated, no. However, she stated another family member had complained to the facility about the lack of care and services, but nothing has changed. She stated Resident 2 is very unhappy and has declined. 9. During a resident group interview on 10/10/13 at 1100 hours, 13 residents from all three clinical areas of the facility attended. Seven of 13 residents stated, when they put the call light on, someone will answer the call light, find out what the resident needs, turn the call light off and leave the room. The residents stated no one ever comes back to help them. Two residents stated they have become incontinent because it takes forever for their call light to be answered. Seven residents stated they have complained to the facility staff and Administrator about the CNAs not answering the call lights timely, but nothing ever changes. The residents stated they feel mad, ignored and frustrated. One resident stated he was told he could not get out of bed because there were not enough CNAs to help him. The residents stated even the facility staff complain there is not enough staff. One resident stated there are not enough social workers. All of the residents present agreed with this statement. The residents stated there were three social workers at one time, now there are only two. One resident was observed holding a Bluetooth to her ear. When questioned why she was using a Bluetooth, the resident stated her hearing aide has been broken for over a year and the social worker gave her the Bluetooth to use until the hearing aide is replaced. The resident did not know when her hearing aide will be replaced.

Based on interview and clinical record review, the facility failed to implement their policy and procedure to prevent neglect of 15 of 24 sampled residents (Residents 1, 12, 5, 8, 11, 13, 18, 19, 22, 14, 7, 23, 3, 10 and 24) and six nonsampled residents (Residents E, D, F, B, R and Q). *Resident 12 was admitted to the facility with no skin breakdown. The facility failed to implement a repositioning and a toileting schedule, despite the fact the facility was aware Resident 12 spends long periods of time up in her motorized wheelchair. The facility staff was not aware Resident 12 has a specialized motorized wheelchair able to tilt/recline to offload the pressure areas. These failures resulted in Resident 12 developing a skin excoriation to her buttocks, while in the facility, which deteriorated to five Stage III (full thickness tissue loss. subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Some slough (dead tissue) may be present) pressure ulcers. *Resident 5 developed two pressure ulcers on the buttocks while at the facility. Although daily skin assessments were supposed to be provided of the buttocks area, neither pressure ulcers were documented in the clinical record and no additional treatment was being provided for the pressure ulcers. This places the residents at risk for infection, decreased functional ability, and independency. *The facility failed to provide Resident 1 with PICC line (Peripherally Inserted Central Catheter) care in accordance with the physician's orders [REDACTED]. Staff failed to show they were flushing the PICC line with [MEDICATION NAME] (anticoagulant used to maintain the catheter patency). In addition, the facility failed to follow the physician's orders [REDACTED]. These failures may have contributed to Resident 1's PICC line becoming clogged. Intravenous antibiotics infusing too fast have the potential for development of inflammation of a vein. *The facility failed to follow Resident 13's physician's orders [REDACTED]. This poses psychological anguish to the resident. *The facility failed to follow Resident 8's physician's orders [REDACTED]. This poses the potential for development of pressure ulcers. *The facility failed to follow Resident 11's physician order [REDACTED]. The facility failed to provide showers to the resident since admission (7/1/10). This poses the risk for decline in mobility and skin impairment. *Resident 19 required suctioning, but the nursing staff failed to suction the resident timely. *The facility failed to manage or prevent Resident 18's pain consistent with the plan of care and failed to monitor or assess the effectiveness of pain medication after administration. This resulted in Resident 18 being transferred to the acute hospital twice in four months (6/7/13 and 10/14/13). *The facility failed to provide Resident 22 with incontinence care timely, turn and reposition the resident while in bed and wheelchair; and accurately assess and provide appropriate treatment to promote healing of a pressure ulcer. Resident 22 developed a Stage III pressure ulcer to the sacrum while in the facility. *Resident 23, who is a bilateral below the knee [MEDICAL CONDITION], was not provided with enablers to assist with bed mobility and was not assisted out of bed into a wheelchair since admission. *The facility failed to ensure Resident 24's pain was addressed and prescribed pain medications were administered timely. Resident 24 verbalized she had uncontrolled generalized pain when she attempted to end her life. *Resident 7's call light is not answered timely. As a result, she has to remain in soiled briefs for extended periods of time, which results in skin irritation. *During a resident group interview, seven residents stated their call lights are not answered timely resulting in the residents becoming incontinent. The residents stated, when they address concerns to the facility staff, nothing gets resolved. This resulted in a decline in the residents' quality of life. *The facility failed to ensure Resident 3 was provided with services to ensure a referral for the RNA program was done. This poses the risk for decline in range of motion. *The facility failed to ensure Resident 10 was provided with a pressure pad alarm (alarm to alert staff the resident gets unassisted) on her wheelchair to prevent another fall. This poses the risk of the resident sustaining a fall with the possibility of serious injury. *The facility failed to ensure RNA services were provided to Resident 14 and Resident Q to prevent declines mobility. *Resident E was not provided with eye care to treat her [MEDICAL CONDITION], resulting in [MEDICAL CONDITION]. In addition, Resident E was not provided room visits from the activities staff, resulting in feelings of isolation. *Resident D was not provided information regarding her monetary funds until the bank was ready to foreclose on her home. This resulted in Resident D suffering anxiety regarding her future. Resident D's call light was not answered timely, resulting in incontinence, was not provided routine showers, RNA services and room visits by the activities staff. *Resident F not seen by a dentist until his condition required emergency treatment. He was not provided hygiene care to maintain his dignity. *Resident B's call light was not answered timely on a number of occasions, resulting in the resident being incontinent. Resident B was not provided RNA services. *Resident R was not provided assistance to ambulate. As a result, the resident has become weaker. Immediate Jeopardy was identified on 10/11/13 at 0930 hours, regarding the facility's failure to prevent negligence by: * Failure to assess and prevent pressure ulcers, residents with multiple pressure ulcers developed in the facility were observed. * Failure to follow the physician's orders [REDACTED]. * Multiple residents' complaints regarding the lack of incontinence care, nails not trimmed, lack of showers, lack of RNA services, lack of room activity services, lack of linen, and urine odor in the environment. * Multiple complaints regarding Social Services such as lack of hearing aides (causing social isolation), failure to arrange dental appointments, lack of a full time qualified Social Worker. * Multiple complaints regarding lack of RD assessments, resulting in weight loss and/or weight gain. The Administrator was made aware of the Immediate Jeopardy on 10/11/13 at 1210 hours. On 10/13/13 at 1500 hours, the facility's final plan of correction to abate Immediate Jeopardy was reviewed with DON 1 and Administrator 1. The corrections the facility took were to immediately identify residents who require IV therapy and audit for appropriate orders, providing flushes, and staff inservicing. Immediately identify residents who need to be referred to the audiologist or other medically related social services. Immediately identify residents who reside in the facility with lack of peri-care, and provide timely incontinence care. Immediately inservice RNA staff, and adjusted staffing to meet the current resident needs based on RNA review. Immediately inservice staff on answering call lights, and obtain additional staffing by the DSD. Immediately increase CNA staffing, and increase treatment nurse staffing to one more nurse per day. The facility provided documented evidence staff, including nursing staff, rehabilitation therapists, maintenance and housekeeping departments received inservices as they came on duty, prior to providing care to residents. The inservices included information related to provide residents incontinence and peri-care, RNA program, social services, activities, infusion therapy, and call lights. On 10/18/13 at 1430 hours, Administrator 2 and DON 2 were informed the Immediate Jeopardy was abated. Findings: 1. Resident 12 is cognitively intact, requires total assistance from at least two staff members for transfers, and extensive assistance for bed mobility, is always incontinent of bowel and bladder. The MDS identified there was a pressure reducing device for chair and bed; however, no turning or repositioning program is in place. Review of a Physician's Progress Note dated 10/1/13, showed Resident 12 developed pressure ulcers (a wound to the tissue due to unrelieved pressure). Resident 12 was provided a specialized wheelchair which can help relieve pressure while being seated in the wheelchair. Resident 12 stated she was not aware of her motorized tilt/reclining wheelchair in relationship to weight distribution to reposition herself and relieve pressure. The facility failed to provide Resident 12 information/instruction regarding the use of the specialized wheelchair to help her relieve pressure while up in the wheelchair. The facility failed to provide good incontinence care to promote the healing of her wounds. (Cross reference to F314) 2. Resident 1 was readmitted to the facility from the acute care hospital on [DATE], with a PICC line inserted in her left forearm for intravenous antibiotic therapy. The physician's orders [REDACTED]. the physician's orders [REDACTED]. Observation and interview showed the licensed nurses were not using the IV pump or flushing the PICC line with [MEDICATION NAME]. As a result, Resident 1's PICC line became clogged. (Cross reference to F328) 3a. Resident 5 stated he was not turned regularly, resulting in a pressure ulcer. The LVN documented the resident was getting regular skin assessments but did not document any pressure ulcers. (Cross Reference F 314) b. Resident 5 had a fall in September 2013, after being dropped from the mechanical lift. The facility did not document the fall, assess the resident after the fall or notify the physician and did not inservice staff members in the use of the mechanical lift. Resident 5 stated he had a fall in May 2013, and was left on the floor for over 20 minutes because no one answered his call light and yells for help. (Cross Reference F323) c. Resident 5 has a documented decline in ROM on 9/13/13. The resident has not received RNA services to improve ROM function. (Cross Reference F318) d. Resident 5 stated he is fully continent of his bowels and bladder. The resident stated he needs assistance when he moves his bowels. Resident 5 stated he has been incontinent in the bed due to long wait times for the call light to be answered. (Cross Reference F311) e. Resident 5 stated he does not get his showers on a regular basis. He must insist on his showers. (Cross Reference F241) 4. Resident 19 needed to be suctioned due [MEDICAL CONDITION] of the esophagus. The LVN providing the treatment did not suction the resident for over two hours. Two other nurses were aware the resident needed suctioning but did not assist the resident either. (Cross Reference F309) 5a. Resident E has [MEDICAL CONDITION] and was not seen by her eye physician for over 16 months. The resident repeatedly ask for an appointment. Resident E stated she has lost her remaining eye sight. (Cross Reference F250) b. Resident E has not received room activity visits in six weeks due to low staffing. (Cross Reference F248) 6a. Resident D reported incontinence due to long waits for her call light to be answered. (Cross Reference F 241) b. Resident D stated she was not made aware of where her money was going. Not until she was in danger of having her home auctioned off did she receive assistance. (Cross Reference F 250) c. Resident D has not received room activity visits in six weeks due to low staffing. (Cross Reference F248) d. Resident D stated she has to insist on her showers or she won't receive them. (Cross Reference F241) e. Resident D stated she did not receive her RNA services for eight days. (Cross Reference F311) 7a. Resident F's family member stated she usually finds food on the resident's face from lunch when she visits later in the day. Resident F was frequently found in need of a bath, so the family has hired a caregiver to give the resident baths.(Cross Reference F241) b. Resident F's family member requested a dental visit for the resident for five months. The dentist recently visited and documented it was a dental emergency. (Cross Reference F 250) 8a. Resident B stated his call light is not answered promptly causing him to become incontinent of his bowels three times. (Cross Reference F241) b. Resident B stated he is not getting regular RNA services and has lost his ability to walk. (Cross Reference F311) 9. Resident R stated, when she was admitted to the facility, she could walk with a walker. She was told not to walk to the bathroom without assistance. The resident stated no one comes to assist her to the bathroom and she has now become weaker. (Cross Reference F241) 10a. Resident 22 developed a Stage III pressure ulcer (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Some dead tissue may be present) to the sacrum (tailbone area) while in the facility. The care plan problem showed to check and provide incontinence care every two hours, turn and reposition every two hours, the maximum amount of time in the wheelchair for the resident was two hours, and shift the resident's position every 30 minutes while on wheelchair. Based on interviews with Resident 22's family members on 10/16/13, 10/17/13 and 10/22/13, Resident 22's incontinence brief was not changed and the resident was not turned and repositioned in bed as per the resident's care plan. Based on observation and interview with the facility staff, the resident stays in the wheelchair more than two hours and the resident's position was not shifted every 30 minutes while in the wheelchair. In addition, there was no documented evidence in the clinical record the pressure ulcer was reassessed by an RN when the pressure ulcer deteriorated, and the physician was not consulted for appropriate treatment. (Cross Reference F 314) b. During an interview with Resident 22's family member, she stated she had observed residents in their wheelchairs, in the hallway with rings of urine on their pants. She further stated she advocated for the residents who were unable to verbalize their concerns and asked the staff to provide incontinence care for these residents. 11. Resident 24 has chronic pain. The care plan problem to address chronic pain showed the goal is for the resident's pain to be controlled to a pain scale from 0 to 4. Review of the MAR from 9/1/13 to 9/24/13, showed, during the evening shift, the resident had pain of 6 to 9 (on a pain scale from 0 to 10, 0 being no pain and 10 being the worst pain); however, the pain medication ordered PRN was not administered and there was no documented evidence nonpharmacological interventions were provided to address the resident's pain. After the physician ordered the pain medication to be given routinely every twelve hours on 9/25/13, and pain medications were administered routinely, the MAR from 9/26/13 to 10/16/13 showed the resident continued to have pain of 6 to 8 on the morning and evening shifts; however, there was no documented evidence the nurse reassessed the resident's comfort level after taking the pain medication. (Cross Reference F 309) 12. Resident 14 had a surgical procedure to repair a [MEDICAL CONDITION]. The care plan problem to address alteration in mobility showed to provide RNA ambulation with a FWW (front wheeled walker - a walking frame that has two wheels in front and two rubber [MEDICATION NAME] at the back) five days a week; however, the resident stated he did not get the treatments five days a week. Resident 14 requested the facility provide it five days a week because he wants to get stronger and be able to go home, but he did not get the requested service. (Cross Reference F 311) 13. Resident Q stated she knows she if supposed to get RNA ambulation with a FWW three times a week, but she never got it until 10/15/13. (Cross Reference F 311) 14. During initial tour on 10/10/13 at 0820 hours, Resident 7's room was entered. The call light above the door in the hallway was on. Resident 7 stated the call light had been on for ten minutes because she had been incontinent of urine and stool and needed the CNA to change her diaper. At 0855 hours, during a return visit to Resident 7's room, Resident 7 stated the CNA had come to her room a few minutes ago and left to get "stuff" to change her. (Cross reference to F311) 15. During the resident group interview on 10/10/13 at 1100 hours, seven of 13 residents stated, when they put the call light on, a staff member will come to their room, turn the light off and tell the resident someone will be back to help them. But no one comes back to help them. Two of these residents stated they were incontinent because "it took forever" for the CNAs to answer their call lights. The residents stated they have complained to the facility but nothing ever changes. The residents stated they feel mad, frustrated and ignored. (Cross reference to F240 and F244) During the resident group interview, one resident stated dinner is over at 1800 hours and snacks are rarely given at bedtime. One resident stated she was without food for 14 hours. Seven of 13 residents agreed with this statement and stated they get very hungry by the morning. Three residents stated they got snacks routinely but only because their physician's had written orders for them to get snacks. (Cross reference F368) 16. Clinical record review for Resident 23 was initiated on 10/10/13. Resident 23 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. During an interview with Resident 23 on 10/10/13 at 1530 hours, a trapeze was observed hanging over Resident 23's bed; no side rails or enablers were on the bed, and an electrical wheelchair was in the corner of the room. When asked, Resident 23 stated he could not turn independently in bed because he does not have side rails and he had not been up in the wheelchair since his admission. (Cross reference to F279, F311, and F406) 17. During initial tour, interview was conducted with Resident 13. Resident 13 stated, "I can not hear you; let me just get my hearing aide in my drawer." When the resident placed the hearing aide in the right ear, it was a Bluetooth (a wirelesss technology used for hands free use of a mobile telephone) not a hearing aide. Resident 13, stated "I can not communicate very well because I can not hear them, especially during our resident council meeting." Review of SSA progress notes and IDT notes since 2012 to present showed in all documentation the resident did not need referrals or outside resources at this time. No documentation was found regarding a broken or replaced hearing aide. (Cross reference to F250) 18. Resident 3 has impairment on both lower extremities. Review of the Physical Therapy Discharge Summary dated 6/27/13, showed the discharge recommendation is for a functional program with the RNAs. During an interview with RNA 5 on 10/11/13 at 1450 hours, RNA 5 stated Resident 3 is not in the RNA program. During an interview and clinical record review with the Rehab Manager on 10/11/13 at 1545 hours, the Rehab Manager verified a referral was made for the RNA program for Resident 3. The Rehab Manager stated the referral should have been acted upon as soon as possible. (Cross reference to F318) 19. Resident 10 sustained a fall on 5/22/13. The physician was notified and gave an order for [REDACTED]. On 10/15/13 at 0900 hours, 10/16/13 at 0920 hours and 10/17/13 at 1430 hours, Resident 10 was observed sitting in a wheelchair with no pressure pad alarm. An interview was conducted with CNA 4 on 10/16/13 at 0920 hours. CNA 4 stated Resident 10 never uses an alarm in the wheelchair. (Cross Reference to F323, ex 3)

Based on observation, interview, and clinical record review, the facility failed to provide the necessary care and services to help seven of 24 sampled residents (Residents 11, 18, 19, 17, 24, 10, and 2) to attain or maintain the highest practicable physical, mental, and psychosocial well-being. *The facility failed to manage or prevent Resident 18's pain consistent with the plan of care and failed to monitor or assess the effectiveness of pain medication. This resulted in Resident 18 being transferred to the acute hospital twice in four months time. *Resident 19 was having difficulty breathing due to increased secretions. LVN 4 was aware of Resident 19's problem, but waited over two hours to assist the resident. Two other nurses knew the resident needed suctioning, but did not assist the resident. The family members were not informed about the change in the resident's condition, not allowing them to be with Resident 19 prior to his death. *The facility failed to follow Resident 11's physicians's order to be out of bed in a wheelchair while awake. This poses the risk to develop skin problems and a decline in mobility. *The facility failed to ensure a comprehensive assessment of a nonpressure related skin condition was done for Resident 17. This poses the risk of not having a thorough evaluation of the progress or lack of progress of the skin condition. *The facility failed to ensure Resident 24's pain was addressed and prescribed pain medications were administered timely. Resident 24 verbalized she had uncontrolled generalized pain when she attempted to end her life. *The facility failed to monitor the weight weekly for Resident 10 who has a [DIAGNOSES REDACTED]. This poses the risk for fluid overload which could compromise the function of the heart or the lungs. *The facility failed to ensure a knee immobilizer (a brace used to immobilize the joint) was provided when Resident 2 was up in the wheelchair. The knee immobilizer was ordered to treat Resident 2 is status [REDACTED]. This poses the risk of movement at the joint resulting in a disruption of the fracture. In addition, the facility failed to ensure an annual PPD skin test (Purified Protein Derivative- a skin test used to determine if you have been exposed to TB-[MEDICAL CONDITION]) was performed as ordered. This poses the potential risk of not treating the resident for TB and possible spread of TB to other residents and staff. Findings: 1. An interview was conducted with Resident 11's spouse on [DATE] at 1045 hours. When Resident 11's spouse was asked about the treatment and services Resident 11 receives from the facility, the spouse stated the typical problem is call lights, not getting showers, delay in receiving pain medications, changing of diapers, and not getting up out of bed. The spouse stated it is probably because of lack of staff, especially in the afternoon and evening. The spouse stated they basically stay with the resident for eight to nine hours everyday, and brings food and cares for the resident. During an interview with CNA 9 on [DATE] at 1120 hours, CNA 9 was asked if Resident 11 is able to get up and sit in a wheelchair. CNA 9 stated Resident 11 is unable to get up without a mechanical lift and needs extensive assistance. CNA 9 stated Resident 11 very seldom sits in the wheelchair because Resident 11 is always asleep. During an interview with LVN 5 on [DATE] at 1145 hours, LVN 6 was asked the last time Resident 11 got up. LVN 6 stated, "As far as I know, not often. Resident 11 wants to stay in bed most of the time." 2. During initial tour, an interview was conducted with Resident 18 on [DATE] at 0845 hours. Resident 18 stated, "I have been waiting for my pain pill. I ask the night nurse to give me my pain pill before her shift ends, but until now, no pain pill yet." A wall clock was observed in Resident 18's room. Review of Resident 18's clinical record was initiated on [DATE] at 0800 hours. Resident 18 was initially admitted on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Resident 18 is cognitively intact. Continued clinical record review showed Resident 18 was transferred to the acute care hospital on [DATE], because of generalized body pain. Resident 18 was transferred to the acute care hospital on [DATE], because of generalized body pain. Resident 18 was transferred to the acute care hospital twice in four months for the same reason, pain. Review of the physician's recapitulated orders for the month of [DATE] showed an order dated [DATE], for [MEDICATION NAME] (a narcotic [MEDICATION NAME] used to relieve moderate to severe pain) ,[DATE] mg, one tablet by mouth three times a day (0900, 1300, and 1700 hours) for pain management. Review of the MAR for the month of [DATE] showed on ,[DATE], 2, 3, 4, 7, 8, and ,[DATE] for 0900 and 1300 hours, the space to document the administration of [MEDICATION NAME] was unsigned (indicating the medication was not administered. The PRN medication form showed no reason why it was unsigned or whether it is given. There is no documentation to show an assessment was done for the effectiveness of the pain medication that was given. Review of the Controlled or Antibiotic Drug Record showed [MEDICATION NAME] ,[DATE] mg tablets were signed out for Resident 18 at 0900, 1300 and 1700 hours each day for ,[DATE], 2, 3, 4, 7,8 and ,[DATE]. Interview and review of MAR and controlled drug record was conducted with LVN 4 on ,[DATE] at 0810 hours. LVN 4 was asked the reason why Resident 18 was transferred to the acute care hospital. LVN 4 stated they transferred Resident 18 because of generalized body pain, particularly in the abdominal area. LVN 4 was asked how often Resident 18 is getting the pain medication. LVN 4 stated Resident 18 is getting [MEDICATION NAME] ,[DATE] mg three times a day, a [MEDICATION NAME] (narcotic [MEDICATION NAME] to treat severe, ongoing pain that cannot be controlled with other medicines) 75 mcg every three days, and [MEDICATION NAME] ,[DATE] mg by mouth every eight hours for pain management. LVN 4 was asked about the MAR and the Controlled or Antibiotic Drug Record discrepancy. LVN 4, verified the above findings. She stated "I forget to sign the MAR because I am really busy, but I really did give the pain medication to the resident." LVN 4 was asked about their policy after pain medication administration. She stated they should sign it off right away and reassess the effectiveness of the medication. 3. Clinical record review for Resident 17 was initiated on [DATE]. Resident 17 was readmitted on [DATE]. Review of the Physician and Telephone Orders form showed a clarification of an order dated [DATE], to cleanse incontinence associated skin damage to the bilateral buttocks with soap and water, pat dry and apply zinc oxide every shift/as needed for twenty one days. Review of the Wound/Skin Evaluation and Documentation Form dated [DATE], and [DATE], showed the bilateral buttocks incontinence associated skin damage has redness as as description of the wound bed, no undermining (tissue destruction that occurs around the wound perimeter under intact skin)/tunneling (channels that extend from a wound into and through subcutaneous tissue or muscle), no drainage, no odor, surrounding skin color is normal, no pain, surrounding tissue/wound edges are normal. The section to document size and shape shows a line across the length, width, depth, and shape. It failed to address the size of the bilateral buttocks incontinence associated skin damage. During an interview and clinical record review with LVN 3 on [DATE] at 1200 hours, LVN 3 stated the initial order on admission was treatment to bilateral buttocks excoriation. LVN 3 stated the order was clarified the following day to cleanse the bilateral buttocks associated skin damage with soap and water and apply zinc oxide. LVN 3 stated it was clarified for the bilateral buttocks associated skin damage because it is not a pressure ulcer, is not located on a bony prominence and is located at the inner buttocks. LVN 3 stated she does not measure the size. When asked how does she measure improvement and or deterioration, LVN 3 stated, if the color changes from red, then becomes pink to light pink and then goes back to its normal color. 4. Clinical record review for Resident 19 was initiated on [DATE]. Review of the History and Physical dated [DATE], showed the physician documented Resident 19 [MEDICAL CONDITION] of the esophagus. The physician documented Resident 19 has a normal heart rhythm and clear lungs. Review of the care plan to address the problem of [MEDICAL CONDITION] dated [DATE], showed the goal for the resident to have comfort. The approach to the problem was to monitor for breathing problems. Review of the MAR dated [DATE], showed a physician's orders [REDACTED]. Review of the nurse's note dated [DATE], showed at 1000 hours, LVN 4 documented she suctioned Resident 19. Further review showed at 1215 hours, LVN 4 documented the resident was alert and at 1300 hours, Resident 19 was deceased . There was no documentation the physician or family members were notified about the change of condition. An interview with LVN 3 was initiated on [DATE] at 1545 hours. LVN 3 stated she and CNA 5 went to Resident 19's room at 1000 hours to do a treatment. LVN 3 stated the resident did not look well and was very pale. She stated she told the CNA the resident was not well and CNA 5 stated she had already informed LVN 4 at around 0800 hours about the residents condition. LVN 3 stated she lowered the head of the resident's bed and the resident made a rattling sound. The LVN stated she told the ADON about the resident's condition. When LVN 3 was asked if she assessed the resident's breathing sounds or his oxygen concentration or suctioned the resident, LVN 3 stated, no. An interview with CNA 5 was initiated on [DATE] at 1530 hours. CNA 5 stated she informed LVN 4 on [DATE] at around 0800 hours, that Resident 19 was having difficulty breathing. The resident was making a loud gurgling sound and needed to be suctioned. CNA 5 stated the LVN was busy passing medication and did not go to the resident. CNA 5 stated at 1000 hours, she returned to Resident 19's room to assist LVN 3 change the resident's dressing. CNA 5 stated LVN 3 returned to Resident 19's room with the ADON, who agreed the resident was not doing well, but neither nurse suctioned the resident. The CNA stated she did not observe Resident 19 being suctioned by any nurse on [DATE]. CNA 5 stated at 1200 hours, she returned to Resident 19's room and the resident had expired. An interview with LVN 4 was initiated on [DATE] at 1610 hours. LVN 4 confirmed CNA 5 informed her Resident 19 needed suctioning at around 0700 to 0730 hours. She stated she was busy administering medications and returned to the resident's room at 1000 hours. The LVN stated she suctioned the resident. LVN 4 was asked if she notified the physician or family about the resident's condition. LVN 4 stated she did not notify the physician about Resident 19's condition because his condition had not changed. An interview with Resident 19's family member was initiated on [DATE] at 1400 hours. The family member stated she was the durable power of attorney for Resident 19 and the facility would usually call her if the resident had a change of condition. The family member stated, on the day Resident 19 died , no one called the family to let them know he was not doing well. She stated it came as a surprise when he died . The family member stated she was called at 1315 hours and informed the resident had died . The family got to the facility within five minutes. The family member stated the resident was already cold, she stated she felt he died earlier than 1300 hours. The family member stated, had they known he was dying, the family would have gone to be with the resident. 5. During the initial tour with MDS Coordinator 1 on [DATE] at 0825 hours, Resident 24 was observed in bed. MDS Coordinator 1 stated the resident can not hear well. On [DATE] at 1435 hours, it was observed Resident 24's bed was empty. RN 2 was asked where Resident 24 was. RN 2 stated Resident 24 was transferred to the acute care hospital yesterday ([DATE]) at around 1000 hours. RN 2 further stated MDS Coordinator 1 found Resident 24 with the call light cord wrapped around her neck. An interview with MDS Coordinator 1 was conducted on [DATE] at 1440 hours. MDS Coordinator 1 narrated what happened. She stated she saw Resident 24's call light was on. She went into the room and found two CNAs uncoiling the call light cord from Resident 24's neck. Resident 24 was in bed and stated she wanted to kill herself. MDS Coordinator 1 asked Resident 24 why she wanted to kill herself. Resident 24 stated she hurts all over. One of the CNAs stated Resident 24 just got her pain medication. Clinical record review for Resident 24 was initiated on [DATE]. The MDS dated [DATE], showed the resident has cognitive impairment. It also showed the resident has occasional moderate pain. The care plan problem dated [DATE], to address chronic pain showed to administer pain medications as ordered by the physician and assess for non-verbal signs and symptoms of pain: excessive perspiration, pallor, decreased appetite, nausea, and change in sleep pattern. It also showed the goal was for the resident's pain to be controlled to a pain scale from 0 to 4 (0 is no paint to 10, the most severe pain). The physician's orders [REDACTED]. The physician's orders [REDACTED]. The physician's orders [REDACTED]. The physician's orders [REDACTED]. Review of the psychiatrist's note dated [DATE], showed the resident stated "let me sleep and help me." The documentation showed the resident was started on routine pain medications. Review of the MAR from [DATE] to [DATE], showed, on the evening shift, the resident had pain from 6 to 9 on a pain scale of 0 to 10 on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and [DATE], but there was no documented evidence the PRN pain medication was administered or nonpharmacologic interventions were provided. Review of the MAR from [DATE] to [DATE] and from [DATE] to [DATE], showed the resident continued to have pain ranging from 6 to 8 on the pain scale on the morning and evening shifts even though [MEDICATION NAME] ,[DATE] mg was being administered at 0900 hours and 2100 hours. It also showed [MEDICATION NAME] ES ,[DATE].5 mg was administered on ,[DATE], ,[DATE], and [DATE], in addition to the [MEDICATION NAME] ,[DATE] mg. An interview was conducted with LVN 4 on [DATE] at 0850 hours. LVN 4 stated Resident 24 was assigned to her on [DATE]; however, she was not present during the incident because she came in late. LVN 4 stated the resident complained of pain two weeks ago, ranging from 7 to 10. She stated the physician ordered pain medication to be administered routinely. She stated, after that, the resident did not complain of pain, but screamed most of the time. She stated the resident would verbalize "Lord please help me" and sometimes the resident would verbalize "Lord take me away." LVN 4 further stated that was just her behavior. LVN 4 was informed that review of the MAR from [DATE] to [DATE] showed the resident's pain was not controlled and the goal on the care plan for the resident's pain to be controlled between 0 to 4 was not achieved. LVN 4 was asked if she reassessed the resident's comfort level after giving the pain medication. LVN 4 replied, yes. LVN 4 was asked where is it documented. LVN 4 reviewed the MAR and acknowledged there was no documentation if the medication was effective. During an interview with CNA 12 on [DATE] at 0910 hours, she stated the resident always screams and is confused. CNA 12 stated the resident put the call light on all the time, but the resident does not want to be touched. CNA 12 stated the resident does not want anything done. An interview was conducted with RN 2 on [DATE] at 0925 hours. RN 2 was informed review of the MAR for [DATE] showed the resident had pain from 6 to 9, but the pain medication was not given. She reviewed the clinical record and acknowledged the pain medication was not given and there was no documentation of interventions implemented to address the resident's pain. She acknowledged she filled out the Pain Evaluation dated [DATE]. She stated the Pain Evaluation was completed when there is a new order for pain medication. She was informed Section IV of the form, which includes the onset of pain, effect of pain, quality of pain, what improves pain, what makes pain worse and if the resident is satisfied with the current pain control, was left blank. She acknowledged it was not completed. RN 2 stated, when she assessed the resident, the resident did not have pain. 6. Clinical record review for Resident 10 was initiated on [DATE]. Resident 10 was admitted to the facility on [DATE]. Review of the physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. Review of the Weight Record for the months of July and [DATE] showed the resident's weights were as follows: *on [DATE], 136 pounds and *on [DATE], 139 pounds. The clinical record failed to show documented evidence the resident's weights were monitored weekly as ordered. An interview and clinical record review was conducted with MDS Coordinator 1 on [DATE] at 1040 hours. MDS Coordinator 1 was asked why the resident was on weekly weights. The MDS Coordinator stated the resident had a history of [REDACTED]. MDS Coordinator 1 verified Resident 10's weights were not monitored weekly as ordered. 7. On [DATE], clinical record review was initiated for Resident 2. Resident 2 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. On [DATE] at 0945 hours and 1545 hours, Resident 2 was observed sitting up in the wheelchair. A knee immobilizer was not observed on her left lower leg. On [DATE] at 1530 hours, Resident 2 was observed sitting up in the wheelchair. A knee immobilizer was not observed on her left lower leg. CNA 10 verified Resident 2 was not wearing a knee immobilizer while up in the wheelchair. On [DATE] at 0800 hours, an interview was conducted with CNA 9. When asked about Resident 2's need for a knee immobilizer, CNA 9 stated Resident 2 is supposed to have it on when she is up in the wheelchair, but she has not applied the knee immobilizer to Resident 2's left knee for the last two days. CNA 9 was unable to find the knee immobilizer among Resident 2's belongings. On [DATE], an interview and clinical record review was conducted with ADON 1. ADON 1 verified the findings and stated the left knee immobilizer should be applied while Resident 2 is up in the wheelchair.

Based on interview and clinical record review, the facility failed to prevent accidents for three of 24 sampled residents (Residents 5, 11 and 10) and one nonsampled resident (Resident F). *Resident 5 had a recent fall while being transferred with a mechanical lift. The facility did not document the fall, assess the resident, or inservice the staff on proper use of the mechanical lift after the fall. Two weeks later, Resident F had an injury while being transferred with the mechanical lift. The same staff members involved with Resident 5's accident were involved with Resident F's accident. The facility did not provide appropriate follow up after the first accident, which may have prevented the second accident. In addition, Resident 5 had a previous fall in which he was injured. The resident stated he was on the floor for over 20 minutes. His roommate was yelling for help until someone came to assist Resident 5. *There is insufficient help to assist Resident 11 to transfer with a mechanical lift to the wheelchair. This poses the risk of accident/injury. *The facility failed to ensure Resident 10 was provided with the pressure pad alarm in her wheelchair to prevent another fall incident. This places the resident at risk for accident/injury. findings: Immediate Jeopardy was identified on 10/11/13 at 0930 hours, regarding the facility's failure to prevent accidents by not identifying, documenting or investigating Resident 5's accident and not providing any assessment of the resident after the accident. In addition, no follow up inservices or training was provided to staff members which could have prevented the accident and injury to Resident F. The Administrator was made aware of the Immediate Jeopardy on 10/11/13 at 1210 hours. The facility provided inservice education to all staff members regarding answering call lights, and additional CNAs were scheduled to assist with care. On 10/18/13 at 1430 hours, Administrator 2 and DON 2 were informed the Immediate Jeopardy was abated. Findings: 1a. An interview with Resident 5 was initiated on 10/10/13 at 0745 hours. Resident 5 stated he has had three falls since being admitted to the facility. The resident stated he had a fall around two weeks ago while being transferred with the mechanical lift. Resident 5 stated he was dropped during the transfer. CNA 13 was assisting a male CNA to transfer Resident 5 to the wheelchair. The male CNA was operating the lift while CNA 13 was securing the resident around the waist. Resident 5 stated he was dropped and landed on the floor. Other staff members had to be called into the room to assist the resident off the floor. When asked if he was hurt, he stated he landed on his buttocks, but no one came in and assessed him afterward for any injuries. Clinical record review for Resident 5 was initiated on 10/10/13. Review of the MDS dated [DATE], showed Resident 5 has good cognition. Review of a Social Service note dated 10/1/13, showed SSA 1 documented Resident 5 stated he had a fall. According to the documentation, SSA 1 checked with nursing and "there was no noted injury or incident." Review of the nurses' notes from 9/1/13, through 10/10/13, showed no documentation of any fall, no assessment of the resident for injuries after a fall, no 72 hour monitoring after the fall or any documentation the physician was notified about a fall. Review of the physician's orders [REDACTED]. An interview with Administrator 1 was initiated on 10/11/13 at 1100 hours. The Administrator was asked for an investigation into Resident 5's recent fall. The Administrator stated she would check her records, but had no knowledge of any recent falls. Administrator 1 returned at 1330 hours and stated she had no investigation of any recent fall. An interview with CNA 13 was initiated on 10/15/13 at 1430 hours. CNA 13 stated she and a male CNA were transferring Resident 5 to the wheelchair a few weeks ago and the resident was dropped to the floor. The CNA stated other staff members had to be called into the room to assist the resident off the floor due to the resident's size. CNA 13 was asked if, after the incident, she was provided an inservice in the use of the mechanical lift. She stated, no. When asked when was the last time she had any inservice in the use of the mechanical lift, the CNA stated she did not remember. An interview with SSA 1 was initiated on 10/16/13 at 1000 hours. SSA 1 was asked about the Social Service note. SSA 1 stated Resident 5 told him about the fall. He confirmed he informed ADON 2 about the incident. An interview with ADON 2 was initiated on 10/17/13 at 1200 hours. The ADON was asked to provide copies of the last inservice regarding the mechanical lift; however, no documentation was provided. b. Further interview with Resident 5 was continued on 10/10/13 at 0745 hours. Resident 5 stated, in May 2013, he had another fall while seated in bed. According to the resident, he slipped out of the bed and hit the bedside table on the way down. He banged his head and landed face down on the floor, unable to move. Resident 5 stated, at the time, he had a roommate who hit the call light for him to get help. No one answered the call light, so the roommate began to yell. According to Resident 5, it took over 20 minutes for anyone to come to his aid. The resident stated he was bleeding, had to be sent to the hospital and received nine stitches to his head. Review of the Fall Investigation confirmed Resident 5 did have a fall from the bed on 5/22/13. According to the investigation, Resident 5 was assisted promptly after the fall. The resident sustained [REDACTED]. Resident 5 was transferred to the hospital and received a CT (coaxial tomography) scan of the head. A nurse's note dated 5/23/13, showed the resident had nine sutures over the left eye. An interview with Resident 5's former roommate, Resident 23, was initiated on 10/10/13 at 1400 hours. Resident 23 confirmed Resident 5's story, except the resident stated he had to yell for help for 15 minutes. Resident 23 stated he was angry at the staff for taking 15 minutes to answer the yells and told them so. The staff member replied to Resident 23, "you were only yelling for 10 minutes." 2. An interview with Resident F's family member was initiated on 10/18/13 at 1000 hours. The family member stated Resident F was being transferred via the mechanical lift on 10/13/13, and the metal bar at the top of the lift hit Resident F in the head and face. The family member stated she was told CNA 14 was handling the lift and was in the process of lowering the sling when the bar swung around and hit the CNA and the resident. The family member was asked if two people were assisting with the transfer. The family member stated she was told only CNA 14 was assisting the resident, but she did not clarify with the nurse who called her. The family member stated she had observed only one person transferring Resident F with the mechanical lift on many occasions. The family member stated, after the injury, she went to visit Resident F and found her with a dressing on her head that was saturated with blood. She had to insist the resident be sent to the hospital to receive a CT scan due to the resident having a history of bleeding in the brain. Resident F was sent to the hospital, had a CT scan and received a medical glue to the top of the head to keep the skin tear at the scalp together. Clinical record review for Resident F was initiated on 10/16/13. Review of the IDT report dated 10/17/13, showed the resident was being assisted with the mechanical lift and was injured. An interview with ADON 2 was initiated on 10/16/13 at 1400 hours. The ADON stated two CNAs were assisting the resident when the lift hit Resident F. An interview with CNA 13 was initiated on 10/16/13 at 1520 hours. CNA 13 stated she was assisting another CNA when the accident occurred. When asked when was the last time she had any inservice in the use of the mechanical lift, the CNA stated she did not remember. 3. During an observation on 10/11/13 at 1130 hours, CNA 9 was observed using a mechanical lift to transfer Resident 11 by herself with the help of the resident's spouse. Review of Resident 11's clinical record, initiated on 10/10/13 at 1000 hours, showed Resident 11 was admitted on [DATE]. Resident 11 has a history of a mechanical fall. Review of Resident 11's MDS showed ADL support is provided with two plus persons' physical assistance. Review of the Care Directive regarding transfers showed Resident 11 is dependent, mechanical lift with two persons' assistance. An interview was conducted on 10/11/13 at 1210 hours with Resident 11's spouse. When asked about transferring Resident 11 to a wheelchair, Resident 11's spouse stated they seldom transfer Resident 11 to the wheelchair because it is really hard. It takes the help of two or three persons to use the mechanical lift. Resident 11's spouse verified only one CNA was transferring Resident 11 to the wheelchair using the mechanical lift. An interview was conducted on 10/11/13 at 1230 hours with CNA 9. When asked about transferring Resident 11 using a mechanical lift, CNA 9 stated she usually uses it by herself because they do not have enough staff to help. CNA 9 verified the above findings. 4. Clinical record review was initiated for Resident 10 on 10/15/13. Resident 10 was admitted to the facility on [DATE]. The MDS dated [DATE], showed the resident needs one person's extensive assistance for bed mobility and transfers. Review of the Nurse's Note dated 5/22/13 at 2030 hours, showed Resident 10 got up from her wheelchair and made a step towards the bed and fell . The physician was notified and gave an order for [REDACTED]. Review of the physician's orders [REDACTED]. On 10/15/13 at 0900 hours, 10/16/13 at 0920 hours and 10/17/13 at 1430 hours, Resident 10 was observed sitting in a wheelchair with no pressure pad alarm. An interview was conducted with CNA 4 on 10/16/13 at 0920 hours. CNA 4 was asked if Resident 10 uses a pressure pad alarm when she is in the wheelchair. CNA 4 stated, since Resident 10 was admitted , she never uses an alarm in the wheelchair. During an interview with RN 2 on 10/17/13 at 1445 hours, she was asked to verify Resident 10 does not have a pressure pad alarm in the wheelchair. RN 2 went to the activities room and checked Resident 10. RN 2 came back to the nurses' station and stated, yes, the resident does not have a pressure pad alarm in place. RN 2 was informed of the findings. RN 2 reviewed the clinical record and stated Resident 10 should have the pressure pad alarm in the wheelchair.

Based on review of the facility's P&P, interview and clinical record review, the facility failed to provide medically indicated social services for three of 24 sampled residents (Residents 4, 13 and 7) and three nonsampled residents (Residents D, E, F). *Resident E did not receive her eye appointment for 16 months. The resident has glaucoma and has lost the remaining vision in her eyes. *Resident D was not assisted with financial matters until her home was in danger of being auctioned off. *Resident 4's hearing aids broke, but the facility failed to obtain repair of the broken hearing aides. As a result, Resident 4 is unable to hear sufficiently to enjoy every day activities. *Resident F was not given dental services until the dentist documented if was a dental emergency, and is waiting for a bariatric bed *The facility failed to follow Resident 13's physician's orders [REDACTED]. This resulted in psychological anguish to the resident. * Resident 7 was schedule for cataract surgery on her left eye in February 2012. When the surgery did not take place, no documentation of any social worker follow up was found in the clinical record until October 2013. When interviewed, Resident 7 states she is now blind in her left eye. Findings: 1. An interview with Resident E was initiated on 10/10/13 at 0830 hours. Resident E stated she has glaucoma and has not seen her eye doctor in over a year. She stated she spoke to SS about the issue over six months ago, but still hasn't received an eye appointment. She has asked repeatedly to see her own eye physician due to the lose of her remaining eye sight. The resident stated she has lost more of her independence. Last year she could dial and answer her phone and provide more of her own care. Now she can not answer her phone when old friends call her. She stated, due to her friends' ages, the only way they communicate is by telephone and she is losing contact with them. Clinical record review for Resident E was initiated on 10/10/13. Review of the physician's orders [REDACTED]. Review of the Optometric note dated 5/14/13, showed the physician documented the resident was not provided an eye examination due to the resident wanting to be seen by her own eye physician. Review of the IDT quarterly SS note dated 6/18/13, showed Resident E wants to help with her own care, but she now needs more help than in the past. The note showed the care plan was reviewed. The note does not show any documentation regarding the need to schedule an eye appointment. Further review showed the resident did not have any further quarterly SS notes. An interview with SSA 1 was initiated on 10/16/13 at 1100 hours. SSA 1 confirmed Resident E's last eye appointment was 7/16/12. 2. Clinical record review for Resident D was initiated on 10/10/13. Review of the MDS dated [DATE], showed Resident D has good cognition. Review of the Social Service Evaluation Quarterly dated 6/27/13, showed Resident D is alert and oriented and capable of making decisions. The evaluation showed the resident was doing well. Further review showed no documentation regarding any financial issues or financial assistance being provided to the resident. Review of the Social Service Progress Note dated 8/14/13, showed Resident D made a call to the Social Security office and received notice her income was stopped due to her current stay in the facility. According to the note, Resident D was upset about this situation. Review of the Social Service Progress Note dated 9/11/13, showed Resident D remained upset about her financial situation. Resident D was crying and had thoughts of dying. An interview with Resident D was initiated on 10/10/13 at 0800 hours. Resident D stated she was admitted to the facility in March 2013. The resident stated she has [DIAGNOSES REDACTED] and has not been able to work. When her parents passed away, they left her a mobile home, which is where she resided all her life. The resident stated she received SSI that paid the mobile home space rent and allowed her to live independently. In March 2013 the resident had a fall at home and ended up at the facility temporarily. Resident D stated the plan is for her to go home or to a lower level of care. According to Resident D, in early September 2013, the resident received a notice the mobile home she owned would be auctioned off to pay for the back space rent. Resident D stated she was not aware her SSI payments had been stopped until August 2013. She was still sending checks to the mobile home park but her bank accounts were overdrawn, causing the bank to close her accounts. The resident stated she was not aware of her money issues until it was too late and she was not made aware by the facility of where her money was going. An interview with SSA 1 was initiated on 10/16/13 at 1100 hours. SSA 1 confirmed Resident D's story. SSA 1 stated he has worked at the facility a few months and has been made aware of Resident D's problems. SSA 1 stated he has been working to assist the resident with her financial problems and to stop the auction of her home. SSA 1 was asked if Resident D had been aware of the money issue prior to August. SSA 1 stated the resident appeared not to be aware where her money was going prior to August. 3. An interview with Resident F's family member was initiated on 10/18/13 at 1000 hours. The family member stated she has requested a dental appointment for Resident F for five months. The family member stated the resident does not get good oral care and she is worried about gum disease. Clinical record review was initiated on 10/18/13. Review of the Dental Care note dated 10/15/13, showed the dentist documented "initial visit sore swollen gums 9-10 periodontal emergency." There were no previous dental notes available in the record. 4. During initial tour, interview was conducted with Resident 13. Resident 13 stated, "I can not hear you; let me just get my hearing aide in my drawer." When the resident placed the hearing aide in the right ear, it was a Bluetooth (a wireless technology used for hands free use of a mobile telephone) not a hearing aide. When Resident 13 was asked where is the real hearing aide, Resident 13 stated, "It was broken since last year, and they gave this device to me six months ago." Resident 13 stated she told the nurses and social services she really needs a replacement for her hearing aide because she can not hear and does not know how to read lips. But the social services told her they can not replace it right now because of the insurance. When asked how she feels when she is talking to people and can not verbalized her thoughts about the conversation, Resident 13, stated "I can not communicate very well because I can not hear them, especially during our resident council meeting. All the residents were asking for my opinion and I just answered them back with, yes, because I can not hear or understand them. I can drop or forget everything, like my lipstick, hair salon, but not my hearing aide; I really need it." Review of Resident 13's clinical record was initiated on 10/10/13 at 0915 hours. Resident 13 was admitted to the facility on [DATE]. Review of Resident 13's MDS shows she is cognitively intact. Review of the physician's orders [REDACTED]. Review of a hearing aid center report dated 1/12/12, showed hearing receiver replaced and faceplate changed and it was received by the facility. Review of SSA progress notes and IDT notes since 2012 to present showed in all documentation the resident did not need referrals or outside resources at this time. No documentation was found regarding a broken or replaced hearing aide. During an interview conducted with LVN 5 on 10/10/13 at 0945 hours, LVN 5 was asked about the hearing aide. She stated it was with the resident. LVN 5 was asked to locate the hearing aide, but she could not find it. LVN 5 verified the above findings. LVN 5 stated, she will follow it up with the SSA. During an interview conducted with SSA 1 on 10/11/13 at 1500 hours, SSA 1 was asked about the hearing aide. SSA 1 verified the above findings. He stated, "I just started here two months ago. As far as I know, they provided the resident a device (Bluetooth) or amplifier for the meantime, but I just got an approval from the insurance (medi-Cal) for both a hearing test and hearing aides today." 5. Review of the facility's P&P titled Social Services dated May 2002 showed social services will assist residents in obtaining needed clinical and support services. Social Services or designee maintains a list of individuals requiring dental/denture care, vision care, hearing services. During an interview with Resident 4 on 10/8/13 at 1120 hours, Resident 4 stated her hearing aides have been broken for at least two months and no one has told her anything about what is going on with her hearing aides. She stated she still attends meetings and activities to get out of her room and see other people, but she cannot hear what is being said, so she does not know what is going on a lot of time. Resident 4 stated this really bothers her. She stated she cannot talk with friends or enjoy activities without being able to hear. During an interview with Social Services Assistant 1 on 10/8/13 at 1145 hours, she stated she began employment with the facility in May of this year and began her assignment on Resident 4's unit in July 2013. She is aware of Resident 4's broken hearing aides, and is currently in possession of them. She stated she is unsure how long they have been broken, when, or how she was made aware of the need for repair, but stated she normally makes a notation on the Social Services Progress Notes the same day she is informed of a problem. She stated there is no tracking system in place for devices that need repair. She acknowledged it is her responsibility to make sure the appropriate repair services are called and to have the devices delivered for servicing. Social Services Assistant 1 knew the repair service company name and the contact person to call. She could not remember the date when she notified the repair company. She was not able to explain why the hearing aides have not been sent for repair. Clinical Record review was initiated on 10/8/13, for Resident 4. Review of the Hearing Evaluation Sheet shows results of an audiometry exam (a hearing test that evaluates a person's ability to hear) performed on 10/29/12. Under remarks by the examiner "AU - severe SNHL" (severe hearing loss in both ears) was documented. The sheet also showed the resident wears hearing aides in both ears. Review of Resident 4's MARs for June, July, August, and September 2013 showed the hearing aides were no longer being used as of 6/26/13, as indicated by a "0" or "broken" written in the designated box. Review of all of Resident 4's Social Services Progress Notes showed no mention of Resident 4's broken hearing aides needing repair. Review of the Nurses' Progress Notes dated 6/26/13 through 10/8/13, (after the hearing aides were lost) showed no documentation of, or communication to social services regarding, the broken hearing aides. 6. Clinical record review for Resident 7 was initiated on 10/10/13. Resident 7 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. no longer work). During an interview with Resident 7 on 10/10/13 at 0820 hours, and on 10/13/13 at 1210 hours, Resident 7 stated she had cataract surgery before coming to the facility. She was told at the time of that surgery she would need cataract surgery on her other eye. Resident 7 stated she has no vision in her other eye now, but the social worker told her she has an appointment to see the eye doctor in January. During a review of the physician's orders [REDACTED]. Review of the consults and social work notes contained in Resident 7's clinical record does not show a previous ophthalmology consult. During an interview with SSA 2 on 10/16/13 at 0920 hours, SSA 2 was asked for documentation of previous ophthalmology consults for Resident 7. The SSA reviewed an IDT note dated 4/19/12, showing a section for social services to address the resident's needs for hearing, vision, and dental are all marked "no." The comments section shows "ophthalmology recommendation by physician but (resident) refuses ophthalmology consult, will revisit in three months..." Resident 7 was in the hallway near the nurses' station at the time of this record review. Resident 7 was asked if she refused to go to the ophthalmologist last year. Resident 7 stated she had never refused to be seen by the ophthalmologist. Resident 7 stated she is now blind in her left eye. A quarterly social service evaluation dated 6/30/12, shows, under sensory concerns, the resident has some vision problems, able to read large print only, has eyeglasses for reading...social services will refer resident for any ancillary services. When asked if there is any documentation to show a referral had been made for an ophthalmology evaluation after 6/30/12, the SSA stated she would look in the old record. On 10/16/13 at 1100 hours, the SSA stated she called the ophthalmologist's office and had them fax a copy of their appointment calendar showing Resident 7 had canceled her scheduled cataract surgery on 2/21/12. Review of the faxed material shows Resident 7 was seen by the ophthalmologist on 1/9/12; a preoperative appointment was scheduled for 2/14/12, is marked as a "no show;" a scheduled surgery for [REDACTED]. When asked why there was no social service follow up after the surgery was canceled, and why there was no further discussion of an ophthalmology evaluation found in the clinical record after 4/9/12, for Resident 7, the SSA was unable to answer. The SSA stated Resident 7 now has an appointment for the ophthalmology evaluation on 1/13/14. When asked what day of the week this appointment is scheduled, the SSA checked the calendar and found this date is a Monday. When reminded Resident 7 is scheduled for dialysis on Monday, Wednesday and Friday, the SSA changed the appointment to a Tuesday. When reminded Resident 7 will not miss bingo, the SSA stated she will discuss the appointment day and time with Resident 7 before finalizing the appointment.

Based on observation, interview and clinical record review, the facility failed to address risk factors for developing pressure ulcers, promote prevention for pressure ulcer development, by not implementing interventions that were consistent with the needs of four of 24 sampled residents (Residents 12, 15, 5 and 22). *Resident 12 was admitted to the facility with no skin breakdown. A repositioning, and a toileting schedule, was not implemented despite the fact the facility was aware Resident 12 spends long periods of time up in her motorized wheelchair. Facility staff was not aware Resident 12 has a specialized motorized wheelchair that is capable of "tilting/reclining to offload (take the pressure off) pressure areas. The facility failed to include in the care plan interventions related to Resident 12's motorized tilt/reclining wheelchair in relationship to weight distribution. This failure resulted in Resident 12 developing a skin excoriation to her buttocks, which deteriorated to five Stage III (full thickness tissue loss. subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Some slough (dead tissue) may be present) pressure ulcers. *Resident 5, known to be at risk for the development skin breakdown, was not provided thorough skin assessments to identify areas of skin breakdown. As a result, Resident 5 was not provided the treatment to prevent pressure ulcers and was not identified to have pressure ulcers until he was sent to the acute care hospital, where he was identified to have two Stage II pressure ulcers to the sacrum and the right buttock. *The facility failed to ensure the necessary services was provided to prevent development of a pressure ulcer and promote healing for Resident 22. The facility failed to provide incontinence care timely, turn and reposition the resident while in bed and wheelchair, and accurately assess and provide appropriate treatment to promote healing. Resident 22 developed a stage III pressure ulcer to the sacrum (tailbone) while in the facility measuring 7 cm x 5.5 cm with a depth of unable to determine due to 80% slough. *The facility failed to assess Resident 15's pressure ulcer for over a week. This poses the risk of the pressure ulcer progressing, going unidentified and the physician not being contacted to obtain appropriate treatment orders to promote healing. Findings: According to the 2009 National Pressure Ulcer Advisory Panel (NPUAP), pressure ulcers have been defined as localized tissue injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure (due to staying in one position for too long without shifting weight), or pressure with shear (occurs when layers of skin rub against each other or when the skin remains stationary and underlying tissue moves and tears, causing tissue damage). Review of the facility's P&P titled Skin Integrity dated 8/2009, showed, in the event a resident is admitted with or develops a skin pressure ulcer, wound care is provided to treat, heal and prevent, if possible, further development of skin ulcers. The resident's skin is inspected daily when ADLs are performed. Changes in the resident's skin are reported to the nurse. For chair bound residents, reposition every 1 to 2 hours, position change "offloading" hourly for dependent residents who are sitting. 1. On 10/15/13, clinical record review for Resident 12 was initiated. Resident 12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the MDS (an assessment tool) dated 4/2/13, showed Resident 12's memory is cognitively intact, she is self-sufficient once in a wheelchair; however, she requires total assistance from at least two staff members for transfers, and extensive assistance for bed mobility. The MDS identifies Resident 12 is always incontinent of bowel and bladder. The Skin Conditions Report Identified Resident 12 is at risk of developing pressure ulcers, and showed Resident 12 had intact skin. The MDS showed there was a pressure reducing device for the chair and the bed; however, no turning or repositioning program as in place. In addition, the MDS showed Resident 12 had no behavior of rejecting ADL care. Review of the history and physical dated 2/12/13, showed Resident 12 has the capacity to understand and make decisions. Review of a Physician's Progress Note dated 10/1/13, showed left gluteal pressure ulcer Stage II, as documented by nurses' notes. Risk factor, immobility, the resident is in the wheelchair all day and will not lie down during the day. The pressure relief used is a pressure reducing cushion. The physician added Resident 12 is up for 12 to 13 hours continuously; she is competent and will not go back to bed in the afternoon. The pressure ulcer may progress despite good nursing care. Review of laboratory results for Resident 12 obtained on 10/15/13, showed the resident's [MEDICATION NAME] level is 3 (normal 3.2-5.5 gm/dl). [MEDICATION NAME] can be an indicator of protein status, essential for wound healing, and [MEDICAL CONDITION] over a period of time. Observations of Resident 12 on 10/7/13 at 1600 hours, on 10/10/13 at 1100 hours, 10/15/13 at 0930 hours, and 1600 hours, showed Resident 12 was sitting up in a motorized wheelchair with a cushion. On 10/15/13 at 1630 hours, Resident 12 stated she had been up in the chair for "quite a while." Review of the Wound/Skin Evaluation and Documentation form dated 9/25/13, showed Resident 12 was identified with a left inner buttock excoriation (redness). The documentation showed the following: a. On 9/28/13, LVN 3 reevaluated Resident 12's skin, and documented the resident developed a facility acquired Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough) pressure ulcer. However, there is no documentation of the wound measurements. b. On 9/29/13, the licensed nurse documented the Stage II pressure ulcer measured 1.5 cm long x 1.5 cm wide x 0.1 cm deep. c. On 10/5/13, the licensed nurse documented the Stage II pressure ulcer measured 1.5 cm long x 1.5 cm wide, unable to determine depth. Review of a physician's orders [REDACTED]. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. some slough (dead tissue) may be present)," clean with normal saline, pat dry, and apply Santyl ointment ([MEDICATION NAME] agent to remove dead tissue), and cover with a dry dressing. There is no documentation to show a skin evaluation and assessment was done to show when the Stage III pressure ulcer was identified. During an interview with LVN 3 on 10/11/13 at 1400 hours, she stated Resident 12 is incontinent of bowel and bladder. LVN 3 stated, in the mornings, CNAs place two incontinent adult diapers to Resident 12, put her in her motorized wheelchair, and "off she goes" all day long, wearing the same diapers. LVN 3 stated Resident 12 refuses to come back to bed to rest or change the diapers. LVN 3 stated Resident 12 is not compliant with care, and sits too much in the wheelchair with no offloading. LVN 3 stated Resident 12 has a Stage III pressure ulcer; she (LVN 3) is supposed to do a weekly skin assessment, but she did not have time to do a complete assessment this week or to call the physician to ask for a low air loss mattress for wound management. On 10/15/13, Resident 12 was assessed by RN 1. Review of the Wound/Skin Evaluation and Documentation form showed she developed five (5) Stage III pressure ulcers as follow: Left buttock, site #1: Stage III pressure ulcer, measuring 2 cm long x 2 cm wide, and unable to determine depth, with 100% slough. Not noted on admission. Left buttock, site #2: Stage III pressure ulcer, measuring 4 cm long x 4 cm wide, and unable to determine depth, with 100% slough. Not noted on admission. Left buttock, site #3: Stage III pressure ulcer, measuring 2 cm long x 2.5 cm wide, and unable to determine depth, with 100% slough. Left Gluteal fold, site #1: Stage III pressure ulcer, measuring 3.7 cm long x 3.3 cm wide, and unable to determine depth, with 100% slough. Not noted on admission. Left Gluteal fold, site #2: Stage III pressure ulcer, measuring 3 cm long x 3 cm wide, and unable to determine depth, with 100% slough. Not noted on admission. Review of a physician's orders [REDACTED]. On 10/15/13 at 1000 hours, the surveyor was approached by the facility's Medical Director. He stated he was made aware Resident 12 now has five Stage III pressure ulcers. He stated that may not be right, because RN 1 is unable to assess and document pressure ulcers. He would like to reassess Resident 12's skin the next morning. During an observation of Resident 12's wound care treatment, accompanied by the Medical Director and RN 1 on 10/16/13 at 0810 hours, Resident 12 was observed lying in bed, awake and alert. CNA 1 rolled Resident 12 to the right side lying position, and pulled down two adult diapers saturated with urine, exposing approximately two dressings to her gluteal area. The Medical Director removed the crumbled dressings and exclaimed, "Oh my God!" Five pressure ulcers were observed among an area of heavily reddened, deeply creased, macerated skin around the original injuries. Five wounds were noted covered with yellow/brown with white macerated tissue throughout. A scant amount of serosanguineous (yellowish/red blood components) drainage was noted on the adult diapers, and wipes used during the incontinence care. During the observation of the wound care, the Medical Director calmly explained to Resident 12 five pressure ulcer sites had developed to her buttocks. He stated, regardless of the wheelchair cushion in her wheelchair, she needs to change positions, and offload the gluteal area; the pressure ulcers developed primarily due to pressure. Review of a Physician's Progress Note dated 10/1/13, showed a note signed by the Medical Director showing he was asked to review Resident 12's pressure ulcers to her left gluteal fold. The physician documented the wound had progressed since his last review on 10/1/13, now is a Stage "UTD (unable to determine)." This ulcer has progressed primarily because of prolonged sitting. "I had another conversation with the resident and she agreed to decrease her sitting in wheelchair." During an interview with the ADON on 10/16/13 at 0820 hours, the ADON was asked who is responsible to supervise the care provided by the treatment nurses in the facility. She stated the facility used to have wound consultants; now she is supposed to assess the wounds, but she has no specialized training in wound care. On 10/15/13 at 1630 hours, an interview was conducted with the Acting Activities Director, she stated Resident 12 goes outside the facility on the patio to water the plants, sometimes she gets on a bus and goes shopping. She stated Resident 12 sits all the time in her wheelchair. She stated she wears two adult diapers because Resident 12 urinates a lot. During an interview with Resident 12 on 10/16/13 at 1500 hours, Resident 12 was observed lying in bed. Resident 12 stated she is lying down to offload the gluteal area. She stated she has MS, and she has lack of sensation, doesn't feel her lower extremities, and doesn't' feel any pain. "I never felt the sores on my buttocks." "I did not know I had these wounds in my buttocks." When Resident 12 was asked why she asks for two diapers in the morning, she stated she has to keep running after the CNAs to help with her toileting needs; "it's too difficult." Resident 12 stated she doesn't want to lose her independence. Resident 12 stated she was not aware of her motorized tilt/reclining wheelchair in relationship to weight distribution, to be used for repositioning. b. On 10/15/13 at 1600 hours, a visual inspection of Resident 12's wheelchair was conducted, accompanied by the Rehabilitation Services Manager. He stated Resident 12 has a specialized tilting/reclining wheelchair that offloads pressure areas; He stated Resident 12 can even do it by herself. This information was not included in the resident's current care plan. Review of the Wheelchair Mobility assessment dated [DATE], showed Resident 12 received training on how to drive straight, complete a circle, drive wide, door entrance, corners, going clockwise, down the hallway, and weaving through the hallway; However, there is no documentation to show evidence Resident 12 was trained how to tilt or recline her wheelchair to reduce pressure, or alternative techniques to reduce pressure when she is out in the community. Review of a care problem dated 10/15/13, to address the Stage II gluteal pressure ulcer due to incontinency, prolonged sitting in the wheelchair, refusing to go back to bed to relieve pressure for a few hours showed approaches showed for the RD to evaluate and determine caloric needs for healing, monitor meal intake, monitor weekly weights, observe for signs and symptoms of infection, protect skin from moisture, use briefs as appropriate, apply moisturizer to the skin, multivitamins and minerals, evaluate positioning/mobility interventions and or restorative needs, notify the physician of failure in healing. However, The facility failed to include interventions in the care plan related to Resident 12's motorized tilting/reclining wheelchair in relationship to weight distribution. During an interview with LVN 3 on 10/16/13 at 0900 hours, she stated she has two stations to provide skin treatment. She stated she told Resident 12 many times to go to bed earlier. LVN 3 stated she did not order a low air loss mattress before because she was more concerned what else she could do regarding the resident's wheelchair. She had no idea the wheelchair could be tilted, PT never told them. c. During an interview with the DSD on 10/16/13 at 0915 hours, the DSD stated, if a resident has a wound, they should be checked at least every 2 hours, changed and given perineal/incontinence skin care. The DSD was asked if the residents are turned and repositioned every two (2) hours on a schedule. She stated "It is expected that staff should turn the residents every two hours in the turn clock." However, she was unable to state how the turn schedule works. During an interview on 10/16/13 at 1000 hours, with CNA 1, she stated she was aware Resident 12 had wounds and should be turned every two hours when she is in bed, but can't be turned while sitting up in her wheelchair. She stated she had been very busy this morning and was working her way up the hall, bathing and assisting other residents with their morning care. She explained she was behind with her morning work schedule and she was aware the resident is supposed to be turned, but she had been trying to catch up and had not forgotten the resident yet. 2. An interview with Resident 5 was initiated on 10/10/13 at 0745 hours. Resident 5 stated he has been at the facility since February 2013. Since his admission, he has developed wounds on his legs and now has pressure ulcers on his buttocks. The resident stated he made a complaint to the Ombudsman a few weeks ago and, since then, he has not been turned. Resident 5 stated the pressure ulcers developed about 10 days ago as a result of the lack of turning. Clinical record review for Resident 5 was initiated on 10/10/13. Review of the care plan to address the problem to address the potential for skin impairment dated 8/19/13, showed Resident 5 was at a moderate risk to develop skin impairment. The approaches/plan are to check the resident's skin daily and do a weekly skin evaluation. Review of the MDS dated [DATE], showed Resident 5 has good cognition. Review of the Treatment Record dated October 2013 showed weekly skin assessments from head to toe to be performed by the treatment nurse. The record showed the skin assessments were completed on 10/1/13, and 10/8/13. Review of the nurses' notes and physician's orders [REDACTED]. Review of the acute care hospital Physical assessment dated [DATE], showed Resident 5 was admitted to the hospital on [DATE], with two Stage II pressure ulcers. One pressure ulcer was on the medial sacral area (tailbone) and one on the right buttock. Review of the Wound/Skin Evaluation and Documentation Form dated 10/14/13, showed Resident 5 was readmitted to the facility on [DATE]. The form showed the resident had one Stage II pressure ulcer on the sacral area. The wound measured 5 cm x 4 cm. The depth of the pressure ulcer is not documented. An interview with LVN 3 was initiated on 10/16/13 at 1400 hours. LVN 3 stated she was giving Resident 5 skin treatments to the buttock area prior to his readmission to the hospital on an as needed basis. LVN 3 was asked, if the weekly skin assessments were done, why the pressure ulcers were not addressed. LVN 3 stated she was not sure. An observation of wound care to the pressure ulcers for Resident 5 was initiated on 10/17/13 at 0930 hours with LVN 3. Resident 5 had two pressure ulcers, one in the center of the buttocks (approximately 3 cm x 3 cm x 0.5 cm) and one on the right side (approximately 3 cm x 3 cm and shallow). LVN 3 was asked about the wound measurements. The LVN stated the wounds were measured as one larger wound a few days ago. 3. During the initial tour of the facility with ADON 2 on 10/15/13 at 0800 hours, Resident 22 was observed in bed. ADON 2 stated the resident is on hospice (care focusing on providing comfort to terminally ill residents) and has a Stage III pressure ulcer to the sacrum. Clinical record review for Resident 22 was initiated on 10/16/13. The MDS dated [DATE], showed the resident was dependent on staff for bed mobility; and incontinent of bowel and bladder. The care plan problem to address incontinence revised 9/18/13, showed to check the resident's incontinence brief every two hours and provide incontinence care as needed. The care plan problem to address potential for skin integrity impairment revised 9/18/13, showed to turn the resident every two to three hours, maximum chair activity of two hours at a time and shift resident's position every 30 minutes. The Wound/Skin Evaluation dated 9/2/13, showed the resident had a Stage II pressure ulcer to the sacrum measuring 6 cm x 5 cm x 0.1 cm, with no drainage. It showed the skin treatment was to apply [MEDICATION NAME] (an ointment that stimulates blood vessel activity and removal of unhealthy tissue). There was no documented evidence the wound was assessed after 9/2/13. The Wound/Skin Evaluation dated 9/15/13, showed the resident had a Stage III pressure ulcer to the sacrum measuring 5 cm x 4.5 cm x 0.1 cm with 30% slough and no drainage. The physician's orders [REDACTED]. The Wound/Skin Evaluation dated 9/23/13, showed the Stage III pressure ulcer measured 4 cm x 3.5 cm x 0.1 cm with 50% slough and no drainage. The Wound/Skin Evaluation dated 10/2/13, showed the Stage III pressure ulcer to the sacrum measured 4.5 cm x 5.5 cm x 1 cm with 20% slough and minimal serous drainage. There was no documented evidence the physician was notified related to the wound status. There was no documented evidence the RN reassessed the wound. There was no change in wound treatment. The Wound/Skin Evaluation dated 10/7/13, showed the Stage III pressure ulcer to the sacrum measured 3 cm x 1.5 cm x 2 cm with 20% slough and minimal serous drainage. The Wound/Skin Evaluation dated 10/14/13, showed the Stage III pressure ulcer to the sacrum measured 3 cm x 1.5 cm with minimal serous drainage. The depth of the wound and the percentage of slough were left blank. During an interview with CNA 8 on 10/17/13 at 0850 hours, CNA 8 stated he showers the resident around 0930 hours. He was asked when does the hospice aide visit the resident. CNA 7 stated the hospice aide comes on Tuesday and Thursday. CNA 8 was asked who will shower the resident. CNA 8 stated he will shower the resident if the hospice aide does not come today. CNA 8 was asked if the resident is aware of toileting needs. He stated the resident is incontinent and wears an incontinence brief. He was asked how many times he changes the incontinence brief. He replied, three times, at the start of his shift (7 to 3 shift), before getting the resident up in the wheelchair and at the end of his shift. He was asked what time he gets the resident up in the wheelchair. He replied, around 1100 hours. He was asked what time he puts the resident back to bed. He replied, 1330 hours, but if the resident's family member is present, he keeps her in the wheelchair. During a wound treatment observation with LVN 3 on 10/17/13 at 0855 hours, LVN 3 was observed preparing her wound supplies. LVN 3 called CNA 8 to assist her during the wound treatment. CNA 8 told LVN 3 that the hospice will be coming and give the resident a shower. LVN 3 was asked what time she normally provides wound treatment to Resident 22. LVN 3 looked puzzled and stated there is no specific time for Resident 22's wound treatment. LVN 3 stated she provides treatments to all residents on the first and second floors of the facility. LVN 3 stated she provides treatment whenever she gets the chance, or usually they call her. LVN 3 was asked to measure Resident 22's wound. LVN 3 removed the old dressing. A pressure ulcer was observed to the sacrum. LVN 3 measured the wound as 7 cm long x 5.5 cm wide and depth unable to determine due to slough. LVN 3 was asked to describe the wound. She stated the wound has 80% slough. After measuring the wound, LVN 3 stated she had a lot of residents waiting for her and hurriedly left the room. Resident 22 was observed in a wheelchair in the activity room at 1020 hours, 1145 hours, and 1225 hours. During an interview with CNA 7 on 10/17/13 at 1220 hours, he was asked if he was assigned to Resident 22. CNA 7 replied, yes. He further stated he gets the resident up in a wheelchair around 1000 hours and brings the resident to the activities room. He stated he sets the resident up at 1200 hours for lunch, and usually puts resident back to bed at around 1330 hours. He stated, today, lunchtime is at 1300 hours and will be finished by 1400 hours. CNA 8, who was present, stated the resident will be back to bed then. CNAs 7 and 8 did not verbalize that they shifted the resident's position while in the wheelchair. On 10/17/13 at 1410 hours, Resident 22 was observed in bed on her back with Family Member 1 at the bedside. During an interview with Resident 22's family member, she was asked if she was aware the resident has a pressure ulcer. She replied, yes. She was asked if the resident is being turned. She stated, whenever she visits the resident, the resident is always on her back. She further stated the staff does not turn the resident as they should. She stated she knows how often the resident should be turned because she is a nurse. She was asked if the staff change the resident timely. She replied, the staff change the incontinence brief, but not as often as they should. The family member stated to call Family Member 2 because Family Member 2 comes to visit the resident almost daily. During an interview with LVN 6 on 10/18/13 at 0955 hours, she was asked what interventions do they implement for residents with pressure ulcers. She replied, turn and reposition. She was asked if this is while the resident is in bed. She replied, obviously. She was asked about repositioning when the resident while she is in a wheelchair. She replied, Resident 22 has a cushion. She was asked what does she teach the CNAs to do to relieve pressure while the resident in the wheelchair. She replied, to put more pillows to relieve pressure. LVN 6 did not verbalize to shift position every 30 minutes while in the wheelchair. An interview was conducted with LVN 3 on 10/18/13 at 1030 hours. She was informed there was a big discrepancy on Resident 22's wound measurement, about 4 cm difference in the length and 4 cm on the width wherein the measurement was performed three days ago. She looked puzzled and did not give an answer. She was asked if there was a deterioration of the wound. She was unable to give an answer. She stated she can not remember because she has the whole first and second floors to provide skin treatments. On 10/18/13 at 1400 hours, Resident 22 was observed in bed, on her back. Resident 22's family member stated the CNA did not change the resident's incontinence brief while the resident was in the wheelchair. The CNA changed the resident's incontinence brief only when the resident was put back in bed. A telephone interview was conducted with Family Member on 10/22/13 at 0800 hours. Family Member 2 stated the resident is not being turned and repositioned and the incontinence brief changed timely because the problem is the facility does not have enough staff to take care of the residents. She stated there was one incident when she visited Resident 22; the nurse accidentally ripped the resident's incontinence brief. The nurse stated she will ask the CNA to change it. Resident 22's family member got another incontinence brief and placed it on the bedside table and went to the nurses' station to remind them to change the resident's incontinence brief. She stated she left the facility at around 1300 hours. She returned to the facility at around 1930 hours and found the clean incontinence brief still on the bedside table. The resident told the family member she is wet and, when she checked, the incontinence brief was still the same ripped incontinence brief the resident was wearing when she left the facility at 1300 hours, and was soaked with urine. She stated this is just one of the several incidents of not changing the resident's incontinence brief timely. 4. Clinical record review was initiated for Resident 15 on 10/16/13. Resident 15 was readmitted to the facility of 9/27/13. Review of the Wound/Skin Evaluation and Documentation form dated 9/28/13, shows the resident was readmitted with SDTI (Suspected Deep Tissue Injury, purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or strong shear; the area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue) on the sacrum (tailbone) area measuring 8 cm long x 11 cm wide, and with a pink/beefy red to purplish in color wound bed. Further review of the clinical record showed the SDTI on the sacrum was last assessed and measured on 10/5/13. An interview and clinical record review was conducted with RN 1 on 10/17/13 at 1000 hours. RN 1 was asked how often they measure and evaluate the progress of the wound or pressure ulcers in the facility. RN 1 stated the wounds and pressure ulcers are assessed and measured weekly. RN 1 was asked why Resident 15's wound on the sacrum was not assessed after 10/5/13. RN 1 reviewed the clinical record and stated the sacrum should have been assessed and measured on 10/12/13.

Based on observation, interview and clinical record review, the facility failed to ensure seven of 24 sampled residents (Residents 1, 2, 5, 3, 8, 9 and 6) with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. *Resident 1 has not received RNA services since 4/10/13. Failure to provide ROM for Resident 1 has resulted in the resident experiencing decline in her ROM. *Resident 5 was identified at high risk for loss of ROM on 8/20/13. He was identified to have a decrease in his ROM on 9/13/13. The resident is not receiving RNA services to prevent further decline. *The facility failed to ensure referral to the RNA program was done for Resident 3. This poses the risk for decline in range of motion. *Resident 8 was not provided with orthotic devices and a sling to maintain their joints in the proper positions and prevent further decline in their ROM. *The facility failed to ensure coordination of services between physical therapy and nursing with the use of an AFO (ankle foot orthotic - a brace, usually made of plastic, that is worn on the lower leg and foot to hold the foot and ankle in the correct position and correct foot drop) for Resident 9. * Resident 2 is status [REDACTED]. Resident 2 has limited ROM in both lower extremities, but has not received RNA services since 6/13/13. Failure to provide ROM for Resident 2 placed the resident at risk for decline. *The facility failed to address the need for treatment and services to prevent further decline in Resident 6's ROM. Findings: 1. During an interview with DON 1 on 10/7/13 at 1100 hours, DON 1 identified 53 residents on Station 3 were receiving RNA treatments. On 10/7/13 at 0800 hours, Resident 1 was observed in bed on her back with the head of the bed raised to about 30 degrees. Resident 1 had a call light pad next to her left foot. CNA 1 was in attendance, feeding the resident. When asked about ROM, the resident stated, "I haven't had range of motion exercises since I was readmitted from the hospital; PT saw me one time." The resident stated her legs used to be more flexible, now she is barely able to lift her foot to activate the call light. "My joints are starting to lock up. They hurt like hell." During the same interview, Resident 1 stated she has limited range of motion in both knees and both hands, her right hand is able to open only slightly before she complains of pain. Review of Resident 1' clinical record showed Resident 1 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the MDS (an assessment) dated 9/7/13 showed Resident 1 has intact cognition, with a BIMS score of 15. Resident 1 requires total assistance with bed mobility, dressing, eating, toileting, personal hygiene and bathing. She has functional limitation in ROM to both upper extremities (shoulder, elbow, wrist, and hands) and lower extremities (hip, knee, ankle, and feet). The MDS showed Occupational Therapy (OT) was provided six of the last seven days. Physical Therapy (PT) was not provided and the RNA services was performed on two days, at least 15 minutes, in the last seven calendar days. Review of the care plan showed a care plan problem dated 9/4/13, to address restorative nursing care plan, impaired functioning mobility status due to status [REDACTED]. The approaches included active range of motion to bilateral lower extremities. During an interview with PT 1 on 10/7/13 at 1300 hours, he confirmed Resident 1 had functional range of motion deficits when she received physical therapy services over two months ago, and there has been further decline of the resident's range of motion since that time due to new surgery to her left shoulder. He stated she is unable to move her upper extremities (arms), but she is on a functional maintenance program that would include performing range of motion exercises to her lower extremities three times a week. PT 1 stated the resident no longer has physical therapy, only restorative exercises which are provided by the RNA staff. PT 1 stated the RNA program is under the "nursing department," and the nurses are supposed to assess, initiate, discontinue, and supervise the RNA's performance. He stated, without therapy, Resident 1 is at risk for formation of contractures to her knees and ankles. He stated the RNA program is to help to promote circulation, joint integrity, and prevent contractures formation. Review of a physician's order dated 9/4/13, showed an order for [REDACTED]. Licensed nurse may initiate, change or discontinue RNA per ongoing evaluation. "Physical Therapy to monitor." Review of the RNA Rehab and Restorative form for September 2013 showed Resident 1 received the RNA exercises provided by RNA 2 and RNA 3 15 times. Review of the RNA weekly summary for September 2013, signed by RNA 1, showed Resident 1 was seen for AROM exercises to the lower extremities three times per week. Resident 1 tolerated with moderate assistance. Resident 1 was cooperative, showed tolerance. The resident did not complaint of any pain. On 10/7/13 at 0945 hours, an interview was conducted with RNA 1. RNA 1 was asked about the restorative services for Resident 1. He stated RNA 2 was the one who provided the services; he stated Resident 1 does not like him. RNA 1 showed a report documenting Resident 1 received ROM 15 minutes or longer for 15 days for the month of September 2013. On 10/7/13 at 1100 hours, the RNA Assignment Sheet dated 10/7/13, was provided by DON 1. The assignment showed RNAs were scheduled as follow: for Station 3, with a census of 56 residents: 1 RNA on the day shift (from 0700 to 1500 hours). On 10/7/13 at 1130 hours, a follow up interview was conducted with RNA 1. The RNA was asked how he feels regarding his assignment. RNA 1 stated the facility management increased the number of residents assigned with the excuse the facility's census is low. When asked how many residents he is assigned to who require RNA services and feeding assistance, he stated approximately all 56 residents on this floor are on the RNA program, "If we have extra help, I could assist the residents, if not, I take at least 15 minutes or more with each resident." Review of the Staff Assignment and Sign in Sheet dated 10/7/13, showed RNA 1 was assigned to 56 residents. On 10/7/13 at 1500 hours, Administrator 1 and DON 1 were informed Resident 1 was not being provided with RNA exercises. Administrator 1 and DON 1 stated, when they are short on RNA staff, they pull a CNA from the floor to fill in. However, no other information was received from the facility that would resolve the staffing issue. 2. Clinical record review for Resident 5 was initiated on 10/10/13. Review of the face sheet date 8/16/13, showed Resident 5 has a history of a stroke. Review of the MDS (an assessment tool) dated 8/18/13, showed Resident 5 had no impairment in his ROM on both the upper and lower extremities. Review of the PT Evaluation and Plan of Treatment dated 8/20/13, showed the PT documented Resident 5 was at risk for a decline in ROM. The resident wants to wait to start PT due to weakness from hospitalization . The PT documented the rehabilitation needs can be met by other disciplines and to reassess if a change of condition warrants. Review of the physician's orders dated August 2013 showed no order for RNA services. Review of the MDS dated [DATE], showed Resident 5 had new onset of impairment to his ROM on both sides of the lower extremities. Review of the physician's order dated 10/4/13, showed an order to begin RNA services. An interview with the Rehab Department Supervisor was initiated on 10/16/13 at 1500 hours. The Supervisor stated the RNAs should be able to fill out the Joint Mobility Assessment with the supervision of a nurse. A joint interview with RNA 4 and RNA 5 was initiated on 10/17/13 at 1035 hours. The RNAs stated they are documenting the Joint Mobility Assessments on all residents' quarterly assessment. The RNAs were asked if they were given supervision or guidance from PT or licensed nurses in regards to the Joint Mobility Assessments. The RNAs stated, no. The RNAs were asked the last time they were inserviced regarding RNA services. The RNA's stated they have not had any RNA education since starting work at the facility. When asked about the RNA staffing, RNA 5 stated the facility routinely has one RNA working a 7.5 hour shift and another RNA who spends half of his shift assisting with activities. The RNAs stated, on Mondays and Tuesdays, the RNAs spend all day weighing residents and don't have time to exercise or walk any one. RNA 5 stated the RNAs could not keep up with the work load but documented the RNA services were being provided. An interview with Resident 5 was conducted on 10/15/13 at 1100 hours. Resident 5 stated he has not received any RNA services or exercises yet. He stated he was just in the hospital last weekend and the PT at the hospital who had worked with him before told him she was surprised how much function the resident has lost. 3. Review of Resident 8's clinical record was initiated on 10/10/13. Resident 8 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of MDS showed Resident 8 is cognitively intact. Review of the physician's orders showed an order dated 9/23/13, for bilateral AFOs (ankle foot orthotic - a device to maintain the ankle joint in a neutral position) and ambulate with a right hemi-cane (three or four footed cane that provides more support) three times a week. A physician's order dated 5/13/12, showed to wear a sling on the left arm or use a trough (an appliance to rest the arm in), on when out of bed and off when in bed. During initial tour on 10/10/13 at 0830 hours, observation showed Resident 8 was sitting in the wheelchair, not wearing a sling on the left arm. During interview and clinical record review with LVN 6 on 10/10/13 at 1045 hours, LVN 6 was asked about the left arm sling for Resident 8. She verified the resident is not wearing a left arm sling while out of bed. During an interview with RNA 5 on 10/11/13 at 1340 hours, RNA 5 was asked about the schedule for application of the bilateral AFOs for Resident 8. He stated, "to be honest with you, we have not used the AFOs with Resident 8. We cannot accommodate all the residents. We have only two RNAs in the whole building." During an interview with RNA 4 on 10/17/13 at 1030 hours, RNA 4 was asked about the schedule for application of the bilateral AFOs for Resident 8. He stated, "I am about to start Resident 8 with AFOs today." RNA 4 was asked about the treatment record dates of 10/12/13 - 10/14/13, showing the treatments were rendered to Resident 8 and was signed off by the RNA. RNA 4 verified those were his initials, but he did not provide the RNA services for the resident. During an interview with Resident 8 on 10/18/13 at 1015 hours, Resident 8 verified the RNA has not been using the AFOs on him. During an interview with CNA 8 on 10/18/13 at 1200 hours, CNA 8 was asked about the left arm sling for Resident 8. He verified Resident 8 is not been provided the left arm sling. 4. On 10/15/13, clinical record review was initiated for Resident 2. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Resident 2's [DIAGNOSES REDACTED]. Review of the history and physical dated 8/29/12, shows Resident 2 sustained a left proximal tib/fib fracture in March 2012 and was re-evaluated by the orthopedist and Resident 2 is to remain non-weight bearing due to the healing fracture. Review of the Joint Mobility Form shows an entry dated 6/2/13. The documentation shows severe limitation in range of motion for Resident 2's left knee and hip, with moderate limitation in the left ankle and minimal limitation in the right knee, hip and ankle. The entry dated 9/2/13, shows severe limitation in range of motion of Resident 2's left knee and hip with moderate limitation for the left ankle and minimal limitation for the right knee and hip. The documentation shows a decrease in range of motion in the right ankle to moderate limitation. Review of the physician's recapitulated orders for October 2013 failed to show an order to address RNA services for ROM to Resident 2's lower extremities. Review of the RNA documentation for June 2013 shows an order (undated) to provide the RNA program for right lower extremity Active Range of Motion five times per week as tolerated; the licensed nurse may initiate, change or discontinue RNA program per ongoing evaluation. An entry dated 6/13/13, shows Resident 2 is stable for greater than 90 days with no noted decrease in ROM. "Will discontinue from RNA and will continue to assess per RAI (Resident Assessment Instrument) schedule. Will encourage participation in activity based exercises." On 10/15/13 at 1545 hours, an interview was conducted with CNA 10. CNA 10 stated Resident 2 requires extensive assistance with use of a Hoyer lift (a mechanical lift used to transfer patients who are unable to stand) for transfer into her wheelchair. CNA 10 stated Resident 2 has no strength in either of her lower extremities. When Resident 2 receives ROM services for her lower extremities, he stated he does not provide ROM, but he was not sure if the RNA did ROM. When asked about ROM for her left lower leg, CNA 10 stated, no. He stated because her left knee was immobilized when up in the wheelchair. When asked if ROM was provided to her left hip or ankle, he stated, no. On 10/15/13 at 1600 hours, an interview and clinical record review was conducted with RNA 3. When asked if Resident 2 receives RNA services for ROM to her lower extremities, RNA 3 stated she used to, but it was discontinued. RNA 3 stated Resident 2 received AROM to her right lower extremity but it was discontinued on 6/13/13. On 10/17/13 at 0800 hours, an interview was conducted with CNA 9. CNA 9 stated Resident 2 complains of pain on the left when she is being dressed. When asked if Resident 2 receives ROM to her lower extremities, she stated, no and was not sure why. On 10/17/13 at 0830 hours, an interview and clinical record review was conducted with ADON 1. ADON 1 verified Resident 2 has decreased ROM in both lower extremities. ADON 1 verified RNA services for ROM were discontinued on 6/13/13, but she was unable to explain why. ADON 1 stated Resident 2 should be re-evaluated and RNA services provided. On 10/17/13 at 1015 hours, an interview and clinical record review was conducted with the Rehabilitation Manager. The Rehabilitation Manager verified Resident 2's left proximal tib/fib fracture occurred in March 2012 and was immobilized using a knee immobilizer. Review of the PT documentation dated 8/27/13, shows to advance to the RNA program for ROM to both lower extremities. Documentation dated 11/19/12, shows RNA ROM program to both lower extremities ongoing and no problems reported. The recommendation shows to continue RNA passive ROM five times per week to both lower extremities. The Rehabilitation Manager was unable to provide further documentation to show any further evaluation was performed by PT services. The Rehabilitation Manager stated Resident 2 should be re-evaluated at least every six months for the use of the immobilizer and need for ROM services. The Rehabilitation Manager stated nursing should consult with PT/OT frequently for residents with limitations in ROM. (cross reference to F278) 5. Review of the facility's P&P titled "Restorative Program Referral" dated 9/03, showed the Resident Program Referral Form is a working document that may be used by nursing or therapy to document the transition of a resident from therapy to nursing/restorative or resident/family. The form showed the Restorative Program Referral Form is signed by a nursing representative to acknowledge transition of the resident and the following will be completed: progress note, physician's order, restorative flowsheet, care planning, and review with resident or resident's authorized representative. Clinical record review for Resident 3 was initiated on 10/10/13. Resident 3 was admitted on [DATE]. Review of the admission and quarterly MDS dated [DATE], and 9/5/13, showed impairment on both sides of the lower extremity. Review of the Physical Therapy Discharge Summary dated 6/27/13, showed the discharge recommendation is a functional program with RNAs. Review of the Restorative Maintenance Program Referral Form dated 6/27/13, showed a referral by physical therapy to restorative nursing for lower extremity active range of motion, 20 repetitions for two sets. During an interview with RNA 5 on 10/11/13 at 1450 hours, RNA 5 stated Resident 3 is not on the RNA program. During an interview and clinical record review with ADON 3 of the Restorative/ Maintenance Referral Program on 10/11/13 at 1505 hours, ADON 3 was asked how the restorative program referral is done. ADON 3 stated the physical therapist will explain and give instructions to the RNA about the restorative program. The RNA signs the referral form that instructions were given and the licensed nurse has to call the physician. Review of the Restorative/Maintenance Program Referral Form showed a signature that instructions/training was given. The form shows an no signature under "noted by nursing." ADON 3 was asked whether the referral was done. ADON 3 stated the referral was not done. During an interview and clinical record review with the Rehab Manager on 10/11/13 at 1545 hours, the Rehab Manager verified referral was made for the RNA program. the Rehab Manager stated the referral should be acted upon as soon as possible. 6. During an observation on 10/10/13 at 1210 hours, in the dining room, Resident 9 was observed with an AFO to the right lower extremity. Clinical record review for Resident 9 was initiated on 10/10/13. Resident 9 was admitted on [DATE], and was readmitted on [DATE]. Review of the quarterly MDSs dated 2/7/13 and 9/6/13, showed Resident 9 has impairment on one side of the upper extremity and lower extremity. During an interview with RNA 2 on 10/11/13 0745 hours, RNA 2 was asked if Resident 9 is in the RNA program. RNA 2 went to check in the RNA book. RNA 2 stated Resident 9 is receiving RNA services. Resident 9 receives both lower extremity AROM, has a right AFO to be on when up in the wheelchair, in the RNA program for dining, and a splint on the right upper extremity. During an observation in the activity room on 10/11/13 at 0950 hours, Resident 9 was observed sitting in the wheelchair. Resident 9 had an AFO to the right lower extremity. During an interview with RNA 2 on 10/11/13 at 1000 hours, RNA 2 stated RNA 2 placed the AFO to Resident 9's right lower extremity after breakfast. RNA 2 stated she had to do both lower extremity AROM today (10/11/13) before applying the AFO to the right lower extremity. An interview and clinical record review was conducted with the MDS Coordinator on 10/11/13 at 1525 hours of the following: a. Review of the Physician Order Sheet showed an admission order for physical therapy evaluation and treatment as indicated. The MDS Coordinator stated Resident 9 was discharged on [DATE], and was readmitted on [DATE]. The MDS Coordinator verified there is no order for the RNA application of the AFO. b. Review of the October 2013 RNA Rehab and Restorative Form showed RNA initials on 10/9-10/10/13, to indicate the application of the right AFO when up in the wheelchair and off when in bed. The MDS Coordinator stated the form should have been pulled out of the RNA binder since Resident 9 got readmitted on [DATE] and there is no physician's order to continue the RNA application of the AFO. The MDS Coordinator stated, if the resident is on physical therapy, the physical therapist will evaluate if the AFO needs to be continued. c. Review of the record prior to admission to the acute hospital showed a physician's order dated 6/7/11, for the RNA program for a right AFO to be on when up in the wheelchair, off when in bed; monitor skin pre and post AFO application for redness or open areas, notify charge nurse if noted. During an interview with the Rehab Manager on 10/11/13 at 1545 hours, the Rehab Manager stated Resident 9 is on physical therapy and, while Resident 9 is on physical therapy, the physical therapist will determine the continual need for the AFO. Review of the Physical Therapy Evaluation and Plan of Treatment dated 10/7/13. showed Resident 9 had an AFO to the right lower extremity on its prior level of function. During an interview with the Rehab Manager on 10/17/13 at 1515 hours, the Rehab Manager stated physical therapy will assess the continued need for the AFO and physical therapy needs to coordinate with nursing for the use of the AFO. 7. Review of Resident 6's clinical record was initiated on 10/15/13. The MDSs dated 6/6/13, and 9/6/13, shows the resident has limitation of range of motion to both upper and lower extremities. Review of Resident 6's care plan failed to show documented evidence the resident had a care plan problem to address the possible further decline in range of motion to the upper and lower extremities. On 10/15/13 at 0930 hours, 1220 hours, and 1500 hours, Resident 6 was observed sitting in a wheelchair in the activities room. On 10/17/13 at 1045 hours, MDS Coordinator 1 was asked why Resident 6 has no care plan or RNA order to prevent further decline to the upper and lower extremities. She reviewed the resident's clinical record and acknowledged there was no care plan problem to address limitations to the resident's upper and lower extremities to prevent further decline. MDS Coordinator 1 stated Resident 6 should have a care plan develop.

Based on observation, interview, and closed clinical record review, the facility failed to routinely assess and evaluate one of two sampled residents (Resident 1). The facility failed to assess Resident 1's head for complications that may arise from the presence of a metal plate which had been surgically implanted to his skull, under his skin, to cover his brain. On 9/28/12, a CNA noticed a piece of metal hardware protruding from Resident 1's head (near the temporal area). The skin surrounding the exposed metal plate was red and there was drainage. Upon examination, by LVN 1, drainage around the metal plate and was able to insert a cotton-tipped applicator inside an opening around the plate. Green, pus-like discharge was noted. On 10/2/12, Resident 1 was transferred to the acute hospital, and on 10/4/12, underwent surgical repair, elevation and removal of the damaged metal plate. The absence and delay in assessment can cause a delay in treatment and a decline in his medical condition. Findings: Review of the facility's P&P titled "Skin Integrity Policy" dated 8/09, show the nurse completes a weekly visual skin inspection and the resident's skin (unless the resident is independent in ADLs) is inspected daily when ADLs are performed. Review of the facility's form titled "Shower Day-Skin Check" show the CNAs are to check "yes" or "no" under the sections titled: face shaved, ears clean, nose clean, fingernails trimmed and cleaned, toenails trimmed and clean, feet swollen and teeth clean. However, there was area on the sheet to address the resident's hair or head area, even though staff knew Resident 1 had a metal plate surgical implanted into his skull. Closed clinical record review for Resident 1 was initiated on 10/15/12, which showed Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident 1's MDSs (assessment tool) dated 5/10/12 and 7/31/12, show he was dependent on staff for all his ADL care, including hygiene needs. His cognitive status was severely impaired. A physician's orders [REDACTED]." This was to be documented on his weekly summary assessment. Review of nurse's notes dated 9/28/12 at 1140 hours, show the right side of Resident 1's head, near the temporal area, was red and a metal plate was visible. Staff documented the physician was notified and a computed tomography (CT) scan (scan to show detailed pictures of structures inside of the body) was ordered. The CT was scheduled for 10/1/12 and his family was going to accompany him. The next nurse's notes which showed staff assessed the resident's head was on 9/29/12 at 2055 hours; a licensed nurse documented "patient conts (continues) with redness to right temporal area" of head below visible metal plate. The next entry was on 9/30/12 11 pm - 7 am, showed the resident's right temporal area continues with redness below the visible plate and to handle (his head) gently at all times. The resident had no signs or symptoms of pain or distress. On 10/1/12 at 1410 hours, staff document the resident was out of the facility to have his CT scan done, and he was accompanied by a family member. Review of the physician's progress note dated 9/29/12, showed the physician visited Resident 1 and noted the depressed plate. He documented to get a CT scan and to follow-up with the Neurosurgeon. Additional review of the licensed nurses' notes showed on 9/29/12 at 2055 hours, a nurse documented Resident 1 "conts (continues) with redness to right temporal area of head, below visible metal plate." Resident did not have complaints of pain. On 10/2/12 at 1340 hours, the nurse's note showed Resident 1's physician was aware of Resident 1's right temporal area metal plate exposed with "minimal drainage noted, with 0.5 cm in depth. Drainage with slight brownish in color." Resident is awake and pain medication given as ordered. The licensed nurse documented "Upon assessing the affected area, Resident noted to want to strike out, he does not want the affected site to be touched." A new physician's orders [REDACTED]. A late entry dated 10/2/12 at 1500 hours, showed the treatment nurse documented Resident 1 was noted to have crusting on the hardware (to the right side of his head), with a 0.5 cm depth. The drainage was described as greenish. When staff attempted to cleanse the area the resident tried to strike out. On 10/2/12, Resident 1 was transferred to the acute care hospital emergency department to evaluate the exposed metal plate in his right temporal area. Review of the emergency department report dated 10/2/12, showed Resident 1 was identified to have a depressed skull on the right side with hardware (metal plate) exposed. There was some yellowish drainage (crusted) over the skin and hair surrounding the exposed plate. A CT scan done on 10/3/12, showed the following: "Right parietal skull has collapsed inward, please correlate with any trauma. [MEDICAL CONDITION] side plate is seen." Review of a Neurosurgical Consultation dated 10/3/12, showed Resident 1 arrived at the emergency department on the afternoon of 10/2/12, and was noted to have a "sunken severely depressed skull fracture and skull defect with previous frontotemporal parietal (front and side of head) bone flap disrupted and migrated inward with titanium mesh and plate disrupted having protruded through the scalp." The Neurosurgeon documented, "In my opinion, the patient calvarial findings are most likely the result of a fall or a direct traumatic injury or impact to the right side of the skull, resulting in the disruption of the titanium plates and the dislodgment and sinking of the large cranioplasty bone flap..." On 10/4/12, Resident 1 underwent surgery to have the titanium plate removed and the depressed bone flap repaired. During a telephone interview on 10/15/12 at 1337 hours, Resident 1's family member stated a physician at the hospital said for Resident 1's plate was very badly damaged and broken. The physician told her this type of injury had to be from a [MEDICATION NAME] force trauma. She stated part of his skull was sunken in near his forehead and temporal area and the area was infected. On 10/15/12 at 1600 hours, an interview was conducted with LVN 2. LVN 2 stated Resident 1 was dependent on staff for all his ADL care and was not able to transfer himself in or out of bed. She stated he had no behaviors. The LVN was asked about the resident's head. She stated the right side of the resident's scalp, where a metal plate was, was indented. On 10/15/12 at 1627 hours, an interview with CNA 2 was conducted. CNA 2 stated Resident 1 was alert but dependent on staff for all his care needs. CNA 2 stated Resident 1 he was able to use his right hand, but she had never observed him attempting to touch his head. The CNA stated a small area of the metal plate was visible on the right side of the resident's scalp but she did not know when it was first noted to be exposed. On 10/15/12 at 1640 hours, an interview was conducted with the DON. The DON stated on 9/28/12, she examined Resident 1's scalp. She stated his scalp was not red, warm, bruised, swollen or with any drainage. When asked, she was unable to locate any documentation to show Resident 1's head/scalp were assessed prior to 9/28/12. Additional review of the nurses' notes found no documented evidence staff had been assessing the resident's head for the month of September, 2012, prior to 9/28/12. During an interview on 10/16/12 at 0818 hours, ADON 2 stated prior to 8/11/12, Resident 1 resided on her nursing unit. She stated Resident 1 was alert and able to make simple needs known. The ADON stated the right side of Resident 1's head was indented from his forehead to the right side of his head. She stated the metal plate was covered by skin and was not exposed. ADON 2 stated a body assessment including the resident's head was to be completed on the weekly summary form. However, when asked for documentation to show this was done, she was unable to locate a head assessment, related to his head injury or metal plate on the weekly summaries. On 10/16/12 at 0843 hours, an interview was conducted with ADON 1. ADON 1 stated the licensed nurses should be documenting every shift (every eight hours) their assessment of Resident 1's head/scalp. She was unable to locate documentation of any head assessment prior to 9/28/12. On 10/16/12 at 0847 hours, an interview was conducted with RN 1. She stated on 9/28/12, she was asked by LVN 1 to assess Resident 1's head. RN 1 stated upon examination, she observed a metal plate protruding from the right side of the resident's head. She stated a small amount of "sticky brown drainage" was at the base of the metal plate. On 10/16/12 at 0852 hours, an interview was conducted with LVN 1. LVN 1 stated on 9/28/12, CNA 1 approached her and asked her to look at Resident 1's head. She stated when CNA 1 moved Resident 1's hair, part of the metal plate was visible and the hair near the plate was crusted together. LVN 1 stated she observed some drainage around the metal plate, so she took a cotton-tipped applicator and examined the area. LVN 1 stated approximately ? of the tip of the applicator went inside an opening where the plate was. She added when the tip of the cotton applicator had greenish, pus looking discharge on it. During a telephone interview on 10/16/12 at 1054 hours, CNA 1 stated while she was washing Resident 1's hair (on 9/28/12) her hand touched something on the right side of the resident's head and closer examination, she observed some of the metal plate exposed. She stated she the scalp and the skin around the area was red. She said she immediately notified the licensed nurse. When CNA 1 was asked when was the last time she washed Resident 1's hair, she said this was the first time she had touched the right side of his head (metal plate area) when washing his hair, because she was "scared to touch that area before." Observation on 10/16/12 at 1555 hours, Resident 1 was observed in the Surgical Intensive Care Unit at the acute care hospital. He did not open his eyes and only responsive to painful stimuli. On 10/17/12 at 1553 hours, a telephone interview was conducted with Resident 1's Neurosurgeon. the Neurosurgeon stated upon examination of Resident 1's scalp, the titanium plate was observed sticking out of his scalp. He stated the plate was "bent and warped." When the Neurosurgeon was asked what would have caused the titanium plate to be bent and warped; he stated this type of injury had to be from considerable force; either from falling several feet, hitting something like a night stand or from a [MEDICATION NAME] trauma injury. On 10/18/12, at 0930 hours, a follow up interview was conducted with LVN 1. The LVN stated Resident 1's weekly skin assessments were documented on the Treatment Sheets. She stated she only does a head to toe skin assessment when the CNA(s) notifies her there is a skin problem. When LVN 1 was asked the reason she documented on Resident 1's Treatment Sheet on 9/30/12, of having no skin problem identified, she stated she should have documented there was a skin problem. On 10/18/12 at 0950 hours, RN 1 stated residents' get head to toe assessment are to be conducted by the charge nurse and treatment nurse. She added the charge nurse is ultimately responsible for assessing residents and documenting their findings on the Weekly Summary forms. She was unaware of the reason Resident 1's head injury and protruding metal was not documented. On 10/23/12 at 0925 hours, a follow-up telephone interview was conducted with Resident 1's Neurosurgeon. He stated the plate in Resident 1's skull must have been protruding for several weeks, based on his examination. Review of the Pathology Report dated 10/25/12, showed the hardware "appears to represent a single circle metal plate which has been mechanically disrupted into two fragments." The diameter of the plate was 2 cm and less than 1 mm thick. In addition, review of color photographs taken on 10/2/12, at the acute hospital, showed the exposed metal mesh plate with a yellow/brownish crusted like drainage surrounding affected area.

Based on interview and clinical record review, the facility failed to ensure Resident 1 was transferred safely from her wheelchair to her bed. One staff member attempted to transfer Resident 1 by himself and no gait belt was not used during the transfer. Resident 1 collapsed and fell sustaining fractures to both of her ankles. Findings: Clinical record review was initiated for Resident 1 on 4/11/12,which showed Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], shows Resident 1 is usually understood and comprehends most of conversations/usually understanding. On 3/4/12, Resident 1's weigh was 194 pounds. Review of Resident 1's Nurses' Progress Notes form from 3/16 to 3/23/12, show the resident is totally dependent with transfers and needs two or more staff members. Review of the Fall Evaluation form for Resident 1 dated 3/1/12, shows she scored 14. A score of 13 or more means the resident has a high potential for falls. A care plan problem developed for self-care deficit dated 3/1/12, shows she needs to be transferred with two persons assisting her. A gait belt (a belt placed around a resident's waist during transfers is used to assist in lifting, balancing and positioning the resident) must be used. Another care plan problem was developed for her risk for falls dated 3/1/12, which shows she has problems with balance during standing and walking. Review of the Interdisciplinary Progress Note dated 4/2/12, showed on 3/30/12 at approximately 1520 hours, a licensed nurse was passing Resident 1's room and resident had requested to be transferred from her wheelchair onto her bed. The licensed nurse attempted to transfer the resident alone from her wheelchair to her bed but in the process the resident "became unable to bear weight" and the nurse had to assisted her to the floor. The nurse then requested the assistance of two CNAs to help transfer the resident onto bed. The resident complained of pain to her ankles. The physician was notified and x-ray ordered. Review of the x-ray results dated 3/30/12 showed Resident 1 sustained fractures to both the right and left ankles. The x-ray for the right ankle showed "subacute mildly angulated fractures to the distal tibia and fibula. The x-ray for the left ankle showed acute to subacute mild displaced fractures to the distal tibia and fibula. Both x-rays showed the resident had moderate osteoporosis. The resident was transferred to the acute hospital emergency department. On 4/11/12 at 0740 hours, during an interview with Resident 1, the resident was asked how she broke both of her ankles. She stated she was in a chair right next to her bed and wanted to go back to bed. She stated she stood up with "him" (the licensed nurse) and lost her balance. She stated she experienced a "hard fall." She stated she lost her balance, but "he couldn't catch me." On 4/11/12 at 1010 hours, an interview with RN 1 was conducted. The RN stated on 3/30/12, when he entered Resident 1's room she was sitting in her wheelchair which was placed next to the foot of her bed facing the head of her bed. The RN stated the resident asked to go back to bed. The RN stated he stood in front of Resident 1's wheelchair and put his arms underneath both of her armpits in order to assist to transfer her. He stated he counted to three and assisted lifting her to a full, standing position. He stated he did not put a gait belt on the resident prior to trying to transferring her. He stated Resident 1 made 30 to 40 percent of the effort in standing and he made 60 to 70 percent of the effort. He stated he began to pivot to turn her to his right side, towards the bed, however she suddenly fell straight down to the floor with the weight of her body falling onto her feet. The RN stated the resident did not fall to either side but re-emphasized she went straight down falling onto her feet. The RN stated he asked Resident 1 what happened and she responded stating she thought her feet gave way underneath her. The RN said he yelled out for help and while waiting for someone to respond he had to straighten out the resident's legs out from underneath her, layed her down on the floor, and put a pillow under her head. The RN stated he had to go into the hallway and called for help. Two male CNAs came to assist him in getting Resident 1 into bed. The RN revealed Resident 1 is larger than him. When RN 1 was asked if he was aware of how Resident 1 needed to be transferred prior to her fall, he stated no. During an interview with CNA 1 on 4/11/12 at 1045 hours, he stated he has cared for Resident 1 multiple times prior to her fall and she has always required use of a gait belt and two persons to assist her with transferring. The CNA said the gait belt is necessary as it helps to lift Resident 1 to stand from a seated position as well as helping to move her hips over to a chair or bed. He stated, "The lady is a little bit heavy and has to have two people for transfers." He re-emphasized Resident 1 "always, always, always needs two people for transferring" as her knees will sometimes give way when she stands. When asked if Resident 1 was not wearing a gait belt when he first saw her immediately after she fell , he said no and he had put a gait belt on her in order to assist her into bed from the floor. On 4/11/12 at 1120 hours, an interview with the DSD was conducted. The DSD was asked where staff would find documentation showing how each resident needs to be transferred. She stated staff should look at resident's plan of care, care directives, or rehab notes. The DSD stated Resident 1's rehab note dated 10/4/11 shows she is a "stand-pivot" only for transfers and this documentation would be used as a reference for how the resident needs to be transferred. In addition, a care plan problem for self-care deficits shows Resident 1 needs two persons assistance and the use of a gait belt for transfers.

Based on interview, clinical record review and observation, the facility failed to provide supervision and assistive devices to protect one of 22 sampled residents (Resident 1) from falls with injuries, which included a laceration requiring staples for closure, and bruises and abrasions. Resident 1 was identified to be at high risk for falls, requiring supervision. However, the necessary interventions for fall management were not implemented. As a result, on 8/22/11 at 0600 hours, Resident 1 fell out of her bed and sustained a laceration to the back of her head. Resident 1 required transfer to the emergency room , and required staples to close the laceration. On 8/24/11, while in the Rehab Department, Resident 1 leaned forward in her wheelchair and fell face down onto the floor, sustaining abrasions to her left forehead, eye and cheek bone, left cheek ecchymosis (bruising), and left eye edema (swelling) and a hematoma (a blood clot). Resident 1 required transfer to an emergency room for evaluation. Findings: 1a. Review of the facility's P&P titled Fall Management dated 2/2000, showed the facility will implement a fall management plan based on the resident's evaluation. During initial tour rounds of the facility on 8/22/11 at 1300 hours, Resident 1 was observed lying in bed, awake. She is non-English speaking. The resident made eye contact when greeted, but was nonverbal. Resident 1 was observed with a laceration to the back of her head (below her right ear), measuring approximately 1.5 cm, with staples intact. LVN 1 accompanying the surveyor stated Resident 1 had a fall early this morning at 0600 hours. Resident 1 was transferred to the emergency room where she received staples to close the laceration. LVN 1 stated the resident is on a regular bed, which was observed to be approximately 3 feet above the ground, and routine fall precautions instituted, with the call light within reach and visual checks. LVN 1 further stated, at the time of the fall, there was no bed alarm, no low bed, and the resident's room was the furthest room away from the nurses' station. On 8/22/11 at 1430 hours, Resident 1 was observed in her bed. Her call light was hanging on the floor. Resident 1 was leaning to her left side, holding onto an overbed table for support. The overbed table, equipped with wheels, was sliding away. Her bed was approximately 3 feet above the ground. The surveyor had to intervene immediately and contact a staff member to prevent Resident 1 from falling out of the bed. On 8/22/11 at 1500 hours, during an interview with Resident 1's family member, the family member stated on 8/22/11 at approximately 0600 hours, he received a phone call from the facility stating Resident 1 had a fall from her bed. He stated Resident 1 was then transferred to an emergency room , where she had a head laceration repair. The family member stated, during Resident 1's admission to the facility, he reported she moves a lot when in bed because she has pain in her legs. The family member stated, at home, Resident 1 sleeps on a "thin mat on the floor; she likes the bottom." He stated the fall incident caused Resident 1 fear because she is non-English speaking, is depressed, because she used to be at home, and pain, due to the laceration to her head. The family member stated he can't imagine how long Resident 1 was on the floor after the fall, because she is confused, has a vision deficit and is nonverbal. Review of the clinical record for Resident 1 initiated on 8/22/11, showed Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The most obvious symptoms are movement-related, including shaking, rigidity, slowness of movement and difficulty with walking). Review of the MDS dated [DATE], showed Resident 1 has short term and long term memory problems. Resident 1's cognitive skills for daily decision-making are moderately impaired with poor decisions; cues and supervision are required. Resident 1 requires total staff assistance for bed mobility and transfers. The MDS also showed the wheelchair is the primary mode of locomotion and other persons wheeled. Continued review of the MDS showed Resident 1 did not fall any time in the last 2-6 months prior to admission. Review of the Fall Risk assessment dated [DATE], showed Resident 1 had a score of 16. A score greater than 13 shows the resident has a high potential for falls. On 8/23/11 at 0945 hours, during an interview with the DON, she reviewed the initial Fall Risk Assessment for Resident 1 dated 8/10/11. The DON stated, if the resident has a high potential for falls, a High Potential Fall Evaluation form should be completed, because there are areas and factors that may require appropriate care plan implementation for fall management. After reviewing Resident 1's clinical record, the DON confirmed the High Potential Fall Evaluation form was left blank when the resident was assessed to be at high risk for falls. The DON stated that was what the nurse decided to do at the time of the resident's admission. Review of the plan of care showed a care plan problem dated 8/10/11, to address the fall risk related to being disoriented times three all of the time. The approaches check off list showed to complete a resident fall risk assessment form, keep the resident clean and dry, and refer to therapy, screen by PT. None of the other approaches were checked off. There was no documentation of approaches to provide supervision. Review of a Social Service History dated 8/12/11, showed, under prior living arrangements, prior level of functioning, Resident 1 was nonambulatory for the past three years, using a wheelchair to go out in the community. Per the family member, Resident 1 prefers to sleep on the floor on a thin mat. Review of the Nurses' Notes dated 8/22/11 at 0600 hours, showed during rounds, Resident 1 was found on the floor, lying on her right side, next to the trash can; saw some drops of blood on the floor. Resident 1 was transferred to an emergency room for further evaluation. Review of the care plan problem dated 8/10/11, to address the risk for falls showed a revision dated 8/22/11, to provide a low bed and bilateral floor mats. Review of a "Short Term Care Plan" dated 8/22/11, to address the actual fall with injury: laceration on the back of the head, showed the goal, "will have no further fall or injuries for 72 hours." The approaches included: keep the resident's call light within reach and answer promptly, assess the resident for the need for safety devices, encourage the resident to call for assistance if needed, low bed, floor mats next to the bed, visual checks, move to a room closer to the nurses' station. b. On 8/25/11 at 0800 hours, during a follow up observation, Resident 1 was lying in bed with a family member at her bedside. Resident 1 was observed to have multiples abrasions with oozing bloody drainage above her left forehead, her eye and cheek bone, left cheek ecchymosis, left eye edema and left periorbital hematoma (a black eye). On 8/25/11 at 0805 hours, an interview was conducted with Resident 1's family member. He stated he was very upset because Resident 1 never fell while at home; now she had another fall. He stated on 8/24/11, during lunch time, Resident 1 had fallen out of her wheelchair in the Rehab gym. Review of the nurses' notes dated 8/24/11 at 1200 hours, showed, informed by PT, Resident 1 leaned forward from her wheelchair while in Rehab gym and fell to the floor. Resident 1 sustained an abrasion to above the left eye with left eye edema, abrasion to the left cheek bone area, left cheek ecchymosis, left neck ecchymosis, New physician's orders [REDACTED]. On 8/25/11 at 0830 hours, an interview was conducted with the Rehab Manager. She stated Resident 1 fell to the floor out of her wheelchair. The Rehab Manager stated no resident should be left unattended in the gym; there should always be a second person to assist the residents. When asked who was in the gym at the time of the resident's fall, the Rehab Manager stated only one staff member. PT 1, the second staff member, stepped out of the gym to make some photocopies. On 8/25/11 at 0835 hours, an interview was conducted with PT 1. PT 1 stated Resident 1 had finished her exercises and was waiting to be taken back to her room in her wheelchair. PT 1 stated she walked away, turned her back to the resident to pick up a wheelchair footrest, when Resident 1 fell face forward out of the wheelchair. PT 1 stated Resident 1 hit her face on the floor, and started crying in pain. PT 1 stated Resident 1 was sitting in a reclining wheelchair due to poor trunk control, but the back of the wheelchair was not set at the lowest angle. PT 1 stated Resident 1 fell due to her poor sitting balance. Review of the care plan showed a revision dated 8/24/11, to address status [REDACTED]. q - hour x (times) 7." The revision did not include fall precautions related to being kept in a safe position while in a wheelchair. The plan of care failed to show specifics regarding Resident 1's safety while in a wheelchair to prevent another fall from the wheelchair. 2. During tour rounds on 8/22/11 at 1340 hours, accompanied by the DSD, an unsecured television was observed on top of a wood stand adjacent to Resident B's bed, approximately six feet off the floor. The DSD stated Resident B is not interviewable and was admitted to the facility with [DIAGNOSES REDACTED]. The DSD stated the television should have been secured.

Based on observation, interview and clinical record review, the facility failed to ensure a assistive device to prevent falls was in place for one of 15 sampled residents (Resident 23). Resident 23 fell on [DATE], and sustained a skin tear on the right arm. Findings: Clinical record review was initiated for Resident 23 on 10/10/11. The MDS dated [DATE], showed the resident has impaired cognition. The Fall Evaluation dated 9/28/11, showed the resident has a high potential for falls. The care plan problem to address risk for falls dated 9/30/11, showed interventions to put the right side of the bed against the wall with mats on the floor and apply a seatbelt in the wheelchair. Resident 23 was observed in the activity room on 10/10/11 at 1420 hours, in a wheelchair with a seatbelt. A Nurse's Note dated 10/6/11 at 0830 hours, showed the resident was found on the floor. The Event Investigation Final Summary Report dated 10/6/11 at 0830 hours, showed the resident fell in front of the nurses' station. It showed the resident was placed in the wrong wheelchair that did not have a seatbelt. An interview was conducted with RN 2 on 10/11/11 at 1115 hours. She was asked about the fall incident of Resident 23. She stated she did not witness the fall, but the charge nurse reported the fall incident to her. She stated, according to the report, the resident was on a wheelchair without a seatbelt, stood up and lost her balance.

Based on observation, interview, clinical record and facility policy review, the facility failed to accurately and consistently assess skin integrity, identify and address risk factors for developing pressure ulcers, implement preventive interventions and provide appropriate interventions, care and treatment to an existing pressure ulcer to minimize infections and to promote healing to four of 23 sampled residents. (Residents 4, 14, 23 and 15). Resident 4 was not accurately assessed for impaired skin integrity, was not provided with the necessary interventions to prevent pressure ulcers and developed a Stage IV pressure ulcer (full thickness tissue loss, muscle/bone visible). An infection developed in the pressure ulcer. Resident 14 had multiple pressure ulcers but was not provided with necessary interventions to promote healing of multiple pressure ulcers. Resident 23 was identified at risk for skin breakdown. Resident 23 was not consistently assessed for skin integrity, did not receive the necessary interventions to prevent pressure ulcers and developed multiple Stage II pressure ulcers (partial thickness skin loss or blister). Resident 15 was identified at risk for pressure ulcer development. Three pressure ulcers developed and some of the interventions to promote healing and to prevent further pressure ulcer development were observed not consistently implemented. Findings: Review of the facility's policy regarding Skin Integrity Guidelines dated February, 2000, and most recently revised in April, 2005, showed Pressure Ulcer Prevention Precautions included to reposition every two hours or per individualized schedule, and elevate the heels off of the bed surface. Regarding Current Treatment, facility policy included pressure ulcer precautions are included to assist in providing a consistent interdisciplinary approach to treatment. 1. During tour rounds on 7/12/10 at 0800 hours, Resident 4 was observed in bed, positioned on her back with her heels resting on the mattress. RN 1 stated Resident 4 is on an air loss mattress with bolsters on both sides of the bed. An interview was conducted with Resident 4 on 7/12/10 at 1100 hours. She was observed positioned on her back with her heels resting on the mattress. She stated she was not cleaned and she felt she urinated in her incontinence brief. LVN 5 was asked who was the CNA assigned to Resident 4. She stated CNA 4 was assigned to Resident 4, but CNA 4 was on her lunch break. At 1155 hours, CNA 4 came. CNA 4 was asked when was the last time she changed Resident 4's incontinence brief. She replied, at 0800 hours. When asked if she was planning to change Resident 4's incontinence brief, she replied, yes. CNA 4 went in Resident 4's room. The smell of urine filled the room. CNA 4 removed Resident 4's incontinence brief, which was fully soaked with urine. Incontinence brief marks were observed on Resident 4's legs and there was a transparent dressing on Resident 4's right buttock. CNA 4 got a new incontinence brief and put it on Resident 4 without providing any perineal care. Clinical record review for Resident 4 was initiated on 7/12/10. Resident 4 was originally admitted to the facility on [DATE]. The MDS dated [DATE], showed Resident 4 required extensive assistance for turning/repositioning in bed with the assistance of two persons. Resident 4 has a Stage IV pressure ulcer to the right buttock. A physician's orders [REDACTED]. The MDS dated [DATE] showed Resident 4 was readmitted to the facility on [DATE]. There was no documented evidence of a skin assessment when Resident 4 was readmitted to the facility on [DATE]. There was no treatment ordered by the physician to address any skin integrity problems. There was no care plan problem developed to address impaired skin integrity upon readmission. The Nutrition Evaluation dated 4/29/10, did not show any documentation of impaired skin integrity on the right buttock. According to the National Pressure Ulcer Advisory Panel (NPUAP), initial and weekly assessment is recommended to provide an opportunity for the health care professional to detect early complications and the need for changes in the treatment plan. An interview was conducted with LVN 5 on 7/13/10 at 0910 hours. She was asked if they conduct an assessment upon readmission. She replied, yes. She was asked if she can find the readmission assessment of Resident 4 on 4/29/10. She checked the chart and was unable to find any readmission assessment, only a nurse's notes that Resident 4 was readmitted . She stated the treatment nurse completes the skin assessment upon readmission. She checked the treatment book but was unable to find a skin assessment for Resident 4 on 4/29/10. Closed clinical record review for Resident 4 from the previous admission was initiated on 7/13/10. A nurse's note dated 4/17/10 at 1245 hours, showed documentation the treatment nurse noted a discoloration on the right upper buttock. There was no documented evidence of a thorough assessment of the discolored skin and surrounding tissues for firmness or bogginess, warmth or coolness, pain, etc. According to NPUAP, suspected deep tissue injury is a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. A short term care plan problem to address skin discoloration on the right buttock dated 4/17/10, showed actions to continue monitoring, handle with care and protect from further injury. The care plan problem to address skin integrity impairment dated 12/3/09, showed the following actions: turn every two to three hours, float the heels, instruct the resident on turning and position changes, use of bolster mattress and protein supplement as appropriate. The care plan problem did not identify if Resident 4 was low, moderate or high risk for impaired skin integrity, did not take into consideration that Resident 4 required extensive assistance with bed mobility, did not include any action to address pressure reduction or redistribution while in the wheelchair and measures to prevent/reduce shearing or friction during transfer and repositioning. A nurse's note dated 4/22/10 at 1500 hours, showed documentation of a new treatment order to spray [MEDICATION NAME], a mild debridement agent to the blood blister on the right buttock. A skin assessment dated [DATE], showed documentation of a blister on the right upper buttock. It was described as a Stage II measuring 1.4 cm by 1.2 cm with pink/beefy red and 80% black/brown eschar (slough, or dried dead tissue). It had a minimal serous drainage (serum fluid from body tissue). The acute care hospital's transfer summary notes dated 4/28/10 at 0755 hours, showed documentation by an RN that Resident 4 has a pressure sore on her right buttock upon admission to the acute care hospital. The pressure sore was described as unstageable and black with minimal purulent drainage (with pus). A skin assessment dated [DATE] showed an unstageable pressure ulcer measuring 3 cm by 2.9 cm on the right buttock with 75% black/brown eschar and 25% slough. It had serosanguineous (containing serum and blood), purulent, heavy drainage with a foul odor. A nurse's note dated 5/4/10 at 1500 hours, showed a call was placed to the physician and awaiting for the physician to call back. There was no documented evidence the physician was made aware of the current condition of the pressure ulcer. A nurse's note dated 5/6/10 at 1445 hours, showed a new treatment order was received from the physician. A nurse's note dated 5/9/10 at 1630 hours, showed documentation the pressure ulcer is a Stage III (full thickness skin loss, fat visible) measuring 3 cm x 3 cm x 3.5 cm with tunneling (a narrow channel or passageway) at 12 o'clock measuring 7 cm and undermining from 2 to 11 o'clock measuring 3 cm. The skin assessment dated [DATE], showed documentation the pressure ulcer is a Stage IV measuring 2.9 cm x 1.5 cm x 2.6 cm with 25% black/brown eschar and 75% slough, but the RD notes dated 5/10/10, showed development of a Stage III from the blister. There was no care plan problem developed to address the Stage IV pressure ulcer on the right buttock. There was no documented evidence that a wound consult was obtained and a referral to Nutrition/Hydration/Skin committee was made. Review of the facility's P&P entitled Guidelines for Stage IV Pressure Ulcer dated April, 2005, showed documentation the care plan is to be updated to reflect new problem and interventions, consult with ET ([MEDICATION NAME][MEDICATION NAME] treatment) nurse consultant or surgeon and refer to Nutrition/Hydration/Skin committee. A nurse's note dated 5/13/10 at 1315 hours, showed a wound consult and air loss mattress were ordered by the physician and at 1330 hours, a wound culture was done. Result of the would culture showed growth of proteus mirabilis, a bacteria. A nurse's note dated 5/17/10, showed the physician ordered antibiotics to be given for seven days for wound infection. The care plan problem to address skin integrity impairment dated 5/21/10, showed Resident 4 was identified to have moderate risk for skin integrity impairment. The care plan problem showed interventions to turn every two to three hours, float heels off the mattress and incontinence care with each brief change. The Nutrition/Hydration/Skin Committee Review dated 6/16/10, showed documentation the blister on Resident 4's right buttock developed to a cyst with infection, causing tissue damage. There was no documented evidence interventions were developed to address it. On 7/13/10 at 0820 hours, 0930 hours and 1200 hours, Resident 4 was observed in bed, positioned on her back with both heels resting on the mattress. An interview was conducted with CNA 5 on 7/14/10 at 0740 hours. CNA 5 stated prior to Resident 4's transfer to the acute care hospital, Resident 4 was up in a wheelchair and attends activities. When asked how long Resident 4 stays in her wheelchair, she stated Resident 4 stays in her wheelchair from the time Resident 4 gets up in the morning until around 1400 hours. An interview was conducted with LVN 6 on 7/14/10 at 0755 hours. LVN 6 was asked if Resident 4 had the pressure ulcer prior to being transferred to the acute care hospital. She stated she will check the chart and treatment book. She stated she did not find any skin assessment on readmission. An interview was conducted with the RD on 7/14/10 at 0945 hours. She was asked where she gets her information if a resident has a pressure ulcer. She stated she checks on the skin assessments and treatment orders. When asked when she was aware Resident 4 has a pressure ulcer on her right buttocks, she stated it was the date of her assessment, which was dated 5/10/10. An interview was conducted with Resident 4 on 7/14/10 at 1300 hours. She was asked if she is aware she has a pressure ulcer. She replied, yes. She was asked if she had the pressure ulcer prior to going to the acute care hospital. She stated she had the pressure ulcer and it was really painful. On 7/14/10 at 1345 hours, 1530 hours and 1615 hours, Resident 4 was observed in bed, positioned on her back with both heels resting on the mattress. An interview was conducted with CNA 6 on 7/15/10 at 0745 hours. She was asked how they prevent pressure ulcers. She replied they turn the residents every two hours and float their heels. An interview was conducted with LVN 6 on 7/15/10 at 0750 hours. She was asked how they prevent pressure ulcers. She stated they provide an Alternating Pressure Pad (APP) mattress. When asked if a resident is on an APP mattress, do they need to be turned, she replied, yes. She was asked if Resident 4 can turn from side to side. She stated Resident 4 can not turn and the staff members need to turn her. An interview was conducted with the MDS Coordinator on 7/15/10 at 0820 hours. She was asked, if they continue to use the same chart upon readmission of a resident, do they develop a new care plan. She stated they use the same care plan upon readmission unless the resident has a new diagnosis, new medication or any changes. 2. During initial tour round observations with LVN 7 on 7/12/10 at 0820 hours, LVN 7 stated Resident 14 is bedfast, has pressure ulcers, nutrition problems and is very thin. Resident 14 was observed sleeping, facing towards the right side. On 7/12/10 at 1035, 1220, 1255, 1315, 1550, and 1700 hours, Resident 14 was observed sleeping in bed, facing towards the right side. Review of the clinical record was initiated for Resident 14 on 7/12/10. Resident 14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Weight Record showed Resident 14 is 62 inches tall and 60 pounds on admission. On 7/4/10, Resident 14's weight was 64 pounds. Further review of the clinical record showed a form titled, Wound Evaluation and Documentation. No date was shown on the form. The top of the form showed, "Assessment Admission" handwritten. The form showed a Stage I (nonblanchable redness of intact skin) pressure ulcer on the right iliac crest (the pelvis bone) measuring 1 cm x 1 cm, a Stage I on the left iliac crest measuring 1 cm x 3 cm, a Stage I on the left greater trochanter (the lateral portion of the hip at the top of the leg) measuring 4 cm x 4 cm, and a Stage I on the left lateral knee measuring 1 cm x 1 cm; a Stage II pressure ulcer on the coccyx (the tailbone) measuring 1 cm x 1.5 cm, a Stage II on the sacral (just above the coccyx) area (shown labeled as site 1) measuring 2 cm x 1 cm, a Stage II on the sacral area (shown labeled as site 2) measuring 4 cm x 2 cm, a Stage II on the sacral area (shown labeled as site 3) measuring 2 cm x 1 cm x 0.5 cm; and one Stage III pressure ulcer on the left buttock measuring 1 cm x 0.6 cm x 0.5 cm. Review of Resident 14's care plan problem dated 6/11/10, to address potential for skin integrity impairment showed actions to turn approximately every two to three hours. On 7/13/10 at 0640, 0755, and 0820 hours, Resident 14 was observed still sleeping in bed laying facing the right side. On 7/13/10 at 0828 hours, a CNA was observed repositioning Resident 14 after receiving the breakfast tray, facing towards the left side with the head of the bed slightly raised. On 7/13/10 at 0840 and 0935 hours, Resident 14 was observed sleeping in bed, laying towards the left side. On 7/13/10 at 1110, 1220, 1310, 1535, and 1630 hours, Resident 14 was observed sleeping in bed laying towards the right side. 3. Review of Resident 23's closed clinical record was initiated on 7/14/10. Resident 23 was admitted to the facility on [DATE]. A Wound/Skin Evaluation and Documentation form dated 3/27/10, showed Resident 23 had a Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister) measuring 9 cm by 5 cm to the left upper buttock and a Stage II pressure ulcer measuring 2 cm by 2 cm to the right upper buttock. The form also identified skin integrity problems to the left gluteal fold (the crease where the buttock and leg meet) measuring 0.5 cm by 0.5 cm, to the right gluteal fold measuring 0.5 cm by 0.5 cm, with no Stages identified, and back excoriation measuring 4 cm by 1 cm. There was no further assessment of these skin integrity problems or pressure ulcers to identify the wound beds, undermining/tunneling, drainage, odor, the surrounding tissue, pain, etc. Review of the care plan showed no care plan problem had been developed on admission to address these identified skin integrity concerns with actions to implement to prevent further skin breakdown or to promote healing of the pressure ulcers. Review of the "Initial" (sic) Care Plan Conference Summary dated 3/31/10, showed documentation Resident 23 was at increased risk for skin breakdown. The hospice "notes coccyx redness." A physician's telephone order was obtained dated 3/31/10 at 1530 hours, to clean the redness on the coccyx/buttocks with soap and water, pat dry and apply Inzo cream or Soothe Cool with A&D ointment every shift and PRN diaper changes. There was no updated assessment of these skin integrity problems following this care plan conference. Review of the care plan showed no revision was made to the care plan following this care plan conference to address this identified problem of skin integrity, with the treatment orders to treat the wounds. A Wound/Skin Evaluation and Documentation form dated 4/6/10, showed the left lower gluteal fold had a Stage II pressure ulcer measuring 0.5 cm by 0.5 cm with superficial depth, had a pink/beefy red wound bed. There was a minimal amount of serous (a clear liquid excreted from serous membranes) drainage and PRN pain medication required. Another Wound/Skin Evaluation and Documentation form dated 4/6/10, showed the left buttock had a Stage II pressure ulcer measuring 9 cm by 5 cm with superficial depth. The wound bed was described as pink/beefy red with a moderate amount of serous drainage. A Wound/Skin Evaluation and Documentation form dated 4/6/10, showed a Stage II pressure ulcer to the right buttock measuring 2 cm by 2 cm. The wound bed was described as pink/beefy red with a moderate amount of serous drainage. Another Wound/Skin Evaluation and Documentation form dated 4/6/10, showed a Stage II pressure ulcer to the right gluteal fold measuring 0.5 cm by 0.5 cm. The wound bed was described as pink/beefy red with minimal serous drainage. Further review of the physician's orders [REDACTED]. Further review of the care plan showed four short term care plan problems dated 4/6/10, were developed to address the four Stage II pressure ulcers. The approach/plan for each of the problems showed to treat as ordered, monitor for effectiveness, keep clean and dry and notify the physician of complications. There were no other approaches included in the plan to address healing or prevention of new pressure ulcers from developing. A physician's orders [REDACTED]. There was no revision to the care plan to address this newest intervention. Further review of the Wound/Skin Evaluation and Documentation forms showed entries dated 4/12/10. The left lower gluteal fold Stage II pressure ulcer had increased to 1 cm by 1 cm with minimal serous drainage. The Stage II pressure ulcer to the left buttock measured 9 cm by 6 cm with moderate serous drainage. The Stage II pressure ulcer to the right buttock measured 3 cm by 3 cm with minimal serous drainage and the right lower gluteal fold pressure ulcer had increased to a Stage II measuring 0.6 cm by 0.6 cm with 0.2 cm depth, 80% slough and minimal serous drainage. During an interview with the DON on 7/14/10 at 0920 hours, the concern regarding Resident 23's skin integrity problems having been identified on admission without a thorough assessment, care planning and obtaining a physician's orders [REDACTED]. integrity. 4. On 7/12/10 at 0841 hours, observation of Resident 15 found her in bed, lying flat with both of her bare heels resting on the mattress, not elevated. A sign on the wall was observed above her bedside drawers, which said, "please remember to put on her boots when in bed." On 7/13/10 at 0735 hours, Resident 15 was observed in bed. The boots were not on. On 7/14/10 at 0750 hours, Resident 15 was observed in bed on her back with her eyes closed. Elastic stockings (to prevent swelling and promote venous blood return) were noted on both feet; however, both heels were resting on the mattress and were not elevated. A dressing was noted to the resident's left heel under the elastic stocking. On 7/14/10 at 1025 hours, Resident 15 was observed in the same position (lying flat with heels resting on the mattress); however, the boots were at the foot of her bed, but not on her feet. On 7/14/10 at 1028 hours, both boots were observed on the resident's feet. LVN 8 was present and preparing to provide treatment to the resident's left heel pressure ulcer. When asked if the resident's pressure ulcer was developed in the facility, the LVN responded, "got it here." At 1042 hours, the LVN proceeded to remove the left boot and the elastic stocking was noted with wrinkles and not applied correctly, which left indentations on the resident's leg when removed. The right leg stocking was observed more closely and noted applied incorrectly, as it was folded down to the knee and made indentations in the resident's skin. The LVN was asked if the elastic stockings were applied correctly and she replied, "No, they are not." Both of the resident's feet and legs were noted with [MEDICAL CONDITION]. When asked, the LVN stated it was her responsibility as the treatment nurse to educate the CNAs on correct application of the elastic stockings. Upon observation, the left heel pressure ulcer was dark in color and the size of the top of a pencil eraser. On 7/14/10, clinical record review for Resident 15 was initiated. Resident 15 was admitted to the facility on 2/22/10. The MDS dated [DATE], showed the resident was assessed with [REDACTED]. The resident's weight was 100 pounds and height 62 inches. Resident 15 did not have pressure ulcers identified upon admission to the facility. Review of the comprehensive plan of care showed a care plan problem dated 2/23/10, to address the potential for skin integrity impairment related to multiple issues including dementia and impaired functional mobility. The actions included to turn every two to three hours, shift position approximately every one to two hours when sitting in a chair, protect the heels (float off the mattress) and encourage to consume greater than or equal to 75% of meals. The Initial RAP Summary dated 3/2/10, identified Resident 15 with problems concerning ADLs/Urinary Incontinence/Pressure Ulcer. The document identified the resident's need for extensive assistance with bed mobility, transfers and eating. The resident was identified as incontinent of B&B. Resident 15 was at risk for pressure ulcer development due to bowel incontinency and decreased bed mobility. The IDT would proceed to care plan and focus on keeping the resident free of skin breakdown. The resident was identified as at risk for weight loss due to multiple contributing factors including dementia. A care plan problem dated 3/2/10, addressed the risk for further skin breakdown related to multiple issues including cognitive impairment. On 4/29/10 and 5/19/10, the care plan problem was updated with both lower extremity 2+ [MEDICAL CONDITION] as an additional problem. The actions included to turn and reposition every (time not identified) hours and as needed and elevate both legs with pillows. A revision dated 6/18/10, showed an update to apply bilateral Prevalon boots for skin management. A physician's orders [REDACTED]. The RNA feeding program for lunch and dinner was reordered on [DATE]. The Weight Record form showed Resident 15 weighed 92 pounds on 5/19/10. A Wound/Skin Evaluation and Documentation form dated 5/21/10, a Stage I pressure ulcer was identified at Resident 15's coccyx area. It measured 1 cm by 1 cm and had a pink/beefy red wound bed. An entry 6/10/10, showed it was identified as a Stage II pressure ulcer, measuring 0.5 cm by 0.5 cm, with 100% slough in the wound bed. There was no further weekly evaluations documented. Per a short term care plan problem dated 5/21/10, the sacral pressure ulcer had resolved on 7/5/10. b. A Wound/Skin Evaluation and Documentation form dated 6/10/10, showed a left heel UTD (unable to determine) pressure ulcer was identified measuring 0.5 cm X 0.5 cm with a black/brown (eschar) wound bed. There was no further evaluations documented. No plan of care for the left heel pressure ulcer dated 6/10/10 was found. c. A Wound/Skin Evaluation and Documentation form dated 6/13/10, showed a left heel Stage 1 pressure ulcer measuring 4 cm by 3.5 cm with superficial depth and a normal color wound bed was identified. Weekly evaluations were documented. An entry dated 7/12/10, showed the left heel pressure ulcer was documented to be UTD, measuring 1 cm by 0.4 cm with a 100% black/brown (eschar) wound bed. A short term care plan problem for the left heel pressure ulcer dated 6/13/10, included an intervention to relieve pressure. d. A Wound/Skin Evaluation and Documentation form dated 6/22/10, showed a right heel Stage I pressure ulcer measuring 1 cm by 1 cm with a pink/beefy red wound bed. Weekly evaluations were documented and documentation showed it had resolved on the 7/5/10 weekly evaluation. Per a short term care plan problem for the right heel pressure ulcer dated 6/28/10, interventions included heel protectors at all times when in bed. Documentation showed it was resolved 7/5/10. A physician's orders [REDACTED]. An order dated 6/25/10, showed elastic stockings were to be placed on both of the resident's legs in the morning and taken off at night. On 7/14/10 at 1410 hours, an interview with CNA 18 was conducted. The resident was up in a wheelchair in her room. The resident had the elastic stockings on with cotton socks over them and the Prevalon boots were on over the socks. When asked what care instructions she had been given for Resident 15, the CNA stated she was never to take off the boots and the night shift was to remove the elastic stockings. On 7/14/10, clinical record review with RN 1 was conducted. The RN was informed of the observations and interviews and was not aware care plan interventions to prevent pressure ulcer development and promote pressure ulcer healing were not being implemented.

Based on observation, interview and clinical record review, the facility failed to ensure bladder care and services were provided for three of 11 sampled residents (Residents 1, 25 and 27). The facility failed to assess Resident 1 for his clinical needs to continue the use of an indwelling urinary catheter. The facility failed to ensure the staff were aware of the procedures in providing care to Resident 25, and services for the use of a condom catheter (male urinary incontinence device consisting of a flexible sheath that fits over the penis just like a condom, attached to a drainage bag). The facility failed to provide necessary care and service for Resident 27's urinary drainage catheter per the physician's orders [REDACTED]. Findings: Review of the facility's CMS-2567 form containing the written plan of correction dated 8/19/10, showed Resident 1 had been re-evaluated to determine if the resident's clinical condition still warrants an indwelling urinary catheter. The nursing staff will review with the physician and obtain orders as appropriate and his care plan will be revised to reflect measurable goals and appropriate interventions. According to the National Institute of Health, Catheter-Associated UTI dated 5/22/08, the presence of an indwelling urinary catheter increases the chance of developing a UTI. 1. During initial tour rounds on 9/13/10 at 0820 hours, accompanied by LVN 6, Resident 1 was lying in his bed with an indwelling urinary catheter in place. LVN 6 stated the reason Resident 1 needed the urinary catheter was for [MEDICAL CONDITION] (inability to empty the bladder completely). Clinical record review for Resident 1 was initiated on 9/13/10. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Facsimile (FAX) Transmission sheet dated 8/25/10, addressed to Resident 1's physician showed a message the resident "did not have an indwelling catheter prior to his admission to the hospital and no evidence in his clinical record to show he had any issues of retaining urine. We would like to do a trial on him to see if he can urinate without it (indwelling catheter)." On the bottom right corner of the FAX showed the sheet was refaxed to the physician on 9/1/10. No documentation was available to show the physician received or acknowledged the recommendation to discontinue Resident 1's urinary catheter. Review of Resident 1's Bowel and Bladder Assessment Record showed the last assessment date was 7/6/10, with a score of nine (a score of eight indicates the resident is a likely candidate for bladder retraining, a score of 12 indicates the resident is a possible candidate for bladder retraining). No documentation was available to show Resident 1 was reassessed after 7/6/10. Review of Resident 1's care plan problem dated 11/25/09, to address the risk for a UTI due to an indwelling catheter and to address his occasional bowel/bladder incontinence and indwelling catheter showed the last review date was completed on 7/20/10. No additions or deletions to the goals or approach plans were changed. During an interview on 9/13/10 at 1235 hours, when LVN 6 was asked if Resident 1's physician was contacted regarding the use of the indwelling catheter. She stated Resident 1's physician comes once a month and did not know if the physician had responded to the FAXs sent on 8/25/10 or 9/1/10. During an interview on 9/13/10 at 1625 hours, the DSD was unaware if Resident 1's physician had been notified of the recommendation to attempt to discontinue his urinary catheter. Continued review of Resident 1's clinical record on 9/14/10 at 0900 hours, showed a physician's orders [REDACTED]. In addition, Resident 1's Nursing Notes showed an entry dated 9/14/10 at 0100 hours, Resident 1 was started on bladder retraining. During a telephone interview on 9/14/10 at 1343 hours, Resident 1's physician stated the first time the facility had contacted him regarding the attempt to discontinue his urinary catheter was on 9/13/10. 2. www.the-hospitalist.org (Web based Internet site) showed complications from condom catheters include phimosis (foreskin cannot be retracted) and local skin maceration (softening of the skin from constant warmth and moisture), necessitating meticulous care with the use of these devices. www.spinalcord.uab.edu (Web based Internet site) showed it is recommended that condom catheters be changed every other day. Guidelines include the proper selection and fit of the condom catheter, daily penile skin inspection and daily hygiene. During initial tour rounds on 9/13/10 at 0820 hours, LVN 6 stated Resident 25 uses a condom catheter for urinary incontinence. Review of Resident 25's physician's orders [REDACTED]. Review of Resident 25's care plan problem dated 6/29/10, to address his self-care deficit with total assistance from the staff with his toileting needs, showed an approach plan for condom catheter as ordered. A care plan problem dated 1/11/10, to address his bowel/bladder incontinence showed an approach plan to use a condom catheter. No documentation was available to show the condom catheter size, and/or the skin maintenance for the use of a condom catheter. Review of Resident 25's Nursing Notes showed an entry dated 9/10/10, a condom catheter was applied every day during the day time. During an interview on 9/13/10 at 1507 hours, LVN 6 stated Resident 25 wears a condom catheter 24 hours a day. She stated the CNAs change the catheter every day and as needed. When LVN 6 was asked how often condom catheter care is performed, she stated every shift. When LVN 6 was asked if the CNAs remove the condom catheter every shift and put it back on or replaced it every shift, she stated she did not know. During an interview on 9/13/10 at 1550 hours, CNA 21 stated Resident 25 has a condom catheter on during the 7-3 shift, but it is taken off every night when he goes to bed. During an interview on 9/13/10 at 1625 hours, the DSD stated Resident 25 only wants the condom catheter on at night. During an interview on 9/14/10 at 0650 hours, CNA 20 stated Resident 25 does not wear a condom catheter at night. She stated the 7-3 shift licensed nurse puts it on him. She stated he wears a leg bag when he is in the wheelchair. During an interview on 9/14/10 at 0705 hours, LVN 12 stated Resident 25 wears a condom catheter all night. She stated the condom catheter is changed by the treatment nurse or the licensed nurse if it comes off. 3. On 9/13/10, Resident 27's clinical record review was initiated. Resident 27 has a history of UTI, urethritis (inflammation of the tube that drains urine from the bladder), and leakage of the suprapubic catheter (catheter is surgically inserted into the bladder though an incision above the pubic area). Review of the acute care hospital discharge instructions dated 8/16/10, showed the resident had "hematuria (abnormal presence of blood in the urine), likely [MEDICATION NAME] (inflammation of the urinary bladder and ureters-tubes connecting the kidneys to the bladder)." On 8/16/10, Resident 27 was transferred to an acute care hospital for hematuria and was instructed to follow up with a urologist (specialized physician in urinary tract). On 8/18/10, Resident 27 was seen by the urologist with the orders to have KUB (radiographic exam of the kidney, ureters and bladder) done to rule out a bladder stone. There was no documented evidence the staff carried out the KUB order or notified the physician when Resident 27 was identified to have hematuria since 8/20/10. The staff did not notify the physician for the change of the resident's condition regarding recurrent hematuria and pain noted on 8/21/10. The KUB to rule out a bladder stone was not carried out as the order. On 8/22/10, Resident 27 was transferred to the emergency department for hematuria and pain. Consequently, on 8/22/10, Resident 27 had an emergency surgery to evacuate blood clots and bladder stones. Additionally, there was no documented evidence to show staff carried out the order to do catheter care every shift per the physician's orders [REDACTED]. Review of the MDS dated [DATE], showed Resident 27 has memory problems and modified independence in cognitive skills for daily decision-making. Review of the physician's orders [REDACTED]. - Irrigate suprapubic catheter with 30 - 60 ml of normal saline as needed if plugged dated 7/31/08. - May straight cath as needed if the resident hasn't urinated dated 7/9/10. - Suprapubic catheter care three times per day dated 8/13/10. a. On 8/18/10, Resident 27 was seen by a urologist. The following orders were written: - Irrigate the suprapubic catheter with normal saline as needed if clots. - KUB to rule out bladder stones. Review of the physician's progress notes dated 8/18/10, showed the urologist documented "Hematuria clearing now." A care plan problem to address UTI due to indwelling catheter dated 4/29/10, showed the resident was identified with [MEDICAL CONDITION] bladder (the bladder muscle has lost its tone) with recurrent UTI/retention. The plan of care included to monitor the catheter, monitor urine for sediment, cloudiness, odor, blood, and amount, and report any of the above or fever to the physician. A revision dated 8/18/10, added the approach to irrigate the suprapubic catheter as ordered. On 8/20/10, the physician documented on the physician's progress note, suprapubic catheter site clean and follow up with any change. Review of clinical record showed on 8/22/10, Resident 27 was transferred to the emergency department and had surgery to evacuate blood clots and bladder stones. On 9/14/10 at 1030 hours, an interview was conducted with LVN 15 and the DSD. The staff was asked for documented evidence of on going care and service for Resident 27's urinary drainage catheter with history of infection, leakage, hematuria from 8/18/10 to 8/22/10, the date Resident 27 was transferred to the acute care hospital. On 9/14/10 at 1108 hours, the DSD showed the urologist's orders dated 8/18/10. The DSD was asked if the KUB was done, what was the result, and how staff provided care to Resident 27's urinary drainage catheter. The DSD showed the licensed nurses' notes. Review of the licensed nurses' notes showed no documented evidence staff notified the physician of Resident 27's hematuria, noted since 8/20/10 at 0800 hours. The nurses' notes showed Resident 27 was identified to have hematuria on 8/20/10 at 1800 hours and 2300 hours; on 8/21/10 from 0700 hours to 1500 hours, and on 8/22/10 at 0800 hours. On 8/21/10, on the morning shift, the resident was assessed to complain of pain to the back and pubic area in addition to hematuria. On 8/22/10 at 0800 hours, staff documented more blood noted on the resident's penis. On 8/22/10 at 1030 hours, when fresh blood was noted on the resident's penis and the urinary catheter, plus the resident's complaint of pain in the abdominal area, the staff called to notify the physician. On 8/22/10 at 1110 hours, an order to transfer the resident to an acute care hospital for evaluation was received. On 9/14/10 at 1458 hours, LVN 15 stated the KUB was not done as the urologist order on 8/18/10. Review of the emergency room report dated 8/22/10, showed Resident 27 was transported for evaluation of recurrent hematuria. The physician report showed there was bright red blood in the urinary drainage catheter bag. The resident was referred to the acute care hospital urologist. Review of the urologist's consultation report showed the reasons for admission included visible hematuria and urinary infection. Further review of the acute care hospital documentation showed the surgical procedure to evacuate clots and bladder stones and replacement of the suprapubic catheter took place on 8/22/10 from 1602 hours to 1647 hours. b. Review of the treatment record for the months of August and September, 2010, for the period of 9/1/10 to 9/13/10, showed there was no transcribed order to irrigate the catheter and no documented evidence the catheter care was done every shift per the physician's orders [REDACTED]. On 9/14/10 at 0945 hours, an interview was conducted with LVN 8. When asked where they document the catheter care, the LVN stated in the treatment record. Review of the treatment record for September, 2010, showed no documented evidence of catheter care 10 of 13 times in the 3 pm to 11 pm shift and three of 12 times on the 11 pm to 7 am shift. When asked if the resident still needs to have the catheter irrigated, the LVN stated, no, the physician stated no more irrigating the catheter. When asked for the physician's orders [REDACTED].

Based on observation, interview and clinical record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible for three sampled residents (Residents 15, 12, and 5) and one nonsampled resident (Resident H). Resident 12 had a fall which resulted in a fracture that required surgical intervention. Resident 15 had two documented falls, the second of which she was left alone by staff when supervision was required. Resident 5 was not provided functioning assistive devices and superversion. The resident had an incident resulting in a fractured finger and another incident resulting in a fractured hip. Resident H used an electric wheelchair with her left hand. The other hand was paralyzed. A housekeeper was observed handing a reheated steaming cup of coffee to the resident for her to drink. The resident then drove away in the wheelchair balancing the coffee and operating the wheelchair using the same hand. This poses the risk of the coffee spilling, causing burns to the resident. Findings: 1. On 7/12/10 at 1545 hours, Resident 12 was observed sitting in a wheelchair in his room. A seat belt was noted around the resident's waist and attached to the wheelchair was an alarm. Both of the resident's feet were on the foot rests of the wheelchair. Per CNA 19, Resident 12 is nonverbal and his primary language is not English. On 7/12/10, clinical record review for Resident 12 was initiated. Resident 12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDSs showed an annual MDS dated [DATE], and an admission MDS dated [DATE]. Both showed the resident has short and long term memory problems, communication problems and requires extensive assistance with bed mobility. The admission MDS dated [DATE], shows the resident has a decline in transfers, bowel and bladder continence and limitation of ROM of one leg and partial voluntary loss of movement of one leg. On 7/13/10, request of the resident's previous clinical record was requested. It showed Resident 12 was admitted to the facility on [DATE]. A care plan problem dated 11/30/09, showed Resident 12 was identified to be at risk for fall and injuries related to problems including attempting to get up without assistance secondary to dementia with psychotic features. The interventions included RNA ambulation and ROM as indicated, seat belt in wheelchair with an alarm and a bolster mattress. Another care plan problem dated 3/31/09, and updated on 4/22/09, for the risk for injurious falls secondary to poor safety awareness and wandering behavior. The interventions included monitor precipitating events that may lead to fall, for example, toileting needs, wanting to get out of bed or search for food. Review of the Nursing Notes dated 1/21/10 at 1635 hours, showed a family member left the resident in his room, in the wheelchair with the self-releasing seat belt and the alarm and informed the assigned CNA. At 1640 hours, the dinner trays arrived. The CNA was on his way to the resident's room to take the resident to the dining room, heard a sound that somebody fell down with loud screaming by the resident. Two CNAs ran to check all the rooms and found Resident 12 on the floor lying on his right side. The charge nurse was alerted. The resident was able to release the seat belt. The alarm was not heard and was found "off." The resident was able to perform ROM to all extremities and was able to ambulate and was put back in the wheelchair with the self-release belt with the alarm "on." At 1810 hours, using the communication board, the resident complained of pain, with a sad facial expression. Two CNAs were called to assist the resident back to bed. The resident resisted the standing position and was unable to move his right leg, and when his right leg was touched, the resident began screaming. Upon visual observation, Resident 12's right leg had slight swelling on the upper thigh and lower leg. At 1820 hours, the physician was made aware and a stat (immediately) x-ray was ordered. At 2355 hours, the x-ray results showed an acute fracture to the right femoral neck (the part of the long leg bone at the right hip). At 2400 hours, the physician was made aware of the x-ray results and ordered the resident be transferred to an acute hospital emergency room for evaluation. At 1330 hours, the resident was transported via ambulance to an acute hospital emergency room . On 1/22/10 at 0400 hours, the acute hospital emergency room was called in reference to Resident 12 and the facility was informed of the resident's admission to the acute hospital for surgical repair of the fractured femur. 2. Review of Resident 5's closed clinical record was initiated on 7/12/10. The resident was admitted to the facility on [DATE], and discharged to the acute hospital on [DATE], secondary to a fracture of the intertrochanteric right femur. On 8/9/09, the resident underwent [REDACTED]. Review of the fall risk assessments for Resident 5 dated 5/7/09, 6/15/09, and 8/3/09, showed scores of 14, 17, and 21 respectively. A score of 13 or greater indicated the resident is a high risk for falls. Review of the undated High Potential Fall Evaluation dated 5/8/09, showed interventions including provision of a bolster mattress, not to be left alone in the bathroom, therapy screen/restorative program, and alarm in the bed and the wheelchair. Review of the physician's orders [REDACTED]. The physician's orders [REDACTED]. Review of the Pre-restraint/Device Evaluation dated 5/7/09, showed a wheelchair and bed alarm to alert staff when the resident starts to get up. Review of the care plan problems to address risk for fall dated 5/8/09, 6/14/09, and 8/3/09, showed a goal to minimize falls and injuries for 90 days. The approaches include a bed and wheelchair alarm. On 6/16/09, the bed personal alarm was changed to a bed strip alarm. Review of the nurses' notes for Resident 5 showed a nurse's note dated 6/09/09 at 1530 hours, the resident was moved to room 209. During tour rounds on 7/12/10 at 0735 hours with RN 3, observations conducted on 7/12/10 at 1550 hours, on 7/13/10 at 0625, 0630, 0654, 0726, 0830, and 1235 hours, and on 7/14/10 at 0835, 0840 to 0850 hours, Resident 5 was observed in room 209. Room 209 was located second to the last room of the hallway, farthest from the nurses' station. Further review of the nurses' notes and x-ray reports showed on 6/13/09 at 1330 hours, the resident had complained of pain to the left hand. An x-ray was done showing a fracture of the fourth finger with minimal displacement and soft tissue swelling. The nurse's note dated 6/14/09 at 0300 hours, showed the resident was observed by the facility staff crawling under the table in her room. The note showed the bed and wheelchair alarm was in place, but the resident had taken them off. Review of the resident's nurses' notes, investigation report and post fall evaluation showed on 8/3/09 at 1510 hours, the resident was found sitting on the floor in the hallway outside her room. There was no documentation showing the sounding of the alarm during this time. The nurse's note dated 8/8/09 at 0230 hours, showed the resident was assisted to the bathroom; at 0330 hours, the resident complained of severe pain not relieved by medication; at 0520 hours, the resident was transferred to the acute hospital. Review of the acute hospital clinical record for Resident 5 showed the resident was in the emergency roiagnom on [DATE] at 0546 hours. The x-ray report showed the resident had an acute fracture of the right hip. The record showed on 8/9/09, the resident underwent [REDACTED]. Review of the current clinical record for Resident 5 showed on 8/13/09, the resident was readmitted to the facility. The Fall Assessment showed a score of 20, a high risk for falls. The physician's orders [REDACTED]. Review of Resident 5's care plan problem to address at risk for falls dated 8/13/09, 8/21/09, 11/10/09 and 11/18/09, showed a goal to minimize falls and injuries until the next review. The plan of care showed actions for a bed strip alarm while in bed and a personal wheelchair alarm while up in the wheelchair to alert staff when the resident gets up unassisted, frequent visual checks; encourage and assist to activities. Review of the investigation report dated 11/18/09, showed Resident 5 was calling for help on 11/18/09, and was found face down on the floor of her room. The report showed the resident's bed strip alarm was not working and was replaced. There was no documentation showing how the alarm was monitored to ensure proper functioning. In an interview with Resident 5 on 7/13/10 at 0630 hours, the resident was observed sitting in the wheelchair. The resident stated nobody talks to her and she is "very, very lonely". The resident stated the facility staff just stops by and leaves. When asked about the activities, the resident stated "there is nothing there for me." The resident stated she did not know anybody and was in a diaper and felt embarrassed about it. 3. On 7/12/10 at 0841 hours, observation of Resident 15 found her lying flat in bed. The bed was at the standard height, against the wall on the resident's right side and the full length side rail was elevated on the left side. The resident's eyes were closed. Clinical record review for Resident 15 was initiated on 7/14/10. Resident 15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Fall Evaluation form dated 2/23/10, showed the resident had a high potential for falls. Documentation showed interventions were not to leave the resident alone in the bathroom, physical and occupational therapy would perform a screening, and an alarm in bed and the wheelchair would be incorporated. The MDS dated [DATE], showed Resident 15 was assessed with [REDACTED]. The resident required extensive assistance for bed mobility and transfers. The Initial RAP Summary dated 3/2/10, showed documentation the resident fell at home, sustained a fracture of the left femur and had surgery to repair it. Documentation showed the resident was at risk for further falls due to decreased mobility, [DIAGNOSES REDACTED] (abnormal decrease in blood platelets), dementia and poor safety awareness. A personal alarm to the resident's bed and wheelchair was applied to alert the staff if the resident attempted to get up without assistance. The IDT would proceed to care plan to ensure resident safety, focusing on preventing falls, and to ensure the risk of falls was minimized while meeting the resident's ADL needs. A Post Fall Evaluation Version 2 form dated 4/2/10 at 2032 hours, showed Resident 15 had a fall. Description of the fall prior to the event showed the resident was placed behind the desk at the nurses' station, close the the sink for close supervision after attempting many times to get up unassisted from the wheelchair. The resident was stating she wanted to see her husband. Evaluation/action taken to manage falls showed the resident was very anxious and confused. The resident's husband had been admitted to the facility and was on the same floor and the resident was even more anxious when her husband was out of her sight. Resident 15 was kept at the nurses' station due to multiple observed attempts to get up. The resident managed to wheel herself inside the nurses' station while nursing staff attended to another resident and she was on the floor when staff heard the personal alarm sounding. IDT recommendations included a self-release seat belt and an alarm in the wheelchair to remind the resident not to get up, and to adjust psychotropic medications. The IDT team signed and dated the form 4/5/10. There was no documentation to show why the resident could not be with her husband to decrease her anxiety. There was no documentation to show why the nurse did not assign another staff to monitor the resident at the nurses' station. There was no documentation that activities, water or snacks were provided to the resident to keep her hands busy and mind occupied. There was no documentation the nurse called the RN supervisor for assistance with Resident 15. Documentation showed the nurse brought the resident to the nurse station for close monitoring as the resident was observed to have had attempted multiple times to get out of the wheelchair; however, the nurse left the resident unattended. Review of the Fall Evaluation form dated 2/23/10, showed an update dated 4/2/10, with interventions of environmental adaptations/nursing to monitor, move bed up against one wall and self-releasing seatbelt with alarm added. An update dated 4/12/10, showed interventions of wearing non-skid foot wear in bed, positioning pillows and a lap buddy. An Interdisciplinary Team Notes form dated 4/22/10, showed a lap buddy was implemented that the resident could remove on command. An Interdisciplinary Progress Notes form dated 6/15/10, showed a meeting was held to review the resident's fall on 6/4/10. Documentation showed the resident was noted to be on the floor with the wheelchair turned over to the left side and the lap buddy fell out of place. There was no apparent injury noted. Factors that can be considered are as follows: confusion related to the aging process, medical health conditions such as [DIAGNOSES REDACTED]. The plan of care initiated as follows: 1) continue to utilize the lap buddy when up in the wheelchair for safety and prevent from getting up unassisted, 2) personal alarm in bed/wheelchair to alert staff from resident getting up unassisted, 3) provide a safe environment free from any clutter, 4) continue to reorient the resident during episodes of confusion, 5) place the call light within easy reach. In addition, staff would continue to monitor and reassess the resident until the next review regarding plan of care. There was no documentation to show where the resident was when she was found on the floor or if she was alone, and if so, why she was not being monitored as planned. The documentation did not reflect an alarm in place and sounding when the resident was found. There were no new interventions put into place that had not been documented for the previous fall. The care plan problem dated 6/15/10 (rewritten and revised on 6/15/10), did not show an intervention to closely monitor the resident when anxious and attempting to get up out of the wheelchair. 4. On 7/12/10 at 0800 hours, during tour rounds, it was observed Housekeeper 1 handed a steaming cup of coffee to Resident H. Resident H was dressed in short pants. Resident H was operating an electric wheelchair using her left hand. Resident H's right hand had contracted fingers and appeared to be paralyzed. Resident H drove off in the wheelchair. Resident H was operating the wheelchair and holding onto the cup of steaming hot coffee at the same time, using her left hand. An interview was initiated with the DON on 7/13/10 at 1500 hours. The DON was asked if it is safe for Housekeeper 1 to have reheated the coffee and serve it to the resident. The DON stated the coffee should have been reheated and given to Resident H in a more safe manner by a CNA. On 7/14/10 at 0955 hours, during an interview with the RD, the RD stated the corporate policy is to have the coffee machine set to heat the coffee no hotter than 150 degrees F. If the residents want their coffee hotter when served to them, they prefer to have the nursing staff heat it in the microwave, not the housekeeping staff.

Based on observation, interview and clinical record review, the facility failed to provide an adequate nutritional intake to prevent significant weight loss for three of 23 sampled residents (Residents 3, 5, and 15). The facility failed to identify, assess and implement interventions timely to prevent additional weight loss for Resident 3 who required assistance from the staff for her nutritional needs. Resident 3 lost 9% of her weight in 30 days, 17% of her weight in 90 days and 18% of her weight in 180 days. Once the weight loss was identified, the RD failed to provide additional assessments and interventions, including Resident 3's refusal to eat her pureed diet. Resident 5 sustained a significant weight loss when the staff failed to provide appropriate assistance for meals and failed to offer food substitutes for rejected food items. Resident 15 had a severe weight loss due to a decline in intake however, the facility failed to consistently evaluate the implementations of the interventions developed to assist the resident in improving her oral intake of food to prevent weight loss. Findings: Review of the facility's P&P titled "Weights" dated 7/08, showed the facility will utilize weights as one significant component of data collection needed to evaluate the resident's nutritional status. The Nutrition/Hydration/Skin Committee reviews the resident's status and makes recommendations. Significant weight changes are 5% or more in 30 days, 7.5% in 90 days or 10% in 180 days. 1. During initial tour rounds on 7/12/10 at 0750 hours, accompanied by LVN 1, Resident 3 was observed lying in the bed. LVN 1 stated Resident 3 had a weight loss and was receiving hospice services. Clinical record review for Resident 3 was initiated on 7/12/10. Resident 3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 6/2/10, Resident 3 was admitted to the hospital for acute [MEDICAL CONDITION] and dehydration. She was readmitted to the facility on [DATE]. Review of the MDS dated [DATE], showed the resident was five feet tall and her weight was 105 pounds. She required limited assistance from the staff for eating. Review of the Individual Resident Weight History form showed Resident 3's weekly weight was recorded as follows: On 4/1/10 = 108 pounds (admission weight); On 5/1/10 = 107 pounds (lost 1 pound); On 5/30/10 = 99 pounds (lost 8 pounds); On 6/5/10 = 100 pounds (gained 1 pound); On 6/13/10 = 96 pounds (lost 4 pounds); On 6/24/10 = 94 pounds (lost 2 pounds); On 7/1/10 = 90 pounds (lost 4 pounds). Review of the Nutrition Evaluation Progress Notes for Resident 3 showed: On 5/21/10, the RD documented the resident's weight was down two pounds. Resident 3's diet was changed to fortified puree, nectar thick liquids and she was receiving a Magic Cup (a supplement that provides 290 calories and 9 gm of protein) twice a day and Med Plus (a high calorie, high protein supplement; every 2 ounces provides 120 calories and 5 gm protein). The RD recommended to try Resident 3 on a RNA feeding program (a program where the RNAs supervise and cue the residents during meals to encourage better meal consumption). On 6/1/10, the RD recommended a speech therapy evaluation, documented the resident was not hungry, she was eating 10-30% of her meals and was going to alert Resident 3's physician for possible IV hydration or an appetite stimulant. On 6/14/10, the RD documented Resident 3 lost 4% in one week, was eating 10-20% of her meals and to discontinue the RNA feeding program. On 7/9/10, the RD documented Resident 3 weighed 90 pounds, down 9% in one month, 17% in three months and 18% in six months. Resident 3's intake was 5-40% of her meals and to honor Resident 3's wishes for comfort measures. Review of Resident 3's physician's orders [REDACTED]. Review of Resident 3's Change of Condition Care Plan Conference Summary dated 6/29/10, showed her progressive weight loss was reviewed. No dietary interventions were recommended. During an interview on 7/13/10 at 1104 hours, the RD stated Resident 3's weight on 6/1/10 was 99 pounds, a 7% weight loss. When the RD was asked what interventions were recommended, she stated the resident was transferred to the acute hospital on [DATE]. The RD stated on 6/14/10, Resident 3's weight had dropped to 96 pounds. She stated the resident was already receiving protein supplements, like a Magic Cup that had 200 calories in four ounces and Med Plus twice a day. The RD stated she felt she tried everything she could to prevent Resident 3's progressive weight loss. When the RD was asked if a calorie count was ever done on Resident 3, she stated no. When the RD was asked how she was able to determine the amount of calories or protein the resident received without a calorie count, she stated by the meal percentage. During an interview on 7/13/10 at 1225 hours, Resident 3 stated "I am hungry." At 1240 hours, Resident 3's lunch tray arrived. When the plate cover was lifted, Resident 3 made an unhappy face and stated "I do not like pureed food." When Resident 3 was asked if the dietary department had ever discussed with her the types of food she enjoys eating, she stated, no. When Resident 3 was asked what kind of food she enjoys, she stated vanilla ice cream. Resident 3 was asked if she would like a vanilla shake. Her eyes widened and she stated "I do not think they would give that to me." During an interview on 7/13/10 at 1430 hours, CNA 13 stated Resident 3 had drank 180 cc of the vanilla milkshake that was provided to her. During an observation on 7/14/10 at 0735 hours, Resident 3's breakfast tray was on her bedside table. On the plate were pureed eggs and a light brown puree mixture. During an interview on 7/14/10 at 0830 hours, CNA 14 stated Resident 3 only ate a small spoonful of the eggs and two spoonfuls of a brown sticky mixture. She did not know what the brown mixture was that she was feeding the resident. Resident 3 stated she did not like her breakfast. During an interview on 7/14/10 at 0932 hours, the RD stated the last follow up she completed on Resident 3 was dated 6/12/10, because she did not feel a 2.2% weight loss was severe. The RD stated she had never discussed with Resident 3 about an upgraded diet. She was unaware Resident 3 did not like a pureed diet. She stated "I guess I could have brought it up in the IDT meetings." 2. Review of the clinical record for Resident 5 showed the resident was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. The physician's orders [REDACTED]. The physician's orders [REDACTED]. The physician's orders [REDACTED]. The physician's orders [REDACTED]. Review of the weight record showed Resident 5 was admitted , weighing 125 pounds at 63 inches on 8/13/09. From 8/22/09 to 10/11/09, the resident had a progressive weight loss from 118 pounds on 8/22/09 to 109 pounds on 10/11/09. The record showed from 10/17/09 to 3/1/10, the resident's weight fluctuated within 109 to 111 pounds. The record showed on 3/8/10, the resident had a one pound increase from the previous weight of 111 pounds and weighed 112 pounds. The resident's weights again fluctuated from 3/15/10 to 4/12/10, within 109 to 111 pounds. From 5/2/10 to 6/26/10, the resident had progressive weight loss from 112 pounds on 4/12/10, 108 pounds on 5/2/10, 107 pounds on 6/2/10, and 103 pounds on 6/26/10. The record showed the resident was last weighed on 7/3/10, weighing 103 pounds. Review of the Initial Nutrition Evaluation dated 8/13/09, showed the resident was admitted weighing 125 pounds. The evaluation showed the resident's usual body weight was 120 pounds. The Nutritional Progress Notes dated 8/24/09, showed the resident had a 5.6 % weight loss in one week and was referred to the Nutritional/Hydration/Skin Committee Review. Review of the Nutrition/Hydration/Skin Committee Review for Resident 5 dated 8/25/09, showed the resident had a 5.6% weight loss in one week, from 125 pounds to 118 pounds. The notes showed the resident was depressed and the [MEDICAL CONDITION] medication was adjusted. The notes showed the resident was started on Med Plus, four ounces with meals on 8/14/09. The note dated 8/26/09, showed an appetite stimulant medication was not started secondary to the recent change in [MEDICAL CONDITION] medication. The note dated 9/1/09, showed the resident had further weight loss with poor oral intake ranging from 20-40% and the Med Plus was increased to twice daily between meals. The note dated 10/13/09, showed a plan to provide snacks between meals three times daily. The note showed the resident had preferred sweets and candies and the family member had been bringing in the sweets. During tour rounds on 7/12/10, initiated at 0735 hours, Resident 5 was observed in bed, partially facing toward the left. The resident had dark glasses on. There were two brown colored spots on the white blanket partially covering the resident, and a light yellowish stain observed on the linen behind the resident's upper back. When the resident was asked about the spots, the resident stated she had hot chocolate. The breakfast tray was observed set on the bedside table partially slanted toward the inner left side of the resident's bed. When asked how was breakfast, the resident stated there was nothing to eat and she has lost 30 pounds since being in the facility. The resident was observed using her hands, touching the tray. RN 2 came in the room stating the resident required full assistance for eating and the CNA will be in to provide assistance to the resident. A posted sign showed the resident is legally blind. Review of the care plan problem for Resident 5 to address risk for injuries related to visual limitations dated 8/14/09, showed to explain the location of the food on the tray. The plan of care to address nutritional status showed the resident needs set up assistance and to assist with meals. On 7/12/10 at 1245 hours, Resident 5 was observed in bed. The head of the bed was partially elevated. The lunch tray was set on the bedside table positioned in front of the resident from the left. The plate was uncovered and had a plate guard (an semi-circular assistive device clipped to the edge of the plate which allows the resident to scoop food from the plate without pushing it off the plate). The resident stated she did not know what was on the plate. A cup of ice cream was empty. On 7/12/10 at 1250 hours, LVN 8 was at Resident 5's bedside. The LVN stated the resident hand was guided to feel the food. The LVN demonstrated by letting the resident feel the food with her right hand. The LVN stated the cake had a dent which was the mark showing the resident had touch to feel the cake. The LVN stated the resident is allowed to do what she can. The LVN stated the resident likes ice cream and cake. The resident asked the LVN what was the vegetable served to her and requested for pudding or pie. The resident stated she did not know what was for dessert because she is blind. In an interview with CNA 11 on 7/13/10 at 0654 hours, the CNA stated Resident 5 at times get snacks in the middle of the night. When asked about the bedtime snacks, the CNA stated the resident did not ask for snacks at bedtime and it was not provided. On 7/13/10 at 0830 hours, during hygiene care observation provided by CNAs 12 and 9, the breakfast tray was observed set on the bedside table, away from the resident. It was noted to be untouched. On 7/13/10 at 0859 hours, CNA 12 showed the breakfast tray for Resident 5 on the tray cart. On the tray was an unopened bowl of oatmeal and an unopened carton of milk. The breakfast plate was observed untouched. When asked why the bowl of oatmeal was not offered, the CNA stated the resident did not like it. The CNA stated the resident consumed approximately 10% of the breakfast tray. On 7/14/10 at 0835 hours, Resident 5 was observed sitting in the wheelchair. The breakfast tray on the bedside table was positioned in front of the resident. The resident was observed feeling the egg and stated she did not care for eggs. The resident stated she had asked the staff for a meat sandwich. The resident stated she did not care for oatmeal because it got stuck on her teeth. The resident stated she did not know what was on her breakfast tray. The resident stated when the staff brought in the food tray, the staff would say "here is your dinner or lunch." Review of the meal monitoring showed from 8/14/09 to 7/14/10, Resident 5 had mostly consumed less than 50% of the meals but was not offered an alternative. The record showed on 7/14/10, the resident had consumed 15% of the breakfast, but was not provided an alternative. The average meal consumption of the resident in the month of July, 2010, was 20%. On 7/14/10 at 0840 hours, Resident 5 stated the staff did not say anything about the food served. When asked how she knows what food is served, the resident stated she tries to feel the food. The resident stated the staff told her this morning "settle down" and "here is your breakfast." On 7/14/10 at 0900 hours, an interview with the RD was conducted. When asked how the resident is assisted with eating, the RD stated Resident 5 should be informed the location of the food items on the plate using the clock system. The clock system is a way of guiding a blind resident to know the position of food items on the plate based on the clock; for example, the vegetable is at 9:00 on the plate, the meat is at 12:00 on the plate, etc. The RD stated the goal for the resident is to maintain the current weight as it is not reasonable to set a goal of weight gain. When asked about the snacks provided, the RD stated the resident was seen last week eating ice cream by the nurses' station. The RD stated the resident's meal intake has deteriorated from 30-60% to less than 30%. When shown the inservice provided to assist a blind resident in feeding, the RD stated the inservice did not address the feeding for the blind. 3. On 7/12/10 at 1230 hours, observation of Resident 15 found her in the dining room. Resident 15 was observed putting her hands in her plate of food. The resident demonstrated a poor attempt to feed herself. She began pouring her water into her food and mixing it with her hands. On 7/12/10 at 1240 hours, an interview with RNA 3 was conducted. When asked about the level of assistance the resident required when eating, the RNA stated the resident rarely needs help and does it all by herself. On 7/13/10 at 0735 hours, Resident 15 was observed lying flat on her back in bed. The resident's breakfast tray was on her bedside table without any set-up. On 7/13/10 at 1223 hours, Resident 15 was observed at the RNA dining table. RNA 3 set up the resident's tray and turned her back to assist another resident. The resident was observed putting her paper napkin in her mouth. The resident chewed four bites of the napkin, however, did not swallow the bites of napkin, as she took them out of her mouth. LVN 3 observed the resident chewing the napkin and removed it. At 1250 hours, the RNA was observed providing individual attention with cueing and minimal assistance to Resident 15. The resident ate 100 % of her meal. On 7/14/10, clinical record review for Resident 15 was initiated. Resident 15 was admitted to the facility on 2/22/10. The MDS dated [DATE], showed the resident was assessed with [REDACTED]. Resident 15 was 62 inches tall and weighed 100 pounds. The Weight Record showed the following: 2/22/10 - 101 2/27 - 100 3/6 - 99 3/13 - 92 3/20 - 92 3/27 - 94 4/4 - 93 5/2/10 - 100 (both lower legs swelling) 5/8/10 - 98 5/16/10 - 99 5/19/10 - 92 5/23/10 - 92 6/5/10 - 89 6/12/10-89 6/20/10 - 85 6/26/10 - 85 The initial Nutrition Evaluation dated 2/22/10, was reviewed. It showed the resident was 62 inches tall and weighed 101 pounds, with a usual body weight from 95 to 100 pounds. The Nutrition Evaluation Progress Notes showed the following: -An entry dated 3/16/10, showed the resident's weight went from 100 pounds to 92 pounds, a 7% severe loss of weight. The resident was on a mechanical soft diet with an overall oral intake of 30 to 40 %. The resident had been refusing an order for [REDACTED]. The plan was to order between meal snacks three times a day and the RNA feeding program. An appetite stimulant was to be discussed with the physician. -An entry dated 4/19/10, showed the weekly weights showed an overall increase trend. The resident weighed 99 pounds. An appetite stimulant ([MEDICATION NAME]) was ordered on [DATE]. The resident's oral intake was between 30 to 90%, and usually 50 to 60%. -An entry dated 5/5/10, showed the resident's weight was 100 pounds related to good oral intake, supplement and snacks. Nursing reports a decrease in lower extremity [MEDICAL CONDITION]. However, still a nutritional risk. -An entry dated 5/10/10, showed the resident's weekly weights show stability at 98 pounds. The resident feeds herself with oral intake varied from 40 to 90%. The RNA feeding program since 3/16/10, will be discontinued and the resident has reached maximum potential for the program. - An entry dated 5/19/10, showed nursing staff requested a current weight of the resident due to resolving lower extremity [MEDICAL CONDITION]. Weekly weights showed a decline to 92 pounds, which is a severe loss of 7% in one week. The resident's oral intake is unchanged at 30 to 80%. The physician is aware of the weight loss. A care plan problem to address the risk for altered nutritional status dated 2/23/10, and updated 5/24/10, addressed severe weekly weight loss. It included actions of meal set up, cueing, assistance, between meal snacks and the RNA feeding program. The physician's orders [REDACTED]. A Nutrition/Hydration/Skin Committee Review Progress Notes dated 7/6/10, showed the resident's weekly weights were from 85 to 87 pounds. The right heel pressure ulcer and coccyx pressure ulcer had resolved. The left heel pressure ulcer decreased in size. Management continues with supplements, RNA feeding program, psychoactive medications, between meal snacks and [MEDICATION NAME], the appetite stimulant. On 7/14/10 at 1025 hours, Resident 15 was observed lying flat in bed. An open carton of milk with a straw in it and warm to the touch was observed on the resident's overbed table. An unopened pudding cup and an unopened fruit cup were also observed. On 7/14/10 at 1028 hours, LVN 8 was present and preparing to provide treatment to the resident's left heel pressure ulcer. The LVN removed the uneaten snacks from the room to provide wound care. The resident was noted with [MEDICAL CONDITION] to both lower legs and feet. On 7/14/10 at 1200 hours, an interview and clinical record review was conducted with the RD. The RD showed all of the interventions put in place for the maintenance of the resident's weight. The RD was informed of the observations made during the RNA program and the between meal snacks regarding Resident 15. When asked how she determined the interventions were implemented, such as between meal snacks and the cueing and encouraging required, the RD was unable to answer. Review of the nurses' notes dated from 6/13/10 to 7/8/10, showed on 6/15/10, the physician was made aware of the resident's three pound weight loss and the resident's meal intake being greater than 50%. The licensed nurse also documented the swelling to the resident's legs had decreased and the physician stated he expected weight loss due to the decreased swelling. A note dated 6/23/10, showed the physician was notified of the resident's four pound weight loss. The [MEDICATION NAME] was increased to 400 mg twice a day. A noted dated 7/8/10, showed the resident tolerated the RNA feeding program. The resident will eat 30 to 100% of meals. The resident weighs 87 pounds and is able to feed herself with assistance. On 7/14/10 at 1404 hours, an interview with LVN 3 was conducted. When asked why the RNA feeding program was ordered for lunch and dinner only, the LVN stated the resident was not up in the wheelchair in the morning, then added it was too early for the resident. The LVN added the RNA feeds the resident breakfast at the bedside. Review of the MAR indicated [REDACTED]. The LVN stated the initials represented the snacks were given. However, there was no documentation of the percentage consumed by the resident. The LVN then added the resident did not want the snacks. The LVN stated the resident took 180 ml of the house supplement (Med Pass 2.0). On 7/14/10 at 1410 hours, an interview with CNA 18 was conducted. The resident was up in a wheelchair in her room. When asked what information she received concerning the care to be given to the resident, the CNA stated she talks to the resident and gives pericare. On 7/14/10 at 1450 hours, an interview with clinical record review was conducted with RN 1. When asked why the RNA program was only ordered for lunch and dinner, the RN stated the resident is not a morning person. However, there was no assessment or care plan problem that addressed the resident not being a morning person. The RN was informed of the observations made regarding the RNA feeding program meal observations, the breakfast tray left at the resident's bedside without set up and the between meal snacks not given. RN 1 was unable to explain.

Based on observation, interview and clinical record review, the facility failed to ensure one of 23 sampled residents (Resident 3) received adequate amounts of fluid to meet the resident's needs. The facility failed to complete the I&O record for Resident 3 to determine the resident's hydration status. The facility failed to have a complete I&O Record to evaluate the resident's hydration status and to ensure Resident 3 received adequate amounts of fluid to meet the resident's needs. Resident 3 required hospitalization for treatment of [REDACTED]. Review of the facility's P&P titled "Intake and Output Procedure" dated 7/08, showed the facility may record I&O for residents with identified dehydration or if a resident has acute renal impairment. Clinical record review for Resident 3 was initiated on 7/13/10. Resident 3 was readmitted to the facility from an acute care hospital on [DATE], with the [DIAGNOSES REDACTED]. The resident's previous stay was from 5/10/10 to 6/2/10. Review of the emergency room assessment dated [DATE], showed Resident 3's BUN (blood urea nitrogen) was 90 (normal 7-25 mg/dl) and the creatinine was 0.5 (normal 0.7-1.3 mg/dl), suggestive of prerenal azotemia (retention of excessive nitrogenous compounds in the blood caused by failure of the kidneys to remove urea from the blood) secondary to dehydration. Resident 3's baseline BUN was around the 30s-40s mg/dl and her creatinine was around 1.5-2 mg/dl. Resident 3 was admitted to the hospital on [DATE], with [DIAGNOSES REDACTED]. Review of Resident 3's MDS dated [DATE], showed she had short term memory impairment and some difficulty in new situations. She was five feet tall and weighed 105 pounds (47.7 kg). The resident's fluid needs were assessed as 1192 ml per day based on the method of 25 ml per kg of body weight. Review of the RAP summary focus dated 7/7/10, showed Resident 3 had nutritional status problems triggered due to having a pureed diet, weight decline and 0-30% food intake. Review of the care plan showed a care plan problem dated 6/29/10, to address Resident 3's UTI. An intervention was to encourage fluid intake. A care plan problem dated 7/8/10, to address Resident 3's self care deficit showed she required total assistance from the staff for eating. Another care plan problem dated 7/8/10, to address her risk for recurrent UTIs, showed an intervention to encourage and offer fluids as tolerated. Review of Resident 3's Meal Monitor Flowsheet for the period from 7/1/10 to 7/12/10, showed Resident 3's average intake for 12 days was 325 ml, ranging from 180 ml to 600 ml per day. The average intake was less than the amount of fluid needed by Resident 3. No documentation was available to show Resident 3's output. On 7/13/10 at 0920 hours, an interview was conducted with CNA 4. When asked where she documents the I&O on the residents, the CNA stated she only documents the intake on the Meal Monitor Flowsheet. She stated she does not monitor output or documents the accumulation of intake. On 7/13/10 at 1017 hours, an interview was conducted with CNA 1. When asked where she documents the I&O on the residents, the CNA stated the intake is documented on the Meal Monitor Flowsheet only. Review of the Meal Monitor Flowsheet shows the percentage of meal intake and the amount in ml the resident drank. On 7/13/10 at 1030 hours, an interview was conducted with the DSD. She stated the only I&O Flowsheet used is the Meal Monitor Flowsheet. She did not know where the residents' output would be documented. On 7/13/10 at 1030 hours, the DON stated the staff should be documenting on the Intake/Output Record. When LVN 1 was shown the Intake/Output Record, she stated she had not used that I&O sheet in a long time. No documentation was available to show documentation of weekly assessments of intake and output or the average 24 hour intake or output. During an observation on 7/13/10 at 1225 hours, upon entering Resident 3's room, the resident stated "I am thirsty. Can you get me something to drink?" No water pitcher was seen near her bedside. At the end of her overbed table out of her reach, was a small red and white cooler. Resident 3 rang her call light and LVN 1 entered the room. LVN 1 opened to cooler. Inside were three glasses with nectar thick liquid, covered with clear wrap, and placed on ice. LVN 1 handed Resident 3 one glass and she took three sips of fluid and asked LVN 1 if she could keep the glass within her reach. Resident 3 stated she could not reach inside the cooler to get the glass. LVN 1 was asked the reason Resident 3 did not have fluid at her bedside. She stated the resident needs assistance and might spill it. Review of Resident 3's IDT Progress Notes dated 5/17/10, showed staff was to be inserviced to ensure frequently used items at the bedside were within reach. A note dated 5/20/10, showed, CNAs were inserviced in placing belongings within reach. During an observation on 7/14/10 at 0735 hours, no water pitcher or fluids were within reach of Resident 3.