Every finding on record at The Rehabilitation Center of North Hills

Based on interview and record review, the facility failed to ensure that staff monitored and documented intake (food and fluid consumption) and output (urine and stool amounts) in accordance with professional standards of practice and per the facility's policy and procedure (P&P) for one of three sampled resident (Resident 1), who had a nephrostomy tube (N-tube - a tiny plastic tube put through the skin of your back directly into the kidney to drain urine out of the body into an external bag). This deficient practice had the potential to result in unrecognized nephrostomy tube obstructions, leakages, or improper urine drainage and negatively affect the resident's health status. Findings: During a review of Resident 1's admission Record, the admission Record indicated that the facility originally admitted Resident 1 on 7/18/2024 and readmitted the resident on 10/25/2025 with diagnoses including dislocation of cervical (the first seven vertebrae [the bones that make up the spinal column] and labeled C1 to C7) vertebrae on C3 and C4, spinal cord injury at C5 and C6, artificial openings of urinary tract status, displacement of nephrostomy catheter, and neuromuscular dysfunction of bladder (happens when damage to the brain, spinal cord, or nerve stops the balder muscles and nerves from working together correctly). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 4/27/2026, the MDS indicated that Resident 1's cognition (ability to think, understand, and make decisions) was moderately impaired. The MDS also indicated Resident 1 was dependent on staff for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's physician order dated 7/15/2026, the physician order indicated transferring the resident to General Acute Care Hospital 1 (GACH 1) for evaluation of fresh blood output in nephrostomy tube. During a review of Resident 1's GACH 1 Discharge summary dated [DATE], the GACH 1 Discharge Summary indicated that the resident underwent right side nephrostomy tube exchange on 7/16/2026. During a review of Resident 1's Order Summary Report dated 7/18/2026, the Order Summary Report indicated an order to measure the output of nephrostomy tube every shift. During a review of Resident 1's physician's progress notes dated 7/20/2026, the physician's progress notes indicated that the resident was readmitted to the facility following hospitalization for hematuria (blood in the urine), and the resident was hospitalized due to infection associated with nephrostomy catheter, hematuria, nephrolithiasis (kidney stones), and hyponatremia (blood has too little salt or sodium). The physician's progress notes further indicated the assessment and plan that included to continue routine nephrostomy tube care, to monitor drainage amount, color, and tube patency, and to notify provider for obstruction, leakage, or decreased output. During a review of Resident 1's Treatment Administration Record (TAR - a daily documentation record used by a licensed nurse to document treatments given to a resident) for 7/2026, the TAR indicated for the section of empty right side nephrostomy drainage bag every shift dated 7/18/2026, from 7/18/2026 night shift to 7/26/2026 day shift, the licensed nurses marked with check marks only and did not document the urine output. During a concurrent interview and record review on 7/30/2026 at 2:03 p.m., with the Director of Nursing (DON), reviewed Resident 1's medical records and stated that the resident was transferred to hospital on 7/16/2026 then returned to the facility on 7/18/2026. The DON reviewed Resident 1's physician orders and the intake and output (I/O) records in the Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications given to a resident) for 7/2026. The DON stated that the evening shift nurses totaled the daily I/O amounts and the weekly average amounts every Sunday, but the licensed nurse did not include the urine amounts from the nephrostomy bag. The DON further stated that the daily I/O monitoring would be the most important, but the weekly I/O monitoring evaluations would be used to decide for the possible fluid retentions or deficits, and the monthly I/O monitoring evaluation would be used to continue or to discontinue the I/O monitoring. The DON reviewed the progress notes for Resident 1 and stated that there were no documentation for the weekly I/O monitoring evaluation summary that included nephrostomy urine output. During a review of the facility's P&P titled, Intake and Output Monitoring, last reviewed on 1/21/2026, the P&P indicated that it was the policy of the facility to provide care and services for residents who require monitoring of their intake and or output consistent with the standard of practice and to provide guidelines for maintaining a measurement of resident's intake and output and to assess fluid balance. The P&P further indicated that fluid intake and output shall be recorded for each patient when ordered by the physician, intake and output records shall be evaluated and documented weekly by a licensed nurse, and after 30 days the patient shall be re-evaluated by the licensed nurse to determine further need or discontinuation of recording of intake and output. During a review of the facility's P&P titled, Quality of Care, last reviewed on 1/21/2026, the P&P indicated, The resident's coordinated care plan is established and maintained in consultation with the resident's attending physician/practitioner, representatives of the nursing home and the resident/representative as applicable.

Based on interview and record review, the facility failed to notify a physician regarding a resident's refusals for changing the dressing on their nephrostomy tube (N-tube - a tiny plastic tube put through the skin of your back directly into the kidney to drain urine out of the body into an external bag) stoma (a small, surgically made opening in the skin of the back that leads directly into the kidney) for one of three sampled residents (Resident 1). This deficient practice placed the resident at risk for kidney and/or wound infection, increased risk of hospitalization related complications, and a decline in the resident's overall health status.Findings: During a review of Resident 1's admission Record, the admission Record indicated that the facility originally admitted Resident 1 on 7/18/2024 and readmitted the resident on 10/25/2025 with diagnoses including dislocation of cervical (the first seven vertebrae [the bones that make up the spinal column] and labeled C1 to C7) vertebrae on C3 and C4, spinal cord injury at C5 and C6, artificial openings of urinary tract status, displacement of nephrostomy catheter, and neuromuscular dysfunction of bladder (happens when damage to the brain, spinal cord, or nerve stops the balder muscles and nerves from working together correctly). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 4/27/2026, the MDS indicated that Resident 1's cognition (ability to think, understand, and make decisions) was moderately impaired. The MDS also indicated Resident 1 was dependent on staff for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's physician order dated 7/15/2026, the physician order indicated transferring the resident to General Acute Care Hospital 1 (GACH 1) for evaluation of fresh blood output in nephrostomy tube. During a review of Resident 1's GACH 1 Discharge summary dated [DATE], the GACH 1 Discharge Summary indicated that the resident underwent right side nephrostomy tube exchange on 7/16/2026. During a review of Resident 1's physician order dated 7/18/2026, the physician ordered to cleanse with normal saline (NS - a saltwater) solution, pat dry and cover with dressing everyday and as needed every dayshift for Resident 1's right side nephrostomy tube stoma. During a review of Resident 1's physician's progress notes dated 7/20/2026, the physician's progress notes indicated that the resident was readmitted to the facility following hospitalization for hematuria (blood in the urine), and the resident was hospitalized due to infection associated with nephrostomy catheter, hematuria, nephrolithiasis (kidney stones), and hyponatremia (blood has too little salt or sodium). The physician's progress notes further indicated the assessment and plan that included to continue routine nephrostomy tube care, to monitor drainage amount, color, and tube patency, and to notify provider for obstruction, leakage, or decreased output. During a concurrent interview and record review on 7/30/2026 at 10:07 a.m., with Treatment Nurse 2 (TN 2), reviewed Resident 1's physician order dated 7/18/2026 for right side nephrostomy tube stoma dressing change daily and Treatment Administration Records (TAR - a daily documentation record used by a licensed nurse to document treatments given to a resident) for 7/2026. TN 2 stated that Resident 1 had been refusing dressing changes for the nephrostomy tube site so TN 1 did not change the dressings on 7/19/2026, 7/20/2026, 7/21/2026, 7/23/2026, 7/26/2026, 7/27/2026, 7/28/2026, and 7/29/2026. TN 2 stated that TN 2 or other nursing staff did not notify Resident 1's physician about Resident 1's refusals of their nephrostomy tube site dressing changes after checking the progress notes. TN 2 stated, if not notified, the physician would not know about the resident's treatment refusals. During a concurrent interview and record review on 7/30/2026 at 2:29 p.m., with the Director of Nursing (DON), reviewed Resident 1's TAR for 7/2026. The DON stated that Resident 1 was readmitted on [DATE] to the facility and the physician ordered to change Resident 1's nephrostomy tube site dressing daily. The DON stated if the resident refused the dressing change, the licensed nurses should notify the physician and document in the progress notes, then should initiate a care plan regarding the treatment refusals after educating risks and benefits. The DON stated there was no documentation indicating that the physician was notified and there was no care plan about the refusal of nephrostomy tube site dressing changes until that morning (7/30/2026). During a review of the facility's policy and procedure (P&P) titled, Notification of Changes, last reviewed on 1/21/2026, the P&P indicated, 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 need to alter treatment significantly. Complete the notification of the physician and family/responsible party/legal representative with name, date, and time.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a document designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) addressing a resident's refusal for changing the dressing on their nephrostomy tube (N-tube - a tiny plastic tube put through the skin of your back directly into the kidney to drain urine out of the body into an external bag) stoma (a small, surgically made opening in the skin of the back that leads directly into the kidney) for one of three sampled residents (Resident 1). This deficient practice had the potential to negatively affect the delivery of care and services to a resident. Findings: During a review of Resident 1's admission Record, the admission Record indicated that the facility originally admitted Resident 1 on 7/18/2024 and readmitted the resident on 10/25/2025 with diagnoses including dislocation of cervical (the first seven vertebrae [the bones that make up the spinal column] and labeled C1 to C7) vertebrae on C3 and C4, spinal cord injury at C5 and C6, artificial openings of urinary tract status, displacement of nephrostomy catheter, and neuromuscular dysfunction of bladder (happens when damage to the brain, spinal cord, or nerve stops the balder muscles and nerves from working together correctly). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 4/27/2026, the MDS indicated that Resident 1's cognition (ability to think, understand, and make decisions) was moderately impaired. The MDS also indicated Resident 1 was dependent on staff for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's physician order dated 7/15/2026, the physician order indicated transferring the resident to General Acute Care Hospital 1 (GACH 1) for evaluation of fresh blood output in nephrostomy tube. During a review of Resident 1's GACH 1 Discharge summary dated [DATE], the GACH 1 Discharge Summary indicated that the resident underwent right side nephrostomy tube exchange on 7/16/2026. During a review of Resident 1's physician's order dated 7/18/2026, the physician ordered to cleanse with normal saline (NS - a saltwater) solution, pat dry and cover with dressing everyday and as needed every dayshift for Resident 1's right side nephrostomy tube stoma. During a review of Resident 1's physician's progress notes dated 7/20/2026, the physician's progress notes indicated that the resident was readmitted to the facility following hospitalization for hematuria (blood in the urine), and the resident was hospitalized due to infection associated with nephrostomy catheter, hematuria, nephrolithiasis (kidney stones), and hyponatremia (blood has too little salt or sodium). The physician's progress notes further indicated the assessment and plan that included to continue routine nephrostomy tube care, to monitor drainage amount, color, and tube patency, and to notify provider for obstruction, leakage, or decreased output. During a concurrent interview and record review on 7/30/2026 at 10:07 a.m., with Treatment Nurse 2 (TN 2), reviewed Resident 1's physician order dated 7/18/2026 for right side nephrostomy tube stoma dressing change daily and Treatment Administration Records (TAR - a daily documentation record used by a licensed nurse to document treatments given to a resident) for 7/2026. TN 2 stated that Resident 1 had been refusing dressing changes for the nephrostomy tube site, so TN 1 did not change the dressings on 7/19/2026, 7/20/2026, 7/21/2026, 7/23/2026, 7/26/2026, 7/27/2026, 7/28/2026, and 7/29/2026. When TN 2 was asked what the next step was for any residents' refusal to receive the treatments, TN 2 stated that the licensed nurses should explain the risks and disbenefits of refusal dressing changes to the residents and/or the responsible parties, then should document in the progress notes. TN 2 reviewed Resident 2's care plans and stated that the facility did not develop or implement a care plan for Resident 1's refusals of nephrostomy tube site dressing changes. During a concurrent interview and record review on 7/30/2026 at 2:29 p.m., with the Director of Nursing (DON), reviewed Resident 1's TAR for 7/2026 and care plans. The DON stated that Resident 1 was readmitted on [DATE] to the facility and the physician ordered to change Resident 1's nephrostomy tube site dressing daily. The DON stated if the resident refused for it, the licensed nurses should notify the physician and document in the progress notes and then should initiate a care plan regarding the treatment refusals after educating risks and disbenefits. The DON stated there were no documentation indicating that the physician was notified or there was no care plan about the refusal of nephrostomy tube site dressing changes until that morning (7/30/2026). During a review of the facility's policy and procedure (P&P) titled, Develop-Implement Comprehensive Care Plans, last reviewed on 1/21/2026, the P&P indicated, Refusal of Treatment: 1. A resident may choose to refuse services or treatments that staff believe may be indicated to assist the resident in reaching his or her highest practicable level of well-being or to keep the resident safe. 2. When a resident's choice to decline care or treatment poses a risk to the resident's health or safety, the comprehensive care plan musta. Identify the care or service being declined.b. The risk the decline poses to the resident.c. Efforts by the interdisciplinary team to educate the resident and the representative, as appropriate; andd. Attempts to find alternative means to address the identified risk.

Based on interview and record review, the facility failed to develop and implement a comprehensive, person centered care plan (a document outlining individualized approaches to meet a resident's specific needs) for 1 out of 26 sampled residents (Resident 118) by failing to: 1. Develop an accurate, person centered care plan for Resident 118 who has diagnosis of epileptic seizure (a sudden, uncontrolled electrical disturbance in the brain that can cause changes in behavior, movements, sensations, awareness, or consciousness) to monitor and document presence or absence of seizure activity. 2. Implement the care plan interventions for monitoring, documenting, and reporting hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar) signs and symptoms as indicated in the care plan titled, At risk for hypoglycemia/hyperglycemia related to diagnosis of DM.3. Develop an accurate, person centered care plan for Resident 118. The care plan included interventions to administer seizure and diabetes medications and monitor their effectiveness; however, the resident was not prescribed any anti-seizure or diabetes medications. These deficient practices had the potential to negatively affect the provision of care and service provided to Resident 118. Findings: During a review of Resident 118's admission Record, the admission Record indicated the facility admitted Resident 118 to the facility on [DATE] with diagnosis including epileptic seizure and type 2 diabetes mellitus (DM -a chronic condition that affects the way the body processes blood sugar). During a review of the History and Physical (H&P) report completed on 07/03/2026, the H&P indicated Resident 118 does not have capacity to understand and make medical decisions. During a review of Resident 118's Minimum Data Set (MDS - a resident assessment tool), dated 7/2/2026, the MDS indicated Resident 118 cognition (the brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) was moderately impaired. The MDS indicated Resident 118 was dependent (helper does all of the effort) with toileting hygiene shower/bathe self, upper and lower body dressing, and rolling left and right. The MDS indicated Resident 118 has diagnoses of DM and seizures. During a concurrent interview and record review on 7/16/2026 at 8:52 am with Director of Nursing (DON), Resident118's Physician Order Report Active with orders as of dated 7/16/2026 was reviewed. The DON stated Resident 118 does not receive any medication for epileptic seizure or DM. During a concurrent interview and record review on 7/16/2026 at 9:10 a.m. with the DON, Resident 118's care plan titled, At risk for hypo/hyperglycemia related to diagnosis of DM, created on 7/20/2025 and revised on 7/16/2026 was reviewed. The DON stated care plan indicated Resident 118 is at risk for hypoglycemia and hyperglycemia. The DON stated the care plan indicated interventions to monitor/document/report to physician as needed signs and symptoms of hypoglycemia: sweating, tremor, increased heart rate, pallor (paleness), nervousness, confusion, slurred speech and monitor/document/report to the physician as needed PRN for s/sx for signs and symptoms of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing (abnormal, deep, and labored breathing pattern), acetone breath (smells fruity), stupor, and coma (a state of unconsciousness where a person cannot be awakened and fails to respond to stimuli, including pain). The DON stated licensed nurses document the monitoring for sign and symptoms of hypoglycemia or hyperglycemia in the electronic Medication Administration Record (eMAR). The DON further stated the care plan has interventions to administer DM medications as ordered by the physician and to monitor/document the effectiveness. The DON stated care plan is not person centered since Resident 118 was not prescribed any DM medication. The DON further stated there is no monitoring for signs and symptoms of hypoglycemia and hyperglycemia in the eMAR or resident record. The DON stated that without monitoring nursing staff may be unable to identify and address episodes of hypoglycemia and hyperglycemia experienced by Resident 118. During a concurrent interview and record review on 7/16/2026 at 9:27 a.m. with the DON, Resident 118's care plan titled, The resident has seizure disorder related to history of intracerebral hemorrhage, (a life-threatening type of stroke that occurs when a diseased or damaged blood vessel bursts, causing bleeding directly into the brain tissue) created 7/20/2025 was reviewed. The DON stated that the care plan did not include an intervention to monitor the resident for seizure activity, which could result in the resident experiencing an epileptic seizure without nursing staff recognizing the symptoms. The DON explained that without monitoring, nursing staff would be unable to identify or report seizure activity promptly. The DON further stated the care plan has interventions to administer seizure medication as ordered by physician and monitor/document effectiveness. The DON stated care plan not person centered since Resident 118 is not receiving any antiseizure medication. During an interview on 7/16/2026 at 9:32 a.m. with the DON, the DON stated that a care plan serves as the guide on how to care for the residents. The DON stated it is important that care plans are current and person centered to reflect the plan of care for the resident's actual condition. During a review of the facility's P&P titled, Develop-Implement Comprehensive Care Plans, reviewed 1/26/2026, the P&P indicated, 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. The facility establishes, documents, and implements the care and services provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life.

Based on observation, interview, and record review, the facility failed to: 1. Ensure one of one sampled resident (Resident 20) was assessed to ensure the resident's ability to self-administer an over-the-counter ointment medication and was able to store it in a safe and secure area. This failure had the potential to result in the wrong administration of the ointment medication and/or the risk of other residents taking the ointment medication for their own use. 2. Ensure one of two crash (a crash cart is an emergency medical cart that contains critical life saving equipment and supplies, including medications, airway devices, and sharps such as needles carts (Cash Cart 1) was properly secured. This failure had the potential to result in accident hazards and delayed emergency care for residents. Findings: 1. During a review of Resident 20's admission Record, the admission Record indicated the resident was admitted on [DATE] with diagnoses including but not limited to hemiplegia (total paralysis of the arm, leg, and trunk on the same side) and hemiparesis (weakness or partial loss movement on one entire side of the body), cerebral infarction (an area of brain tissue death due to lack of blood supply), and congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 20's History and Physical (H&P) dated 3/19/2026, the H&P indicated Resident 20 had the capacity to make needs known but may or may not be able to make complex medical decisions. During a review of Resident 20's Minimum Data Set (MDS – a resident assessment tool), dated 5/18/2026, the MDS indicated Resident 20 had moderately impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). During a review of Resident 20's Order Summary Report dated 9/8/2024 to 6/13/2026, the Order Summary Report did not indicate an order for [NAME] VapoRub (an over-the-counter ointment medication). During a review of Resident 20's Care Plan (CP), revised 6/1/2026, the CP did not indicate assessment and interventions for self-administration of over-the-counter ointment medication. During a concurrent observation and interview on 7/14/2026 at 11:20 a.m. with Licensed Vocational Nurse (LVN 3) in Resident 20's room, there was a Vicks VapoRub over-the-counter ointment medication on Resident 20's overbed table. LVN 3 stated no medications should be left unlocked in residents' rooms, including over-the-counter medications. LVN 3 stated residents need to be assessed to ensure they can self-administer medications safely, a physician order should be obtained, and the medication is kept locked at bedside. LVN 3 further stated Resident 20 may not be able to apply the ointment as recommended and/or other residents could get the medication. During an interview on 7/16/2026 at 12:27 p.m. with the Director of Nursing (DON), the DON stated they were unaware Resident 20 kept Vicks VapoRub at the bedside table. The DON stated residents need to be assessed prior to self-administering medications, a physician order needs to be placed, the medication is ordered, and then the resident can keep the medication at bedside in a locked container. During an interview on 7/16/2026 at 2:11 p.m. with LVN 6, LVN 6 stated if a resident is alert and able to self-administer over-the-counter medications, a physician order could be obtained, when the medication is obtained it should be kept locked in the resident's room to prevent other residents from removing it. During a concurrent interview and record review on 7/16/2026 at 2:23 p.m. with the DON, the facility's policy and procedure (P&P) titled, Resident Self Administer Medications, revised on 1/21/2026 was reviewed. The P&P indicated the interdisciplinary team: a. Evaluates each resident's ability to self-administer medications when the resident requests to exercise this right. b. Determines which medications can be safely administered. c. Must ensure the resident's ability to keep the medication safe and secure. d. Document the ability of a resident to self-administer medication(s) in the resident's health record and care plan. e. Medications shall be kept in a safely locked container at the resident's bedside. The DON stated the facility staff did not follow the P&P. 2. During a concurrent observation and interview on 7/13/2026 at 12:53 p.m., in subacute unit with Registered Nurse 3 (RN 3), observed Crash Cart 1 with a drawer that was not secured, and intravenous (IV) needles were visible inside. RN 3 stated that the Crash Cart was not locked/secured and that IV needles were accessible inside the Cart 1. RN 3 further stated that the crash cart must remain locked at all times to prevent accidents or hazards, as unsecured needles present a potential risk for residents and visitors to get pocked. RN 3 stated that during every night shift, a licensed nurse verifies that all crash carts items are in place to ensure readiness for emergency use. RN 3 emphasized that if the crash cart is not properly secured, there is potential for missing items, which could delay the provision of care to a resident during an emergency. During a concurrent observation and interview on 7/13/2026 at 1:02 p.m., in subacute unit with the Director of Nursing (DON), observed Crash Cart 1 drawer not secured. The DON stated that the crash cart was not locked and there were eight IV needles inside the cart that were accessible. The DON stated that crash carts need to remain locked at all times to prevent accidents or hazards, since unsecured needles are considered hazard and could be accessed by residents or visitors. The DON also stated that keeping the crash carts locked helps ensure all emergency supplies stay in place and are not taken or misplaced, so there is no delay in care if an emergency occurs. During a concurrent interview and record review on 7/15/2026 at 12:02 p.m. with the DON, the facility's policy and procedure (P&P) tiled Crash Cart Management, reviewed on 1/21/2026, was reviewed. The DON stated the facility's policy and procedure indicated the crash carts are to remain secured yet immediately accessible. The DON stated that the policy was not followed. During a review of the facility`s policy and procedure (P&P) titled Crash Cart Management, last reviewed on 1/21/2026, the P&P indicated to ensure that a crash cart or equivalent emergency resuscitation equipment is immediately available, functional, and appropriately stocked to support prompt response to cardiopulmonary emergencies in the Subacute Unit. Crash carts shall remain secured with and immediately accessible. Director of Nursing: Oversight and compliance. Crash cart readiness, inspection compliance. medication expiration, and equipment maintenance shall be monitored through QAPI. During a review of the facility`s policy and procedure (P&P) titled Free of Accident Hazards/Supervision/Devices, last reviewed on 1/21/2026, the P&P indicated the facility provides an environment that is free from accident hazards over which the facility has control, and each resident receives adequate supervision and assistive devices for each resident to prevent avoidable accidents. Environment: Any environment or area in the facility that is frequented by or accessible to residents. Hazards: Elements of the resident environment that have the potential to cause injury or illness.

Based on observation, interview, and record review, the facility failed to ensure four of four sampled residents (Resident 112, Resident 130, Resident 57, and Resident 157) did not have a loop or kink (unwanted twist or bend) in their urinary catheter tubing (a hollow tube inserted into the bladder to drain or collect urine). This failure had the potential for urine backflow into the bladder, increasing the risk of the residents of a urinary tract infection (UTI-an infection in the bladder/urinary tract). Findings: a. During a review of Resident 112's admission Record, the admission Record indicated the facility originally admitted the resident on 9/18/2025 and readmitted on [DATE] with diagnoses including, persistent vegetative state (a condition where a person with severe brain damage appears awake but has no awareness of themselves or their surroundings) and acute kidney failure (a sudden, rapid decline in kidney function occurring within hours or days). During a review of Resident 112's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 6/24/2026, the MDS indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and senses) skills for daily decision making was severely impaired. The MDS indicated the resident was totally dependent on staff for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 112's Order Listing Report, the report indicated an order on 6/29/2026 for an indwelling urinary catheter (a flexible tube inserted into the bladder through the urethra or lower abdomen) French number 16/10 (a standard, medium-sized tube primarily used in adults for both short- and long-term urinary drainage) to drainage bag due to diagnosis of neurogenic bladder (a loss of bladder control caused by nerve damage, brain, or spinal cord problems) every shift. During a concurrent observation and interview on 7/13/2026 at 12:29 p.m. with Licensed Vocational Nurse 7 (LVN 7) in Resident 112's room, observed the resident's urinary catheter tubing with a loop filled with stagnant (not flowing into the drainage bag) urine containing whitish sediments. LVN 7 stated that the tubing should not have kinks or loops and the urine must flow freely. LVN 7 stated that the stagnant urine in the indwelling catheter of Resident 112 can start to grow harmful bacteria and it can back up to the bladder and potentially cause UTI. b. During a review of Resident 130's admission Record, the admission Record indicated the facility originally admitted the resident on 5/12/2025 with diagnoses including but not limited to diabetes mellitus type two (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN- high blood pressure), and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 130's History and Physical (H&P) dated 10/31/2025, the H&P indicated Resident 130 had recent UTI. During a review of Resident 130's MDS, dated [DATE], the MDS indicated Resident 130's cognition is intact. The MDS further indicated Resident 130 has an indwelling catheter. During a review of Resident 130's Physician Order, dated 7/15/2026, the Physician Order indicated an order for suprapubic catheter (a flexible, hollow tube inserted directly into your bladder through a small incision in your lower abdomen, just above the pubic bone) due to diagnosis of obstructive uropathy (any structural or functional blockage in the urinary tract that impedes the normal flow of urine). During a review of Resident 130's Care Plan (CP), revised 6/23/2025, the CP indicated the resident has suprapubic catheter and was at risk of UTI. The CP indicated interventions to check tubing for kinks each shift and anchor safely. During a concurrent observation and interview on 7/13/20261:38 p.m. with LVN 5 in Resident 130's room, observed Resident 130's urinary tubing looped with urine containing white sediments that was not draining into the collection bag. LVN 5 stated that urine that was not draining into the drainage bag could potentially result in urine backflow and cause UTI. LVN 5 stated that the urinary catheter tubing should be repositioned to ensure there are no loops or kinks and that urine is free flowing into the drainage bag. During an interview on 7/15/2026 at 10:32 a.m., with the Director of Nursing (DON), the DON stated the urinary catheter drainage bag should be positioned below the bladder, ensuring the tubing has no kinks or loops because it can cause urine backflow and increase the risk of infection. c. During a review of Resident 57's admission Record, the admission Record indicated the facility originally admitted the resident on 4/18/2023 and readmitted on [DATE] with diagnoses including but not limited to DM, hyperlipidemia (the condition of having too many fats, such as cholesterol in the bloodstream), and depression. During a review of Resident 57's H&P dated 7/10/2026, the H&P indicated Resident 57 had medical history of UTI. During a review of Resident 57's MDS, the MDS indicated Resident 57 had severely impaired cognition, was dependent on staff for ADLs, and had urinary catheter in place. During a review of Resident 57's Physician Order, dated 7/10/2026, the Physician Order indicated an order for urinary catheter due to diagnosis of urinary retention. During a review of Resident 57's Progress Notes, dated 7/10/2026, the resident was readmitted to the facility from hospitalization with diagnosis of UTI associated with indwelling urinary catheter and receiving antibiotic therapy (a medication to treat infections). During a concurrent observation and interview on 7/14/2026 at 9:04 a.m. with LVN 2 in Resident 57's room, Resident 57's urinary catheter tube was observed. LVN 2 stated the urinary catheter tubing had some urine with sediments, and the urine was not draining into the drainage bag. LVN 2 stated the backflow of urine could cause an infection. LVN 2 further stated the resident is currently receiving antibiotics for UTI, and that the urinary catheter tubing should be repositioned to ensure there are no loops or kinks and urine is free flowing into the drainage bag. c. During a review of Resident 157's admission Record, the admission Record indicated the facility originally admitted the resident on 1/2/2026 and readmitted on [DATE] with diagnoses including but not limited to UTI, hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or partial loss of movement on one entire side of the body). During a review of Resident 157's H&P dated 3/3/2026, the H&P indicated Resident 157 had hospitalization on January 2026 for severe sepsis (a life-threatening blood infection) secondary to UTI and urinary catheter in place. During a review of Resident 157's MDS dated [DATE], the MDS indicated Resident 157 had severely impaired cognition, was dependent on staff for ADLs, and had urinary catheter in place. During a review of Resident 157's CP, revised 6/4/2026, the CP indicated the resident had an indwelling catheter and was at risk of UTI, interventions included to position catheter bag and tubing below the level of the bladder and checking for kinks each shift. During a review of Resident 157's COC Progress Notes, dated 4/12/2026 and 6/7/2026. The COC Progress Notes dated 6/7/2026, indicated the resident had a positive urine test for Extended-Spectrum Beta-Lactamase (ESBL – bacteria highly resistant to many common antibiotics). The COC Progress Notes, dated 4/12/2026, indicated the resident had a positive urine test for Carbapenem-Resistant Pseudomonas aeruginosa (CRPA – a bacteria resistant to carbapenem antibiotics). During a concurrent observation and interview on 7/14/1026 at 9:24 a.m. with LVN 3 in Resident 157's room, LVN 3 stated the urinary catheter tubing should not have loops because urine can back up into the bladder and cause UTI. During an interview on 7/15/2026 at 2:48 p.m. with the DON, the DON stated the urinary catheter drainage bag should be positioned below the bladder, ensuring the tubing has no kinks or loops because it can cause urine backflow and increase the risk of infection. During a review of the facility's policy and procedure (P&P) titled, Indwelling Catheter Use, revised on 1/21/2026, the P&P indicated staff should ensure tubing is positioned without loops or kinks to allow urine to flow freely and reduce the potential for urine backflow.

Based on observation, interview, and record review, the facility failed to ensure the safe storage and labeling of medication when: 1. Expired vitamin D supplements (concentrated sources of the essential nutrient vitamin D, which supports bone and immune health) and improperly labeled nicotine lozenges (a medication used to help people quit smoking) were stored and available for use in one of two inspected medication rooms (Station 3 medication room). 2. An internal use medication (a medication intended to be taken by mouth, injection, or inhaled) indicated for under the tongue administration was stored with an external use medication (a medication intended to be applied to the eyes, ears, nose, or skin) in one of four medication carts (Nurse Station 1 Medication Cart 1). These failures placed residents at risk of receiving incorrect, contaminated, or expired medications. Findings: 1. During a concurrent observation and interview on 7/15/2026 at 1:58 p.m., with Registered Nurse 1 (RN 1) in Station 3 medication room, observed a bottle of vitamin D supplements with an expiration date marked June 2026 and a bottle of nicotine lozenges with a paper taped to it with a handwritten first and last name and no other identifying information. RN 1 stated she was not sure whose name was on the nicotine lozenges but it may be a discharged resident. RN 1 stated the expired vitamin D supplements and nicotine lozenges should not be stored in the medication room. During an interview on 7/16/2026 at 12:38 p.m., with the Director of Nursing (DON), the DON stated expired medications should not be kept in the medication room because they could accidentally be given to a resident. The DON stated since the medication is expired, they could be less effective or the resident could have an adverse reaction (undesired harmful effect resulting from a medication or other intervention). The DON stated she was not sure whose name was on the nicotine lozenges. The DON stated if the nicotine lozenges did belong to a resident, it should have either been given back to the resident's family or it should have been put in the medication disposal area. The DON stated it was a medication storage issue as the nicotine lozenges were not labeled correctly and they should not be available to be given without a physician's order. During a review of the facility's policy and procedure (P&P) titled, Pharmaceutical Services-Labeling and Storage, last reviewed on 1/21/2026, the P&P indicated the facility provides accurate labeling to facilitate precautions and safe administration of medications, and safe and secure storage. The P&P indicated drugs shall not be kept in stock after the expiration date on the label. The P&P indicated discontinued drug containers shall be marked, or otherwise identified, to indicate that the drug has been discontinued, or shall be stored in a separate location which shall be identified solely for that purpose. 2. During a concurrent observation and interview on 7/16/2026 at 11:01 a.m., with Licensed Vocational Nurse 8 (LVN 8) in Nurse Station 1 Medication Cart 1 (NS 1 Cart 1), observed a medication box labeled Atropine 1% eye drops (used to treat severe drooling or manage end-of-life respiratory secretions) with an indication to Take three (3) drops under the tongue as needed for secretions or congestion, in the eye drops storage container. LVN 8 stated the medication should probably be stored with the oral medications. LVN 8 stated storing the medication in the wrong route container could be an infection control issue and if the indication is not read correctly, it could be administered to the resident in the eyes. During an interview on 7/16/2026 at 11:28 a.m., with Registered Nurse 4 (RN 4), RN 4 stated the Atropine eye drops are indicated for sublingual (under the tongue) use and should probably be stored with the oral medications to avoid administration via the wrong route. During an interview on 7/16/2026 at 11:46 a.m., with LVN 8, LVN 8 stated the facility pharmacist was consulted, and the pharmacist stated the Atropine eye drops should be stored with the oral medications because the medication is indicated for oral use. During a review of the facility's policy and procedure (P&P) titled, Pharmaceutical Services-Labeling and Storage, last revised 1/21/2026, the P&P indicated medications for external use shall be stored separately from medications for internal use.

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and distribution practices, by failing to: 1. Ensure potentially hazardous foods prepared and stored beyond 24 hours were labeled with a use-by date. 2. Ensure potentially hazardous foods prepared and stored beyond seven (7) days were discarded. 3. Ensure potentially hazardous foods kept in the walk-in refrigerator beyond manufacturer expiration dates were discarded. 4. Ensure potentially hazardous foods kept in the resident refrigerator beyond manufacturer expiration dates were discarded. These failures had the potential to result in harmful bacterial growth that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or toxins) in 86 of 130 residents who received food from the facility kitchen and the resident refrigerator.Findings: 1. During an observation of the facility's kitchen on 7/13/2026 at 8:05 a.m., in the walk-in refrigerator, two trays of plastic cups filled with milk, sealed with film, labeled with the type of milk and the date prepared, and contained no use-by date. The following products and preparation dates were:1 cup of 2% milk prepared 7/7/20261 cup of 2% milk prepared 7/8/20261 cup of 2% milk prepared 7/9/20262 cups of Regular milk prepared 7/10/202619 cups of 2% milk prepared 7/11/202628 cups of Regular milk prepared 7/11/2026 During a concurrent observation and interview on 7/13/2026 at 10:50 a.m., with the Dietary Supervisor (DS), the DS stated that milk portioned out should be discarded three days after the preparation date. Observed the milk labels and the DS confirmed by stating that milk dated 7/7/2026 was seven days from preparation and confirmed that the label omits any use-by or expiration date. The DS stated this increased the risk of serving spoiled food and promoting foodborne illness among residents since they cannot monitor the expiration date of the original product from which it was prepared. The DS stated the milk should have been discarded. During an interview on 7/14/2026 at 2:30 p.m., with the Registered Dietitian (RD), the RD stated that milk is a potentially hazardous food and the lack of labeling a use-by date can promote foodborne illness and should not be considered safe for residents to consume. The RD stated that the milk beyond 24 hours from preparation without a use-by date labeled should have been discarded. During a review of the 2022 FDA Food Code section 3-501.17(B), the code indicated that commercially processed Ready-To-Eat/Temperature Control For Safety Food shall be clearly marked at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded and:The day the original container is opened in the food establishment shall be counted as day one.The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. During a review of the facility's policy and procedure titled, Food Receiving and Storage, dated 11/2017, the policy indicated that food products and beverages must be inspected by facility staff to ensure proper storage and keeping track of when to discard perishable foods including labeling and dating all foods stored in the refrigerator as indicated. The policy did not indicate holding times of potentially hazardous foods and did not specify a three-day policy for storing milk. 2. During an observation of the facility's kitchen on 7/13/2026 at 8:05 a.m., in the walk-in refrigerator, observed a shallow, clear plastic pan, approximately half filled with squares of orange, translucent gelatin labeled Regular Gelatin, Prepared on: Sat 6/27/26. During a concurrent observation and interview on 7/13/2026 at 10:50 a.m., with the DS, the DS stated that prepared gelatin should be discarded three days after the preparation date. During concurrent observation of the gelatin labeling, the DS confirmed by stating that the gelatin was 17 days from the labeled preparation date. The DS stated this increased the risk of serving spoiled food and promoting foodborne illness among residents and the gelatin should have been discarded. During an interview on 7/14/2026 at 2:30 p.m., with the RD, the RD stated that gelatin has the potential to grow mold which can promote foodborne illness and should not be considered safe for residents to consume. The RD stated that the gelatin should have been discarded. During a review of the 2022 FDA Food Code section 3-501.17(A), the code indicated that on-premises prepared Ready-To-Eat/Temperature Control For Safety Food 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 premises, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days and that the day of preparation shall be counted as day one. During a review of the facility's policy and procedure titled, Food Receiving and Storage, dated 11/2017, the policy indicated that food products and beverages must be inspected by facility staff to ensure proper storage and keeping track of when to discard perishable foods including labeling and dating all foods stored in the refrigerator as indicated. The policy did not indicate holding times of potentially hazardous foods and did not specify a three-day policy for storing potentially hazardous foods prepared in the kitchen. 3. During an observation of the facility's kitchen on 7/13/2026 at 8:05 a.m., in the walk-in refrigerator, observed a white, five (5) pound (lbs.- unit of weight) plastic tub of sour cream with a manufacturer printed use-by date of 7/5/2026. During continue observation, the lid had a label indicating a received date of 5/22/2026 and a written opened date of 6/29/2026. During an observation on 7/14/2026 at 9:00 a.m., the same tub of sour cream dated 7/5/2026 was kept in the walk-in refrigerator. During a concurrent observation and interview on 7/14/2026 at 2:30 p.m., with the RD, the RD observed and stated that the tub of sour cream was kept nine (9) days beyond the printed use-by date and should have been discarded. The RD stated that sour cream is a potentially hazardous food and can promote foodborne illness among residents. During a review of the facility's policy and procedure titled, Food Receiving and Storage, dated 11/2017, the policy indicated that food products and beverages must be inspected by facility staff to ensure proper storage and keeping track of when to discard perishable foods including labeling and dating all foods stored in the refrigerator as indicated. 4. During an observation on 7/13/2026 at 11:30 a.m., in the resident refrigerator, observed one unopened carton of butter containing four 4-oz sticks labeled with the resident's name, a receive date of 7/13/2026, and a manufacturer printed use-by date of 10/4/2025. During an interview on 7/14/2026 at 1:30 p.m., with the Director of Nursing (DON), the DON stated that facility staff should check the expiration or use-by dates prior to storing food in the resident refrigerator. The DON confirmed by stating that the butter is beyond nine months from the manufacturer use-by date as indicated on the package and that it should be discarded. The DON confirmed by stating that the facility policy was not followed. During an interview on 7/14/2026 at 2:30 p.m., with the RD, the RD confirmed by stating that facility staff are responsible for checking use-by dates and that butter beyond nine months from its date may present rancidity (spoilage of foods containing fats or oils) which will affect quality and potentially cause adverse gastrointestinal (a term referring to organ of the digestive tract, specifically the stomach and intestines) effects. The RD stated that the butter should have been discarded. During a review of the facility's policy and procedure titled, Use and Storage of Food Brought to Resident, dated 6/2025, the policy indicated that it is the facility's responsibility to monitor refrigerated food so it used by its use-by date and that the facility is responsible for discarding perishable foods on or before the manufacturer's use-by date.

Based on observation, interview, and record review, the facility failed to ensure that a call light (a device used by a patient to signal his or her need for assistance from a professional staff) was within reach for one of 26 sampled resident (Resident 148). This failure had the potential to result in Resident 148 not being able to call for facility staff assistance and delay in the provision of necessary care and services which could negatively affect the residents' comfort and well-being. Findings: During a review of Resident 148's admission Record, the admission Record indicated the facility originally admitted the resident on 4/07/2009 and readmitted the resident on 5/08/2025 with diagnoses including gastro-esophageal reflux disease (a chronic digestive condition where stomach acid or bile repeatedly flows back into the esophagus) and type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 148's Minimum Data Set (MDS - a resident assessment tool) dated 6/24/2026, the MDS indicated Resident 148 sometimes makes herself understood and sometimes understand others. The MDS further indicated Resident 148 was totally dependent on staff for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During an observation on 7/13/2026 at 11:08 a.m. in Resident 148's room, observed resident in bed sleeping. Observed resident`s call light hanging on the metal pole used for gastrostomy tube (G-Tube-a medical device inserted through the abdomen directly into the stomach to provide essential nutrition, fluids, and medications) pump and feeding bag. During a concurrent observation and interview on 7/13/2026 at 11:56 a.m. with Licensed Vocational Nurse 1 (LVN 1) in Resident 148`s room, LVN 1 stated that that the resident`s call light was hanging in the G-Tube pole. LVN 1 stated that, if the resident is unable to access the call light, it may result in frustration and prevent the resident from receiving the timely care they require. LVN 1 further stated that the delay in care may result in negative outcomes such as skin breakdown due to remaining in soiled briefs for an extended period of time. During a review of the facility's policy and procedure (P&P) titled, Resident Call System, last reviewed, the P&P indicated that The facility is adequately equipped to allow residents to call for assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area form the residents` bedside, floor, or toileting facilities.resident call system shall be accessible to residents while in their bed or other sleeping accommodations within the residents` room.

Based on interview and record review, the facility failed to ensure one of 26 sampled residents' (Resident 48's) diagnoses were reflected in the resident's list of diagnoses in the Minimum Data Set (MDS - a resident assessment tool). The MDS did not include the diagnoses of depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), psychotic disorder (severe mental illnesses characterized by a disconnection from reality, primarily involving hallucinations [seeing or hearing things not there] and delusions [false, fixed beliefs]), and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). This failure resulted in Resident 48 having an inaccurate MDS assessment and an incorrect clinical overview of the resident's health status, which could have led to problems with resident safety, quality of care, and continuity of care. Finidngs: During a review of Resident 48's admission Record, the admission Record indicated the facility admitted the resident on 1/10/2026 with diagnoses including, but not limited to, seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), hypertension (HTN-high blood pressure), and dysphagia (difficulty swallowing). During a review of Resident 48's History and Physical (H&P) dated 1/12/2026, the H&P indicated the resident does not have full capacity to make medical decisions but is able to express needs and preferences. During a review of Resident 48's MDS, dated [DATE], the MDSD indicated Resident 48's cognition (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) was intact. The MDS indicated Resident 48 was receiving antipsychotic (medication to treat psychosis (loss from reality) and antidepressant (medication to treat depression) medications. The MDS did not indicate the resident has diagnoses of depressive disorder, psychotic disorder, and Parkinson's disease under the Active Diagnoses section. During a review of Resident 48's psychiatric progress note, dated 3/24/2026, the psychiatric progress note indicated Resident 48 has the following diagnoses and medications: 1. Depressive disorder on Sertraline (Zoloft) (an antidepressant medication). 2. Psychotic disorder and on Risperidone (an antipsychotic medication to control psychosis). During a review of Resident 48's Nurse Practitioner progress note, dated 3/4/2026, the Nurse Practitioner progress note indicated Resident 48 has a diagnosis of Parkinson's disease and on benztropine (a medication to treat Parkinson's disease and symptoms such as tremors and stiffness). During a review of Resident 48's Order Summary Report with active orders as of 7/16/2026, the Order Summary Report indicated the following orders: -Benztropine 1 milligram (mg-unit of measurement) two times a day for Parkinsonism -Risperidone 2 mg two times a day for psychosis manifested by striking out. -Sertraline 100 mg one time a day for depression manifested by verbalization of sadness. During a review of Resident 48's Medication Administration Record (MAR) from 4/1/2026 to 4/30/2026, the MAR indicated Resident 48 received: 1. Benztropine 1 mg two times a day for parkinsonism 2. Risperidone 2 mg two times a day for psychosis manifested by striking out 3. Sertraline 100 mg one time a day for depression manifested by verbalization of sadness from 4/1/2026 to 4/30/2026. During a concurrent interview and record review on 7/15/2026 at 8:54 a.m. with Minimum Data Set Coordinator (MDSC) 1, Resident 48's MDS, dated [DATE], was reviewed. The MDSC stated Resident 48's MDS did not indicate diagnoses of depressive disorder, Parkinson's disease, and psychotic disorder under the Active Diagnoses section. MDSC 1 stated she reviewed the seven day look back period and confirmed that Resident 48 was receiving medications for depressive disorder, Parkinson's disease, and psychotic disorder. MDSC 1 stated these diagnoses should have been reflected in the MDS, as the resident had documented diagnoses of depressive disorder, Parkinson's disease, and psychotic disorder and was receiving an antidepressant, an antipsychotic, and medication for Parkinson's disease. The MDSC 1 stated Resident 10's MDS assessment was not accurate. During a concurrent interview and record review on 7/15/2026 at 10:45 a.m. with the Director of Nursing (DON), Resident 48's MDS, dated [DATE], was reviewed. The DON stated Resident 48's MDS did not indicate diagnoses of depressive disorder, Parkinson's disease, and psychotic disorder under the Active Diagnoses section. The DON stated that Resident 48's MDS should include the diagnoses of depressive disorder, Parkinson's disease, and psychotic disorder to ensure the assessment reflects the resident's current conditions. The DON stated that accurate diagnoses must be documented in the MDS, as this information is required by regulation and is used to generate the care plan. During a review of the facility's policy and procedure (P&P) titled, Accuracy of Assessment, last reviewed on 1/21/2026, the P&P indicated the MDS assessment must accurately reflect the residents' status including but not limited to coordination by a registered nurse of each assessment with the appropriate participation of health professionals. To ensure each resident receives an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas and are knowledgeable about the resident's status, needs, strengths, and areas of decline. Accuracy of Assessment: The appropriate qualified health professionals correctly document the resident's medical. functional, and psychosocial problems and identify resident strengths to maintain or improve medical status, functional abilities, and psychosocial status using the RAI. The assessment must represent an accurate picture of the resident's status during the observation period of the MDS. Facility MDS assessors shall accurately record all information within the residents' MDS Assessment consistent with the resident's status at the time of the Assessment Reference Date.

Based on interview, and record review, the facility failed to review and revise the comprehensive care plan (a document outlining a detailed approach to care customized to an individual resident's need) for two of 26 (Resident 8 and 112) sampled residents. This failure practice had the potential for Residents 8 and 112 not to receive the necessary care and services. Findings: a. During a review of Resident 8's admission Record, the admission Record indicated the facility originally admitted Resident 10 to the facility on [DATE] and readmitted on [DATE] with diagnoses that included gastro-esophageal reflux disease (a chronic digestive condition where stomach acid or bile repeatedly flows back into the esophagus) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 8' s Minimum Data Set (MDS, a resident assessment tool) dated 4/08/2026, the MDS indicated Resident 8 was cognitively (the process of acquiring knowledge and understanding through thought, experience, and the senses) impaired and was totally dependent on staff for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a concurrent interview and record review on 7/15/2026 at 10:59 a.m. with the Assistant Director of Nursing (ADON), Resident 10's Activity Care Plan with a target date of 7/9/2026 was reviewed. The ADON stated that the Activity Care Plan is no longer an active care plan since it has not been renewed and revised after the 7/9/2026 date. The ADON stated that if the care plans are not reviewed, they would not know if the care plans were still effective in meeting the resident`s goals. The ADON stated that the target date is the date when the care plan is evaluated to determine if the care plan goals have been met with the interventions that were provided. The ADON stated that after the evaluation date, they will then renew the care plan if the problem has not been resolved and in the case of Resident 8, the care plan should be renewed because the need for activity is continuous. The ADON stated that without a care plan, the resident may not receive the specific or resident centered services to improve her quality of life. During a review of the facility's policy and procedure (PP) titled, Comprehensive Care Plans-Timing, last reviewed 1/21/2026, the PP indicated that Each resident has a person-centered, comprehensive care plan, reviewed, and revised by the facility interdisciplinary team including the resident and resident representative, if applicable. b. During a review of Resident 112`s admission Record, the admission Record indicated the facility originally admitted the resident on 9/18/2025 and readmitted on [DATE] with diagnoses including, persistent vegetative state (a condition where a person with severe brain damage appears awake but has no awareness of themselves or their surroundings), acute kidney failure (a sudden, rapid decline in kidney function occurring within hours or days) and chronic respiratory failure (occurs when the lungs chronically fail to oxygenate the blood or remove carbon dioxide effectively). During a review of Resident 112's MDS dated [DATE], the MDS indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and senses) skills for daily decision making was totally dependent on staff for ADLs. During a concurrent interview and record review on 07/15/2026 at 9:05 a.m. with the Assistant Director of Nursing (ADON), the following resident`s records were reviewed: -Change of Condition (COC) dated 6/5/2026 which indicated that Resident 112 had an elevated heart rate (an abnormally fast resting heart rate, typically exceeding 100 beats per minute [bpm] in adults) of 120 bpm and the facility received an order to transfer resident to an acute hospital. -Admit/Readmit Evaluation dated 6/9/2026 indicating Resident 112 was readmitted on this date. -Care Plan for respiratory care related to disease process dated 7/8/2026. The ADON stated that upon readmission, residents' care plans are reactivated. The ADON stated that Resident 112 was readmitted on [DATE] and the CP for respiratory care was only reactivated on 7/08/2026, which was a month after Resident 112's readmission. The ADON stated that if there is no CP, there will be inconsistent care provided to the residents. The ADON stated that a CP will identify the goals of treatment and specify the interventions to meet these goals. The ADON stated that in the absence of a care plan, specific and necessary care and services may not be provided to Resident 112 resulting in failure to achieve the resident's treatment goals related to respiratory care. During a review of the facility's policy and procedure (PP) titled, Comprehensive Care Plans-Timing, last reviewed 1/21/2026, the PP indicated that Each resident has a person-centered, comprehensive care plan, reviewed, and revised by the facility interdisciplinary team including the resident and resident representative, if applicable.

Based on observation, interview, and record review, the facility failed to set a resident's low air loss mattress (LALM - designed to distribute a patient's body weight over a broad surface area and help prevent skin breakdown) in accordance with the physician's order for one out of one sampled resident (Resident 122) investigated for pressure ulcer/injury (also known as pressure sores and decubitus ulcers, localized damage to skin and/or underlying tissue caused by prolonged pressure or friction, often over bony areas a skin and soft tissue injury that occurs when skin is under pressure). This failure placed the resident at risk for discomfort and development of new and or worsening of pressure ulcers. Findings: During a review of Resident 122's admission Record, the admission Record indicated the facility originally the resident to the facility on 4/26/2026 with diagnoses that included sepsis (a life-threatening blood infection), anoxic brain damage (brain death), and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of the facility provided document titled Skilled Nursing Facility Admission, Resident 122's History and Physical (H&P) dated 4/27/2026 indicated a significant issue that occurred during the hospitalization: an unstageable pressure ulcer to the sacrum. During a review of Resident 122`s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/1/2026, the MDS indicated the resident`s cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was severely impaired. The MDS indicated the resident was totally dependent on staff for rolling left to right, oral hygiene, toileting hygiene, shower/bath, upper body dressing, lower body dressing. During a review of Resident 122's Care Plan (CP), revised 6/20/2026, the CP indicated the resident has potential for actual impairment to skin integrity at sacrum scare tissue. The CP indicted an intervention to provide Resident 122 with pressure relieving/reducing mattress/pillows to protect the skin while in bed. During a review of Resident 122's Braden scale (tool used by healthcare providers to assess the risk of pressure ulcers) dated 6/20/2026, the Braden scale indicated Resident 122 confined to bed, completely immobile, skin occasionally most, require moderate to maximum assistance in moving complete lifting without sliding against sheets is impossible and the category indicated high risk for pressure ulcer. During a concurrent observation and interview on 7/14/2026 at 8:09 a.m., in Resident 122's room with Registered Nurse 2 (RN 2) observed Resident 122 lying on a LALM set at less than 80 pounds (lbs.-unit of measurement). RN 2 stated that the setting of less than 80 lbs. is not accurate since Resident 122's weight is more than 80 lbs. During a concurrent interview and record review on 7/14/2026 at 9:12 a.m., with RN 2, Resident 122`s physician`s order dated 7/14/2026 and Resident 122's weight dated 7/13/2026 was reviewed. RN 2 stated the physician order indicated an order for LALM setting between 120-160 lbs. every day and night shift. RN 2 stated Resident 122's weight dated 7/13/2026 was 143 lbs. RN 2 stated a LALM is not set according to the Resident122`s weight and physician order, which can potentially result in the development of a wound or worsening of a wound. During an interview on 07/15/2026 at 9:08 a.m., with the Director of Nursing, the DON stated the use of air loss mattress can prevent the development of skin impairment and if the setting is incorrect, it will not achieve the intended therapeutic effect but rather can be the cause of the pressure ulcer. The DON stated nursing staff must follow the physician order. During a review of the facility`s policy and procedure (P&P) titled Low Air Loss Mattress last reviewed on 1/21/2026, the P&P indicated the facility has guidelines to provide residents with a low air loss mattress to reduce skin irritation and breakdown, and to allow maximal effectiveness of the low air loss mattress when a physician orders such therapy. Patient assessment. monitoring. and proper maintenance and use of equipment is required to reduce the risk of entrapment related to variations in bed rail dimensions, mattress thickness. size, or density which can increase the risk of entrapment.

Based on observation, interview, and record review, the facility failed to ensure that respiratory care supplies for two of two sampled residents (Resident 9 and Resident 67) reviewed under the respiratory care area, were changed in accordance with professional standards of practice and facility's policy and procedure. This failure had the potential to place the residents at increased risk of developing respiratory tract infections and distress. Findings: a. During a review of Resident 9's admission Record, the admission Record indicated the facility originally admitted the resident on 6/27/2024 and readmitted on [DATE] with diagnoses including but not limited to end stage renal disease (ESRD - irreversible kidney failure), and paraplegia (loss of movement and/or sensation, to some degree, of the legs). During a review of Resident 9's Order Summary revised 6/4/2026, the Order Summary indicated an order for oxygen at two liters per minute (LPM) via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) as needed for shortness of breath. During a review of Resident 9's Care Plan dated 7/13/2026, the Care Plan indicated the resident is receiving an oxygen therapy to improve breathing. The interventions included providing Resident 9 with oxygen at two LPM via nasal cannula and monitoring for signs and symptoms of respiratory distress, During a concurrent observation and interview on 7/13/2026 at 12:25 p.m. with Licensed Vocational Nurse (LVN) 5 in Resident 9's room, Resident 9's oxygen concentrator (a medical-grade machine used to deliver oxygen) was observed with an oxygen humidifier bottle (a distilled or sterile water bottle used with the oxygen concentrator to prevent nasal dryness and throat irritation) dated 6/4/2026. LVN 5 stated the humidifier bottle should be changed every seven days on Sundays during night shift. LVN 5 stated the humidifier bottle should have been changed timely to prevent the resident from developing an infection. During an interview on 7/13/2026 at 12:30 p.m. with the Director of Nursing (DON), the DON stated the humidifier bottle should be changed per guidelines even if the physician order is to provide Resident 9 with oxygen as needed. The DON stated using a humidifier bottle that has not been changed for over a month is an infection control issue and could cause an infection to the resident. b. During a review of Resident 67's admission Record, the admission Record indicated the facility admitted the resident on 7/29/2024 with diagnoses including but not limited to hemiplegia (mild to moderate muscle weakness) and hemiparesis (severe or complete paralysis), and chronic respiratory failure (a long-term condition where the body cannot adequately deliver oxygen to the blood and remove carbon dioxide from the body). During a review of Resident 67's Order Summary, the Order Summary indicated a Respiratory Therapy order dated 2/17/2026 to change the nasal cannula every Friday and as needed for excessive soiling. During a review of Resident 67's MDS, dated [DATE], the MDS indicated Resident 67's cognition was severely impaired. The MDS further indicated Resident 67 was receiving oxygen therapy, and respiratory therapy seven days for at least 15 minutes a day. During a concurrent observation and interview on 7/13/2026 at 3:10 p.m., with the Respiratory Therapy Director (RTD) in Resident 67's room, Resident 67's nasal cannula was dated 7/5/2026. The RTD stated the nasal cannula should be changed once a week, every Friday, or as needed if it is soiled or falls on the floor. The RTD stated if the nasal cannula is not changed timely the resident could develop an infection. During a review of the facility's policy and procedure (P&P) titled Oxygen Therapy, revised 1/21/2026, the P&P indicated all oxygen tubing, humidifiers, masks, and cannulas to delivery oxygen should be changed weekly and when visibly soiled.

Based on observation, interview, and record review, the facility failed to document the administration of a dose of ciprofloxacin (an antibiotic medication used to treat infections) in the medication reconciliation log (a sheet used to compare medical orders with the medication given to a resident to prevent errors, omissions, duplication, and maintain medication count) for one of three sampled medication carts (Nurse Station 1 Medication Cart 1). This failure resulted in a medication count discrepancy of ciprofloxacin and had the potential to result in a double dosage administration to the resident which can lead to adverse reactions (undesired harmful effect resulting from a medication or other intervention).Findings: During a concurrent observation, interview, and record review on 7/16/2026 at 11:01 a.m., with Licensed Vocational Nurse 8 (LVN 8), observed the Nurse Station 1 Medication Cart 1. Observed the ciprofloxacin count in the medication bubble pack (a type of medication packaging in which each individual dose is sealed inside its own plastic bubble with a foil backing) was nine (9), and the medication reconciliation log indicated the count was 10. LVN 8 stated the 7/16/2026 morning dose was not logged in the medication reconciliation log. LVN 8 stated the medication count should be logged in as soon as the medication is given to the resident to ensure there is a record that the medication was given and accounted for. During an interview on 7/16/2026 at 12:27 p.m., with the Director of Nursing (DON), the DON stated the medication reconciliation log for antibiotics should be filled out and documented once the medication is removed from the medication bubble pack. The DON stated if it is not documented, the medication is not accounted for and there could be a risk for a medication administration error. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, last reviewed 1/21/2026, the P&P indicated the licensed nurse should identify the resident, verify the scheduled medication, and follow standard of practice to pour, pass, and chart.

Based on interview and record review, the facility failed to ensure that all of a resident's active diagnoses were reflected in the admission Record under the Diagnosis Information section for one of one sampled resident (Resident 48). This failure resulted in Resident 48's admission Record containing incomplete information and had the potential to create confusion in the delivery of care and services.Findings: During a review of Resident 48's admission Record, the admission Record indicated the facility admitted the resident on 1/10/2026 with diagnoses including, but not limited to, seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), hypertension (HTN-high blood pressure), and dysphagia (difficulty swallowing). Resident 48's admission Record did not include diagnosis for depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), psychosis (severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality), and Parkinson's disease (a movement disorder of the nervous system that worsens over time). During a review of Resident 48's History and Physical (H&P) dated 1/12/2026, the H&P indicated the resident does not have full capacity to make medical decisions but is able to express needs and preferences. During a review of Resident 48's Minimum Data Set (MDS, a resident assessment tool) dated 4/16/2026, the MDS indicated Resident 48's cognition (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) was intact. The MDS indicated Resident 48 is on antipsychotic (medication to treat psychosis (loss from reality) and antidepressant (medication to treat depression) medication. During a review of Resident 48's Order Summary Report, the Order Summary Report indicated an active order dated 7/16/2026 to administer: - Benztropine (a medication to treat Parkinson's disease and symptoms such as tremors and stiffness) one (1) milligram (mg- unit of measurement) two times a day for parkinsonism. - Risperidone (an antipsychotic medication to control psychosis) two (2) mg two times a day for psychosis manifested by striking out. - Sertraline (an antidepressant medication) 100 mg one time a day for depression manifested by verbalization of sadness. During a review of Resident 48's Nurse Practitioner progress note dated 3/4/2026, the Nurse Practitioner progress note indicated Resident 48 has diagnosis of: - Parkinson's disease and on Benztropine. During a review of Resident 48's psychiatric progress note dated 3/24/2026, the psychiatric progress note indicated Resident 48 has a diagnosis of: - Depressive disorder on Sertraline.- Psychotic disorder and on Risperidone. During a review of Resident 48's Medication Administration Record (MAR, a report detailing the medications administered to a resident by the licensed nurse in the facility) from 4/1/2026 to 4/30/2026, the MAR indicated Resident 48 received Benztropine one (1) mg two times a day for parkinsonism, Risperidone two (2) mg two times a day for psychosis manifested by striking out, and Sertraline 100 mg one time a day for depression manifested by verbalization of sadness from 4/1/2026 to 4/30/2026. During a concurrent interview and record review on 7/15/2026 at 9:10 a.m., with Minimum Data Set Coordinator 1 (MDSC 1), reviewed Resident 48's admission Record, dated 7/14/2026. MDSC 1 stated Resident 48's admission Record did not indicate a diagnosis of depressive disorder, Parkinson's disease, and psychotic disorder under the Diagnoses Information section. MDSC 1 stated the diagnosis of depressive disorder, Parkinson's disease, and psychotic disorder should be included on the admission Record because Resident 48 is taking an antidepressant, antipsychotic, and Parkinson's disease medication and Resident 48 is diagnosed with depressive disorder, Parkinson's disease, and psychotic disorder. During an interview on 7/15/2026 at 10:48 a.m., with the Director of Nursing (DON), the DON stated Resident 48's admission Record should include the diagnosis of depressive disorder, Parkinson's disease, and psychotic disorder and the admission Record is not complete. The DON stated that the admission Record should be updated any time a new diagnosis is added by the provider. The DON further stated that the admission Record is not accurate at this time because the diagnoses are missing. During a review of the facility's policy and procedure (P&P) titled, Identifiable Information, last reviewed on 1/21/2026, the P&P indicated the facility maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized.

Based on observation, interview, and record review, the facility failed to follow infection control practices and food handling practices by failing to ensure leftover milk is removed from the resident`s bedside after two hours for one of one resident (Resident 40). This deficient practice had the potential to place the resident at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages). Findings: During a review of Resident 40's admission Record, the admission Record indicated the facility originally admitted the resident on 1/8/2026 and readmitted the resident on 3/11/2025 with diagnoses including gastro-esophageal reflux disease (stomach contents flow backward, up into the esophagus, the tube that carries food from your throat into stomach) and type two (2) diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 40's Minimum Data Set (MDS - a resident assessment tool) dated 6/10/2026, the MDS indicated Resident 40 had that ability to usually make herself understood and the ability to sometimes understand others. The MDS further indicated Resident 40 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, shower, lower body dressing and putting on/taking off footwear. During a concurrent observation and interview on 7/13/2026 at 10:29 a.m., with Resident 40, in the resident`s room, observed an eight (8) ounce glass filled with milk up to the third of the glass on the overbed table directly in front of the resident. When asked, Resident 40 stated that she had that milk since the night before. During a concurrent observation and interview on 7/13/2026 at 10:56 a.m., with the Infection Preventionist Nurse (IPN), observed the glass of milk (1/3 filled) on Resident 40's overbed table. The IPN stated that Resident 40 had told her the milk was from last night. The IPN stated that around this time when the nurses had already taken out meal trays from the resident, the glass of milk should have already been removed to prevent the resident from ingesting contaminated milk. The IPN stated that consuming contaminated milk can potentially increase the risk of infection or foodborne illnesses. During a review of the facility`s policy and procedure (P&P) titled, Food Receiving and Storage, last reviewed on 1/21/2026, the P&P indicated, The facility should be keeping track of when to discard perishable foods. During a review of the facility`s policy and procedure (P&P) titled, Food Safety Requirement and Prevention of foodborne Illness, last reviewed on 1/21/2026, the P&P indicated, The facility maintains safe food handling practices throughout every stage of the food service process to reduce the potential for cross-contamination and foodborne illness .Food Handling Risks: Associated with food stored on the units may include but are not limited to: food left on trays or countertops beyond safe time and/or temperature requirement.

Based on observation, interview, and record review, the facility failed to ensure proper use of a low air loss mattress (LALM - a specialty bed that alternates pressure to help heal and prevent pressure ulcer/injuries [PU/PIs - injuries that breakdown the skin and underlying tissue when an area of skin is placed under pressure]), for one of four sampled residents (Resident 2) by failing to set the LALM to the correct mode while the resident was lying in bed, and by placing multiple layers of linens on top of the LALM. These deficient practices had the potential to increase the resident's risk for skin breakdown and/or delay the healing of existing PU/PI.During a review of Resident 2's admission Record, the admission Record indicated that the facility originally admitted the resident (Resident 2) on 1/2/2026 and readmitted on [DATE] with diagnoses that included hemiplegia (total paralysis [complete or partial loss of muscle function in a part of the body, often accompanied by a loss of sensation] of the arm, leg, and trunk on the same side of the body) and hemiparesis (paralysis or weakness on one side of the body) following cerebral infarction (CI - a serious medical condition that occurs when blood flow to the brain is blocked, leading to brain cell death), and Stage IV (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) PU of the sacral region (the flat, triangular bone located at the very base of the spine, between the lower back and the tailbone), diabetes mellitus (disorder characterized by difficulty in blood sugar control and poor wound healing), and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 5/4/2026, the MDS indicated Resident 2's cognition (ability to think and make decisions) was severely impaired. The MDS further indicated that Resident 2 was dependent on staff for Activities of Daily Living (ADLs- activities such as bathing, dressing and toileting a person performs daily). The MDS indicated that Resident 2 was at risk for developing PUs/PIs. During a review of Resident 2's Order Summary Report dated 3/3/2026, the Order Summary Report indicated that Resident 2's physician ordered a LALM for wound healing and prevention every shift. During a review of Resident 2's Care Plan (CP- a document that summarizes a resident's needs, goals, and care/treatment) report created on 6/4/2026, the CP indicated Resident 2 required the use of a LALM to relieve pressure, maintain skin integrity and promote healing of an existing wound. The CP further identified Resident 2 as being at risk for developing PU/PI and included interventions to ensure the LALM was properly inflated and set according to the manufacturer's guidelines. During a review of Resident 2's Wound Physician's Progress Notes dated 6/9/2026, the Wound Physician's Progress Notes indicated the following pre-procedure measurement: Location - Sacrococcyx (the tailbone area at the bottom of the spine, right between the buttocks), sacral region. Measurements - the length was 2.7 centimeter (cm - a unit of measurement), the width was 1.0 cm, and the depth was 0.2 cm. During a review of Resident 2's Progress Notes dated 6/10/2026, timed at 11:51 a.m., the Progress Notes indicated that Resident 2 remained at high risk for further skin breakdown and had higher risk/potential for PU development due to generalized muscle weakness, poor mobility, thin and fragile skin, anemia, hypertension (high blood pressure), hyperlipidemia (excessive fat in the blood), acute (sudden, intense flare-up) kidney failure (AKF - kidneys stop working suddenly), DM, and history of osteomyelitis (inflammation of bone or bone marrow, usually due to infection) on sacral wound. During a concurrent observation and interview on 6/16/2026 at 12:52 p.m., in Resident 2's room, with Treatment Nurse 1 (TN 1), Certified Nursing Assistant 2 (CNA 2), and Director Staff Development (DSD), Resident 2 was observed lying in bed on a LALM that was set to static mode (function that stops the mattress from alternating pressure [a feature of some devices that inflate and deflate in sections, such as air mattresses, redistributes pressure across the body, which can help prevent PU and improve circulation]) with the seat inflate function activated. Resident 2 was observed lying on an incontinence (loss of bowel or bladder control), a cloth incontinence linen pad consisting of two different textures with white color top and blue color bottom and a spread sheet. TN 1 stated there were a total of four layers of linen between Resident 2 and the LALM surface. CNA 2 stated staff should place only one layer of linen between the resident's skin and the LALM to promote wound healing. During the observation, the DSD entered the room and stated that the LALM was incorrectly set to static mode with seat inflate activated while the resident (Resident 2) was lying in bed. The DSD stated that the LALM should have been set to the Alternate Mode. The DSD then immediately changed the setting to the alternate mode. During a follow-up interview on 6/12/2026 at 3:15 p.m., with the DSD, the DSD stated that staff should not place more than two layers of linen between the resident and the LALM because excessive layers interfere with the mattress's ability to promote airflow and reduce heat and moisture buildup, reducing the therapeutic effectiveness of the support surface. The DSD further stated that the LALM should be set to the alternating pressure mode while a resident is lying in bed because use of the static mode results in constant pressure, increasing the risk for delayed wound healing and the development of additional PUs. During a concurrent interview and record review on 6/12/2026 at 4:10 p.m., with the Director of Nursing (DON), the DON reviewed Resident 2's Physician Order for the use of LALM. The DON stated that staff should set the LALM to the alternating pressure mode while a resident is lying in bed. The DON further stated staff should not place more than two layers of linen between the resident and the LALM because excessive layers interfere with the therapeutic function of the mattress and do not promote the wound healing process. During a review of the facility's policy and procedure (P&P) titled, Treatment Services to Prevent/Heal Pressure Ulcers last revised on 1/21/2026, the P&P indicated, Support Surfaces and Pressure Redistribution. These products are more likely to reduce pressure effectively if they are used in accord with the manufacturer's instructions. The effectiveness of each product used needs to be evaluated on an ongoing basis, During a review of the undated LAL's instruction manual provided by the facility, the LAL instruction manual indicated the following instructions: Alternate - In Alternate therapy mode, the mattress system will alternate every 10 minutes. User can select for best comfort. Static - Press THERAPY button to suspend alternating function. If needed. The pressure inside of air tubes will be adjusted to the same softness. Press the THERAPY button again; it will switch back to alternating mode. Under the static mode, cell pressure level will be lowered compare to the same pressure level from alternating mode. This special feature is to protect high-risk pressure sore patient from receiving additional pressure, which could lead to pressure sore risks. Seat Inflation - The seat inflation features additional supports to the patient during upright position without bottoming out. User can select this additional feature under either static or alternate mode. During a review of the facility's P&P titled, Low Air Loss Mattress last revised on 1/21/2026, the P&P indicated, Low air loss mattresses provide airflow to help keep skin dry, as well as to relieve pressure. Low air loss mattress covers are specially designed to allow air flow to pass through and prevent moisture buildup. This creates a microclimate between the skin and mattress to keep the user comfortable and prevent skin breakdown. Standard linens will not impede air flow of the low air loss mattress and should be placed in a single layer (flat sheet) loosely over the mattress surface. Fitted sheets should not be used,

Based on interview and record review, the facility failed to notify a resident's family/representative regarding a resident missing their doctor's appointment for one of five sampled residents (Resident 4). This deficient practice had the potential for Resident 4's family not to be involved in Resident 4's plan of care.Findings: During a review of Resident 4's admission Record, the admission Record indicated the facility admitted the resident on 7/16/2025 with diagnoses that include other specified polyneuropathies (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet), moderate protein-calorie malnutrition (a condition resulting from an imbalance between the nutrients your body needs to function and the nutrients it actually gets), and myelodysplastic syndrome (a group of diseases where the bone marrow does not make enough healthy blood cells). During a review of Resident 4's Minimum Data Set (MDS- a resident assessment tool) dated 1/15/2026, the MDS indicated that Resident 4 had intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and required maximal assistance on staff with toileting hygiene, shower or bathing, dressing, personal hygiene, and mobility (movement). During a review of Resident 4's physician's order dated 10/23/2025 at 5:25 p.m., the physician's order indicated an order for an appointment on 12/10/2025 at 2:15 p.m. -2:30 p.m. with Doctor. During a review of Resident 4's physician's order dated 12/10/2025 at 3:22 p.m., the physician's order indicated an order for an appointment on 1/8/2025 at 2:15 p.m. with Doctor. During a concurrent interview and record review on 2/27/2026 at 3:30 p.m., with the Social Service Director (SSD), reviewed Resident 4's physician's order dated 10/23/2025 and 12/10/2025 regarding Resident 4's doctor's appointment. The SSD stated that she (SSD) was responsible for informing the resident and the resident's family or representative if there are any doctor's appointment that have been cancelled or rescheduled. The SSD stated that Resident 4's doctor's appointment dated 12/10/2025 had to be rescheduled to 1/8/2026 because the transportation did not show up. The SSD stated there is no documentation indicating if she notified Resident 4's family or representative regarding the doctor's appointment that had to be cancelled and had to be rescheduled. The SSD stated she should have informed Resident 4's family or representative regarding the doctor's appointment that was cancelled and had to be rescheduled so Resident 4's family or representative can be involved in plan of care. During a review of the facility`s policy and procedure (P&P) titled, Resident Rights, last reviewed on 1/21/2026, the policy indicated residents in long term care facilities have rights guaranteed to them under Federal and State law including the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.

Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain good grooming and personal hygiene for two of four sampled residents (Resident 1 and Resident 2) when the facility failed to trim and clean the residents' fingernails. This deficient practice resulted in Resident 1 and Resident 2 having long fingernails, placing the residents at increased risk for infection, skin breakdown and injury, and cross contamination; and had the potential to negatively affect the residents' comfort, self-esteem, and sense of dignity.Findings: a. During a review of Resident 1's admission Record, the admission Record indicated that the facility admitted the resident on 11/16/2025 with diagnoses including sepsis (a life-threatening blood infection), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and embolism (a blockage in a blood vessel) and thrombosis (the formation of a blood clot inside a blood vessel [vein or artery] that blocks or slows normal blood flow) of superficial veins of left upper extremity During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 11/21/2025, the MDS indicated that Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and senses) was severely impaired. The MDS further indicated that Resident 1 was dependent on staff with activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily), in which Resident 1 made no efforts to complete the activity, or the assistance of two or more helpers was required for the resident to complete the activity. During a review of Resident 1's care plan (CP) titled ADL, created on 11/16/2025, the care plan indicated Resident 1 required assistance in the following areas: Bed mobility (movement).personal hygiene, bathing related to clinical condition: sepsis and hypoxic respiratory failure. The CP indicated an intervention to assist the resident with maintaining good personal hygiene every shift and as needed. During a concurrent observation and interview on 12/26/2025 at 11:28 a.m., with Treatment Nurse 1 (TN 1, Licensed Vocational Nurse [LVN]), observed Resident 1's hands and nails. TN 1 stated that Resident 1's fingernails were long and needed to be trimmed and cleaned. During a concurrent observation and interview on 12/26/2025 at 12:24 p.m., with the Director of Nursing (DON), the DON observed Resident 1's fingernails and stated that Resident 1's fingernails were long and dirty and that staff needed to clean and trim Resident 1's fingernails. b. During a review of Resident 2's admission Record, the admission Record indicated that the facility originally admitted the resident on 11/25/2024 and readmitted on [DATE] with diagnoses including sepsis, contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion [ROM - how far a joint can flex and extend in any direction]) on right elbow, left elbow and left knee, and tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck). During a review of Resident 2's MDS dated [DATE], the MDS indicated that Resident 1's cognition was severely impaired. The MDS further indicated that Resident 2 had functional limitations in ROM on both upper and lower extremities and was dependent on staff with ADLs, in which Resident 2 made no efforts to complete the activity, or the assistance of two or more helpers was required for the resident to complete the activity). During a review of Resident 2's care plan (CP) titled ADL, created on 10/10/2025, the CP indicated Resident 2 required assistance in the following areas: Bed mobility.personal hygiene, bathing related to clinical condition: sepsis and contracted bilateral (both) arms. The CP indicated an intervention to assist the resident with maintaining good personal hygiene every shift and as needed. During a concurrent observation and interview on 12/26/2025 at 1:25 p.m., with the DON and Registered Nurse 1 (RN 1), observed Resident 2's hands and fingernails. The DON stated that Resident 2's fingernails were long and dirty, and that staff needed to clean and trim them. During an interview on 12/26/2025 at 2:37 p.m., with LVN 2, LVN 2 stated she reminds the Certified Nursing Assistants (CNAs) every Sunday that residents' fingernails should be trimmed and cleaned, however, she does not individually verify that each resident's fingernails are actually cleaned and trimmed by the CNAs. During a review of the facility's policy and procedure (P&P) titled ADL Care Provided for Dependent Residents last reviewed 9/17/2025, the P&P indicated, The facility provides assistance for residents unable to carry out ADL. The facility conducts periodic assessments of each resident to identify necessary services with ADL. Facility staff will assist each resident with bathing, grooming, eating, dressing, transferring, and other ADL, as necessary.

Based on observation, interview, and record review, the facility failed to ensure no more than two layers of linen were placed on top of the low air loss mattress (LALM - a specialty bed that alternates pressure to help heal and prevent pressure ulcer/injuries [PU/PI - injuries that breakdown the skin and underlying tissue when an area of skin is placed under pressure]) for one of four sampled residents (Resident 1). This deficient practice had the potential to increase the resident's risk of skin breakdown.Findings: During a review of Resident 1's admission Record, the admission Record indicated that the facility admitted the resident on 11/16/2025 with diagnoses including sepsis (a life-threatening blood infection), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), PU/PI stage III (full-thickness loss of skin, dead and black tissue may be visible) of sacral (the bony region at the very base of your spine and just above the tailbone) region, and dependence on respirator (a medical device to help support or replace breathing).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 11/21/2025, the MDS indicated that Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and senses) was severely impaired. The MDS further indicated that Resident 1 was dependent on staff with activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily), in which Resident 1 made no efforts to complete the activity, or the assistance of two or more helpers was required for the resident to complete the activity. During a review of Resident 1's physician order summary report, the physician order summary report indicated an order dated 12/22/2025 to apply LALM for wound management. During a concurrent observation and interview on 12/26/2025 at 7:53 a.m., with Certified Nursing Assistant 1 (CNA 1), CNA 2, and Licensed Vocational Nurse 1 (LVN 1), observed Resident 1 wearing an incontinence brief and lying on a LALM. The LALM had a fitted sheet with a cloth incontinence (loss of bowel or bladder control) pad made of two different textures of linen. When staff were asked how many layers of linen should be used between the LALM and Resident 1's skin, LVN 1 instructed CNA 1 and CNA 2 to remove Resident 1's incontinence pad and brief. LVN 1 stated there were four layers of linen placed between Resident 1's back and the surface of the LALM. LVN 1 stated that the nursing staff should not use multiple layers of linen on the LALM, as doing so will not promote the wound healing process. During an interview with the Director of Nursing (DON), the DON stated Resident 1 has currently a stage IV (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) PU on the sacrum, and staff should not use more than two layers of the linen, as it would defeat the purpose of the LALM use, and will not promote the wound healing process.During a review of the facility's policy and procedure (P&P) titled, Low Air Loss Mattresses last reviewed on 9/17/2025, the P&P indicated, Low air loss mattress covers are specially designed to allow air flow to pass through and prevent moisture buildup. This creates a microclimate between the skin and the mattress to keep the user comfortable and prevent skin breakdown. Standard linens will not impede air flow of the low air loss mattress and should be placed in a single layer (flat sheet) loosely over the mattress surface. Fitted sheets should not be used. When selecting linens and incontinence pads to place on support surfaces with a low air loss of features, efforts should be made to select non-plastic backed pads and dressings to reduce the potential to block the airflow and trap heat and moisture against the patient's skin.patients should not wear adult incontinence briefs, because these briefs obstruct airflow to the skin.

Based on observation, interview and record review, the facility failed to: 1. Ensure one of one sampled resident (Resident 79), who was at risk for pain and distress (state of extreme sorrow, suffering, or pain) related to chronic pain syndrome (persistent pain that lasts weeks to years) received care and services in accordance with professional standards of practice by failing to ensure Resident 79's unrelieved pain was managed. 2. Ensure nonpharmacological interventions (science-based, non-invasive healthcare interventions that are not primarily based on medication) were provided by the licensed nurses prior to administering as needed (prn) opioid medication (powerful pain-reducing medications) for three (Residents 278, 38, and 41) out of 34 sampled residents. These deficient practices caused Resident 79 to experience continued unrelieved moderate pain (pain rated at four [4] to six [6] out of 10, on a pain scale from zero [0] to 10, where 10 is the worst possible pain) on 7/9/2024 from 10:45 a.m. until 3:06 p.m.; and had the potential to place the Residents 278, 38, and 41 at increased risk of experiencing adverse side effects from opioid pain medication, such as sedation, dizziness, nausea, vomiting, constipation, physical dependence, tolerance, and respiratory depression. Findings: 1. During a review of Resident 79's Admission Record indicated that Resident 79 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic pain syndrome (persistent pain that lasts weeks to years). During a review of Resident 79's History and Physical (H&P), dated 4/6/2024, indicated that Resident 79 had the capacity to understand and make decisions. During a review of Resident 79's Minimum Data Set (MDS - a standardized resident assessment and care screening tool) assessment dated [DATE], indicated that Resident 79's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. During a review of Resident 79's Care Plan for at risk for pain dated 7/9/2024 indicated to anticipate Resident 79's need for pain relief, and to respond immediately to any complaints of pain. During a review of Resident 79's Physician Orders, indicated an order for Oxycodone Hydrochloride (Oxycodone HCl - a medication used to treat moderate to severe pain) oral tablet 10 milligrams (mg- unit of measure), to give one (1) tablet by mouth every six (6) hours as needed for severe pain (pain rated at seven [7] to 10, on a pain scale from zero [0] to 10, where 10 is the worst possible pain); with a start date of 7/8/2024. During a review of Resident 79's Medication Administration Record (MAR- the report that serves as a legal record of the medications administered to a resident of a facility by a health care professional) for 7/2024 indicated that Licensed Vocational Nurse 5 (LVN 5) administered a dose of Oxycodone HCL 10 mg to Resident 79 on 7/9/2024 at 9:52 a.m. for pain rated at 10. During a concurrent observation and interview on 7/9/2024 at 2:33 p.m., with Resident 79, observed Resident 79 grimacing (facial expression of pain) while in bed, inside Resident 79's room. Resident 79 stated that she (Resident 79) was experiencing severe pain rated at 10 in Resident 79's back and stomach area. Resident 79 stated that LVN 5 provided Resident 79 with oxycodone HCl at around 9:52 a.m., but that Resident 79's pain remained unrelieved. Resident 79 stated that she (Resident 79) informed LVN 5 at around 12:00 p.m. of the on-going unrelieved pain that Resident 79 was experiencing. Resident 79 stated that she (Resident 79) was informed by LVN 5 that there was nothing else that could be done or given to Resident 79. Resident 79 stated that she (Resident 79) felt that she (Resident 79) would benefit from additional pain medications. Resident 79 verbalized that she (Resident 79) was frustrated about being left in pain with nothing being done. During a concurrent observation and interview on 7/9/2024 at 2:36 p.m., with LVN 5 and Resident 79, observed Resident 79 inside Resident 79's room crying. Resident 79 stated that she was experiencing pain and continued to cry. During an interview on 7/9/2024 at 2:38 p.m. with LVN 5, LVN 5 stated that Resident 79 was administered Oxycodone HCl 10 mg earlier in the morning (9:52 a.m.). LVN 5 stated that LVN 5 did not reassess the effectiveness of Resident 79's Oxycodone HCL 10mg that was administered early that morning (7/9/2024 at 9:52 a.m.). LVN 5 further stated that pain reassessments are to be done 30 minutes to one [1] hour after a pain medication is given. When LVN 5 was asked if there was anything else being done related to Resident 79's unrelieved pain, LVN 5 stated that LVN 5 informed Registered Nurse 3 (RN 3) of Resident 79's unrelieved pain (time not specified) so that RN 3 can inform Resident 79's physician. During an interview on 7/10/2024 at 10:15 a.m. with RN 3, RN 3 stated that LVN 5 did not inform RN 3 of Resident 79's unrelieved pain on 7/9/2024. RN 3 stated that it was not until 7/9/2024 sometime after 2:38 p.m. that RN 3 discovered that Resident 79 was experiencing unrelieved pain. RN 3 stated that after discovering that Resident 79 was experiencing unrelieved pain, RN 3 called Resident 79's physician and obtained an order for additional pain medication of Morphine Sulfate (a medication used to help relieve moderate to severe pain). RN 3 further stated, unrelieved pain can negatively affect the resident causing the resident to cry, be upset, feel depressed (feel sad), isolate (to separate) oneself and delay healing. During a review of Resident 79's Physician Orders, indicated an order for Morphine Sulfate 15 mg tablet, give one (1) tablet by mouth one time for severe pain, with a start date and time of 7/9/2024 at 2:58 p.m. During a review of Resident 79's MAR dated 7/2024 indicated that Resident 79 was administered Morphine Sulfate 15 mg tablet on 7/9/2024 at 3:06 p.m. During a review of Resident 79's progress notes dated 7/9/2024 at 4:01 p.m., the note indicated that Resident 79 was asleep in bed. The note further indicated that no signs and symptoms of distress were noted. During a follow up interview on 7/11/2024 at 2:00 p.m., with LVN 5, LVN 5 stated that on 7/9/2024 at 10:52 a.m., LVN 5 did reassessed Resident 79's pain level after the administration of Oxycodone HCl and noted that Resident 79 had unrelieved pain of six (6) out of 10. LVN 5 stated that LVN 5 should have documented the reassessment of Resident 79's pain at 10:45 a.m. rather than documenting a late entry of Resident 79's reassessment on 7/9/2024 at 2:53 p.m. LVN 5 restated that LVN 5 informed RN 3 to call Resident 79's physician to obtain additional orders to help manage Resident 79's pain. During a review of Resident 79's Medication Administration Note with an effective date of 7/9/2024 and a created date of 7/9/2024 at 2:53 p.m., the note indicated that the administered medication of Oxycodone HCl 10 mg by LVN 5 to Resident 79 on 7/9/2024 at 9:52 a.m. was ineffective. The note further indicated that Resident 79 was experiencing unrelieved pain of six out of 10. During an interview on 7/11/2024 at 2:53 p.m. with the Director of Nursing (DON), the DON stated that it is important to control a resident's pain to ensure that residents are comfortable and pain-free. The DON stated pain reassessments should be completed within an hour of pain medication administration to check for efficacy. The DON stated, for Resident 79's ineffective pain medication of Oxycodone HCL 10mg administered on 7/9/2024 at 9:52 a.m., LVN 5 should have notified Resident 79's physician immediately to obtain additional orders to help manage Resident 79's unrelieved pain. The DON stated, severe pain is harmful because it can affect a resident's emotional state (the state of a person's emotions in a particular time), level of cooperation, vital signs (measurements of the body's most basic functions), and ability to heal. A review of the facility's policy and procedure (P&P) titled, Pain Assessment and Management last reviewed 4/23/2024, indicated that residents are to receive treatment and care in accordance with professional standards of practice . related to pain management. The policy further indicated that the facility is to monitor the effectiveness of interventions and modify approaches as necessary. The policy states that if pain is not adequately controlled, the facility shall reconsider approaches and make adjustments as indicated. 38549 2. A review of Resident 38's Admission Record indicated the facility admitted the resident on 1/9/2024 with diagnoses including pressure ulcer (a skin injury caused by constant pressure on an area of the body for a long period of time) of the sacral region (the triangular-shaped bone at the base of the spine). A review of Resident 38's MDS dated [DATE], indicated the resident had intact cognition and required setup or clean-up assistance from staff for most activities of daily living (ADLs - the basic personal care tasks that people need to do on their own to live independently). A review of Resident 38's care plan (contains relevant information about a patient's diagnosis, the goals of treatment, the specific orders, and an evaluation plan) for risk for pain related to disease process, initiated on 1/9/2024, indicated the goal that the resident will not have discomfort related to side effects of analgesia (the inability to feel pain) through the review date. Among some of the interventions listed was to keep the resident in a comfortable position. On 7/10/2024 at 8:24 a.m., during a concurrent interview and record review, reviewed Resident 38's physician's orders with Registered Nurse 5 (RN 5). RN 5 stated Resident 38 had a physician's order for Percocet (a type of opioid medication to treat pain) 5-325 milligrams (mg - unit of measurement), give one tablet by mouth every six (6) hours as needed for pain management. Reviewed the resident's 6/2024 Medication Administration Record (MAR - a report detailing the drugs administered to a patient by a healthcare professional) with RN 5. RN 5 stated the resident received Percocet 5-325 mg every day on multiple shifts. When asked what nonpharmacological interventions were provided to the resident, RN 5 stated there was no documentation indicating the licensed nurses provided nonpharmacological interventions to Resident 38 prior to administering Percocet 5-325 mg. Reviewed Resident 38's 7/2024 MAR with RN 5. RN 5 stated Resident 38 received Percocet 5-325 mg every day on multiple shifts. When asked what nonpharmacological interventions were provided to Resident 38, RN 5 stated there was no documentation indicating the licensed nurses provided nonpharmacological interventions to Resident 38 prior to administering the Percocet 5-325mg. RN 5 stated licensed nurses should be attempting nonpharmacological interventions prior to administering prn pain medication because it's possible that the resident may not need the medication. RN 5 stated the potential side effects the resident can experience from receiving too much opioid pain medication include an overdose or an increased risk of sedation. On 7/11/2024 at 10:12 a.m., during an interview, the Director of Nursing (DON) stated it is important for nurses to attempt nonpharmacological interventions prior to administering prn opioid medications because it is possible the resident may not need the medication. The DON stated that opioid medications increased the risk for constipation (unable to have a bowel [stool] movement), sedation, and falls. A review of Resident 41's Admission Record indicated the facility originally admitted the resident on 10/2/2023 and readmitted Resident 41on 10/31/2023 with diagnoses including stage four (4) pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time) of the sacral (bone at the base of the spine) region. A review of Resident 41's MDS, dated [DATE], indicated the resident had moderately impaired cognition and was mostly dependent on staff for ADLs. The MDS also indicated the resident received prn opioid pain medications. A review of Resident 41's care plan for risk of pain, initiated on 11/6/2023, indicated a goal that Resident 41 will not have discomfort related to side effects of analgesia. Among some of the interventions listed included to keep Resident 41 in a comfortable position. On 7/10/2024 at 8:37 a.m., during a concurrent interview and record review, reviewed Resident 41's physician's orders with RN 5. RN 5 stated Resident 41 had a physician's order for oxycodone hydrochloride (Oxycodone HCl- a type of opioid medication used to treat pain) five (5) mg, give one tablet by mouth ever four (4) hours as needed for moderate pain ( pain rated at four [4] to six [6] out of 10, on a pain scale from zero [0] to 10, where 10 is the worst possible pain). RN 5 stated Resident 41 also had a physician's order for oxycodone HCl 10 mg, give one tablet by mouth every four (4) hours as needed for severe pain ( pain rated at seven [7] or higher out of 10, on a pain scale from zero [0] to 10, where 10 is the worst possible pain). Reviewed Resident 41's 6/2024 MAR with RN 5. RN 5 stated Resident 41 received oxycodone HCl 10 mg prn almost every day. When asked what nonpharmacological interventions were provided to Resident 41, RN 5 stated there was no documentation indicating the licensed nurses provided nonpharmacological interventions to Resident 41 prior to administering the prn opioid medication. RN 5 stated licensed nurses should be attempting nonpharmacological interventions prior to administering prn pain medication because it's possible that the resident may not need the medication. RN 5 stated the potential side effects the resident can experience from receiving too much opioid pain medication include an overdose or an increased risk of sedation. On 7/11/2024 at 10:12 a.m., during an interview, the DON stated it was important for nurses to attempt nonpharmacological interventions prior to administering prn opioid medications because it is possible the resident may not need the medication. The DON stated that opioid medications increased the risk for constipation, sedation, and falls. A review of Resident 278's Admission Record indicated the facility admitted the resident on 7/3/2024 with diagnoses including cerebral infarction (a condition that occurs when blood flow to the brain is disrupted, causing an area of brain tissue to die). On 7/10/2024 at 8:32 a.m., during a concurrent interview and record review, reviewed Resident 278's physician's order with RN 5. RN 5 stated Resident 278 had a physician's order for Norco (a type of opioid medication used to treat pain) 5-325 mg, give one tablet every six (6) hours as needed for moderate to severe pain. Reviewed Resident 278's 7/2024 MAR with RN 5. RN 5 stated Resident 278 received Norco 5-325 mg on: - 7/7/2024 at 12:30 a.m. - 7/8/2024 at 3:13 a.m. and 6:45 p.m. - 7/9/2024 at 3:04 a.m. and 3:48 p.m. When asked what nonpharmacological interventions were provided to Resident 278, RN 5 stated there was no documentation indicating the licensed nurses provided nonpharmacological interventions to Resident 278 prior to administering the prn opioid medication. RN 5 stated licensed nurses should be attempting nonpharmacological interventions prior to administering prn pain medication because it's possible that the resident may not need the medication. RN 5 stated the potential side effects the resident can experience from receiving too much opioid pain medication include an overdose or an increased risk of sedation. On 7/11/2024 at 10:12 a.m., during an interview, the Director of Nursing (DON) stated it was important for nurses to attempt nonpharmacological interventions prior to administering prn opioid medications because it is possible the resident may not need the medication. The DON stated that opioid medications increased the risk for constipation, sedation, and falls. A review of the facility's policy and procedure titled, Pain Assessment and Management, last revised in 4/23/2024, indicated that nonpharmacological interventions may be appropriate alone or in conjunction with medications. Some non-pharmacological interventions include: - Environmental - Adjusting the room temperature, smoothing the linens, providing a pressure-reducing mattress, repositioning . - Physical - Ice packs, cool or warm compresses, baths, massage, acupuncture . - Cognitive or behavioral - Relaxation, music, diversions (distraction), activities .

Based on observation, interview and record review, the facility failed to: 1. Ensure oral care to maintain good oral hygiene was provided for one of five sampled residents (Resident 1) who was dependent on staff to carry out all activities of daily living (ADLs- everyday tasks necessary for self-sufficiency and independent living). 2. Ensure that two of five sampled residents (Residents 2, and 3) were provided with routine dental visits. As a result of the noncompliance described above, four (4) live maggots (small, wormlike fly larva [a worm-like creature, which emerges from an egg]) were found in Resident 1 ' s mouth on 7/16/2023; Resident 2 and Resident 3 were not seen for routine dental visits for over two (2) years while admitted at the facility placing the residents at increased risk for cavities (permanently damaged areas in the hard surface of your teeth that develop into tiny openings or holes) and gum disease (an infection of the tissues that hold your teeth in place). On 8/9/2023 at 1:26 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ-a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Assistant Administrator (AADM) and the Director of Nursing (DON) due to the facility's failure to ensure Residents 1, 2, and 3 were provided oral care to maintain good oral hygiene. On 8/11/2023 at 1:57 p.m., the DON provided the Department an IJ Removal Plan which included the following summarized actions: 1. Director of Nurses reviewed and revised Resident 1 ' s care plan to include the following interventions: i) Resident 1 will receive oral care with Chlorhexidine Gluconate Mouth and Throat Solution (a mouthwash that reduces bacteria in the mouth) 0.12 percent (%-unit of measure) twice a day (BID) for oral care. ii) Resident 1 to wear a surgical mask as tolerated and can be removed during ADLs since the resident has the tendency to have his mouth continuously open. iii) Dermatologist (a medical doctor who specializes in conditions that affect the skin, hair, and nails) was consulted and recommended Clindamycin hydrochloride (Clindamycin HCl - medication that destroys or helps stop the growth of bacteria) Oral Capsule 300 milligrams (mg-unit of measure) via gastrostomy tube (GT - a surgically placed device used to give direct access to a resident ' s stomach for supplemental feeding, hydration or medicine) q8 (every 8 hours) until 7/22/2023, Albendazole (medication used to treat infection caused by worms) Oral Tablet 400 mg via GT BID until 7/21/2023 and Ivermectin (anti-parasite [an organism that lives on or in a host organism and gets its food from or at the expense of its host] medication used to treat parasitic diseases) Oral Tablet three mg one tab via gt daily (QD) until 7/21/2023. Both Primary Medical Doctor (PMD) and Pulmonologist (a physician who specializes in the respiratory system) agreed with the order. iv) Resident 1 ' s tracheostomy (a surgically created stoma [hole] in your trachea [windpipe] that provides an alternative airway for breathing) was changed, suctioned and lavaged (washed out) on 7/17/2023. Resident 1 was seen and evaluated by the Pulmonologist on 7/17/2023 on the evening shift (3:00 p.m. to 11:00 p.m.). v) Resident 1 ' s room was terminally cleaned (the cleaning procedures used to control the spread of infectious diseases in a healthcare environment). vi) Resident 1 ' s curtains were changed, and the resident ' s screen windows were checked to ensure that there were no points of entry for flies. vii) Resident 1 to receive oral care by Certified Nursing Assistants (CNA) twice a day with mouthwash and as needed. viii) Resident 1 to receive suction (method of removing excess secretions [mucus] from the mouth) every (q) two (2) hours and as needed. ix) Resident 1 to receive tracheostomy care q shift and as needed. x) Resident 1 to have tracheostomy change q month and as needed. [NAME]) Resident 1 to be monitored q shift for sign and symptoms of oral infection by the licensed nurses such as redness, swelling, and increased mucous secretions. xii) Resident 1 will be evaluated by the Dentist every month for three (3) months or until the Dentist deems it is not necessary, at which point the resident will return to regular scheduled annual (yearly) visits and as needed. xiii) Resident 1 will be referred to the Speech Therapy (provides treatment, support, and care for those who have difficulties with communication, or with eating, drinking, and swallowing) for further recommendations on oral hygiene on 8/12/2023. 2. On 8/11/2023, Director of Staff Developer (DSD) in-serviced CNAs on how to correctly document on the facility ' s ADLs forms by utilizing the correct code on how a resident maintains personal hygiene. 3. Resident 1 received oral care by the CNA and Registered Nurse (RN) Supervisor on 7/16/2023 at around 9:30 a.m. to 10:00 a.m. Resident 1 was immediately assessed on 7/16/2023 by the RN Supervisor and noted Resident 1 to be with no pain, nor discomfort at around 2:00 p.m. Resident 1 ' s mouth was cleaned again by RN supervisor at around 2:00 p.m. to 2:30 p.m. Resident 1 was suctioned by the Respiratory Therapist (RT) at 1:00 p.m. and 3:00 p.m. 4. On 7/17/2023, the DSD initiated in- service on policy and procedure on oral care to CNAs, Licensed Nurses, and Respiratory Therapists. 5. The Director of Nursing/Designee in-serviced each CNA, Licensed Nurse, and Respiratory Therapist on importance of oral care on 8/14/2023. 6. The Dentist provided oral care in-service to the facility staff on 8/16/2023. 7. On 7/17/2023, the Pulmonologist assessed Resident 1 and noted the resident to have no maggots in the mouth cavity. 8. On 7/17/2023, pest control services were called and inspected the facility for flies aside from monthly scheduled inspections. 9. On 7/17/2023, the Maintenance Director checked all possible entrances to ensure there was no exposed penetrations in which flies could enter. 10. On 7/18/2023, the PMD evaluated Resident 1 ' s oral cavity and tracheostomy area. No concerns were identified. 11. On 7/19/2023, the Resident 1 was evaluated by the Dentist in the presence of two (2) RNs. 12. On 8/1/2023, three (3) additional light-emitting diode (LED- type of light) light traps were installed in the facility. 13. On 8/10/2023, the DSD in-serviced the CNAs, Licensed Nurses, and Respiratory Therapists to report to the Director of Nurses and or Designee when residents are identified as refusing oral care, or if staff has difficulty performing oral care to residents. Residents identified will be discussed with the Interdisciplinary Team (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of the resident) for plan of care. Such residents will be referred to the dentist for further recommendations. 14. On 8/11/2023, DSD in-serviced the CNAs on timely documentation regarding ADL charting in the Electronic Medical Record (EMR - an electronic version of a resident ' s medical history). 15. On 8/8/2023, two (2) residents (Resident 2 and Resident 3) were identified as having not been seen by the dentist since 2021. The two (2) residents were examined by the Dentist on 8/8/2023. 16. The Medical Records Director performed an audit on 8/10/2023 of 128 residents and one (1) resident was identified as having not been seen by the Dentist. This resident was evaluated by the Dentist on 8/27/2023. 17. The Medical Records Director will perform Ancillary (supplemental care) Audit Visits every month for three (3) months or until compliance is achieved and findings will be reported to the Administrator. 18. On 7/18/2023, the Assistant Director of Nursing (ADON), the Infection Prevention Nurse (IP), and licensed nurses assessed all residents in the facility, totaling 123 residents, no signs of oral infection nor maggots were noted. 19. On 8/9/2023, a total of 128 residents were assessed again for oral care and no sign and symptoms of infection were identified and was documented in the resident ' s Medication Administration Records (MAR- a report detailing the drugs or care administered to a resident by a healthcare professional). 20. On 7/17/2023, the Respiratory Therapist performed tracheostomy change for all residents with tracheostomy, a total of 20 residents, with no issues or concerns identified. 21. On 7/17/2023, a physician order was obtained for Chlorhexidine Gluconate Mouth and Throat Solution 0.12% bid for oral care to swab and suction for all residents with tracheostomy totaling 20 residents. 22. Starting 8/9/2023, the licensed nurse will assess oral cavities for all residents for signs and symptoms of infection every shift and document in the medical record of the residents if a resident has signs and symptoms of oral infection. 23. Respiratory Director will continue to provide in-service to have all endotracheal tube (a tube that is placed between the vocal cords through the trachea) changed q month and prn (as needed) by the Respiratory Therapist. This will be documented in the Respiratory Treatment Administration Record (RTAR- a report detailing the respiratory care administered to a resident by a healthcare professional). 24. Respiratory Director will continue to provide in-service on current practice for tracheostomy care to be performed q shift and as needed. Any issues or concerns will be documented in the resident ' s medical record in the progress notes. 25. Each resident with a tracheostomy will be suctioned via tracheostomy or orally every two (2) hours and as needed by the Respiratory Therapist. The Respiratory Director will continue to provide in-services on current practice. 26. DSD and or Designee will perform random assessments of resident oral cavities daily and report findings to the IDT. 27. During IDT care plan meetings, the IDT members will discuss family involvement in oral hygiene and provide necessary education which will be documented in the resident ' s medical record under Resident IDT Care Conference Review. 28. Maintenance Director will continue to ensure that the pest control company continues their routine visits monthly and as needed. 29. On 8/10/2023, Maintenance Director initiated a log of daily environmental inspections specific to pest control such as the presence of flies (insect) and larvae (immature form of an insect). 30. The Director of Staff Development and or Designee will monitor during clinical rounds that staff are competent and educated on oral care daily. The Director of Staff Development and or Designee will make visual rounds daily, assessing oral care site to ensure cleanliness and freedom from signs and symptoms of infection. 31. The Director of Staff Development and or Designee will perform weekly oral hygiene assessments of three (3) random residents and will document the findings in the Oral Hygiene Assessment Log. On 8/11/2023 at 4:01p.m., while onsite and after verifying the facility ' s full implementation of the IJ removal plan, the SSA accepted the IJ Removal Plan and removed the Immediate Jeopardy in the presence of the AADM and the DON. Findings: 1. A review of Resident 1 ' s Admission Record indicated Resident 1 was originally admitted on [DATE] and readmitted on [DATE], with diagnoses that included quadriplegia (loss of movement to all four limbs [arms and legs] of the body due to damage to the spinal cord), tracheostomy and gastrostomy (a surgical opening through the skin of the abdomen to the stomach). A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 6/27/2023 indicated Resident 1 had no speech and had severely impaired cognition (ability to think and make decisions). The MDS also indicated Resident 1 was completely dependent on staff for all ADLs. A review of the Change of Condition form for Resident 1 dated 7/16/2023 timed at 12:49 p.m. indicated on 7/16/2023, Family Member 1 (FM 1) notified Registered Nurse 1 (RN 1) that while she was cleaning Resident 1 ' s mouth, FM 1 found maggots on the toothbrush. During an interview with FM 1 on 7/18/2023 at 11:30 a.m., FM 1 stated that she was visiting Resident 1 on 7/16/2023 at around 12:00 p.m. and was brushing his teeth with a toothbrush when she saw movement in Resident 1 ' s mouth. FM 1 stated that when she removed the toothbrush from Resident 1 ' s mouth, there were two live maggots on the toothbrush. FM 1 stated Respiratory Therapist 1 (RT 1) was in the room and she showed RT 1 the live maggots. FM 1 stated that after RT 1 left the room to get RN 1, FM 1 was able to use the toothbrush to remove two additional live maggots from Resident 1 ' s mouth. FM 1 stated Resident 1 has his mouth open the majority of the time so anything could have gotten in his mouth. During an interview with RT 1 on 7/18/2023 at 1:40 p.m., RT 1 stated that on 7/16/2023 at approximately 12:00 p.m. to 12:30 p.m., RT 1 went into Resident 1 ' s room to provide respiratory care. RT 1 stated he observed FM 1 providing oral care to Resident 1 with a toothbrush as FM 1 usually does during her visits. RT 1 stated FM 1 started screaming and called RT 1 ' s attention to Resident 1 ' s side table. RT 1 stated he observed two live maggots on the side table. RT 1 stated FM 1 told him that maggots came from Resident 1 ' s mouth. RT 1 stated he left the room to call RN 1. During an interview with RN 1 on 7/18/2023 at 3:40 p.m., RN 1 stated on 7/16/2023 at approximately 12:00 p.m. to 12:30 p.m. she was alerted by RT 1 that there was a situation with Resident 1. RN 1 stated FM 1 was at Resident 1 ' s bedside and showed RN 1 two live maggots on a toothbrush and then showed RN 1 Resident 1 ' s bedside table that had two additional live maggots. RN 1 stated FM 1 told her that the four (4) live maggots were found inside Resident 1 ' s mouth and FM 1 was able to remove the maggots with the toothbrush. During a concurrent observation and interview inside Resident 1 ' s room, of Resident 1 ' s oral care with Certified Nursing Assistance 2 (CNA 2) on 7/18/2023 at 3:55 p.m., CNA 2 was observed providing oral care to Resident 1 using a mouth swab (a tool to clean the inside of the mouth) and mouthwash. Resident 1 was observed biting down when CNA 2 inserted the mouth swab into his mouth. CNA 2 stated that Resident 1 often bites down during oral care making it hard for CNA 2 to reach all the areas inside the resident ' s mouth with the mouth swab. CNA 2 stated staff documents oral care provided to a resident in the Documentation Survey Report under Personal Hygiene. CNA 2 stated that when she has a hard time providing oral care to Resident 1, she documents NA (not applicable) in the Documentation Survey Report under Personal Hygiene. A review of Resident 1 ' s Documentation Survey Report for July 2023 indicated that facility staff documented Not Applicable (NA- meaning the activity does not apply to the resident and was not done) for Evening shift (3:00 p.m. to 11:00 p.m.) under Personal Hygiene on the following dates: 1. 7/3/23 2. 7/5/23 3. 7/9/23 4. 7/10/23 5. 7/11/23 6. 7/12/23 7. 7/16/23 During an interview and concurrent record review of Resident 1 ' s Documentation Survey Report for July 2023 with the DON on 7/26/2023 at 1:45 p.m., the DON stated that there were several entries mark as NA under the category of personal hygiene. The DON stated CNAs are supposed to perform oral care on residents once per shift, as needed, and then document on the Documentation Survey Report. The DON further stated that they do not have a system in place to assess the adequacy of the oral care provided. The DON stated that resident ' s oral cavities are only assessed during dental visits that occur monthly or as needed. During a concurrent observation and interview on inside Resident 1 ' s room on 8/8/2023 at 11:17 a.m., Resident 1 ' s oral care by Certified Nursing Assistant 3 (CNA 3) was observed. CNA 3 was observed providing oral care to Resident 1 using a mouth swab and mouthwash. Resident 1 was observed biting down when the mouth swab was inserted into his mouth by CNA 3. CNA 3 stated that Resident 1 will usually close his mouth during oral care, so CNA 1 is unable to really see what she is doing inside the resident ' s mouth. CNA 3 stated that she tries her best to clean the inside of Resident 1 ' s mouth. During a concurrent interview and record review with the DON on 8/8/2023 at 12:55 p.m., Resident 1 ' s care plans from 11/17/2023 to 7/15/2023 were reviewed. The DON stated she was aware of Resident 1 ' s tendency to close his mouth during oral care. The DON stated there was no care plan in place to address Resident 1 ' s tendency to close his mouth during oral care. The DON stated there should have been a care plan developed to address Resident 1 ' s tendency to close his mouth during oral care so that interventions could have been created and implemented, which could then direct the nursing team on how to care for Resident 1. During an interview with the DON on 8/9/2023 at 1:08 p.m., the DON stated she was aware that Resident 1 closes his mouth during oral care. The DON stated that she was aware that CNAs were not always able to visualize Resident 1 ' s mouth during oral care. The DON stated the only assessments done on Resident 1's mouth was being conducted by the dentist during Resident 1 ' s monthly visits. The DON stated new interventions were put into place as a result of presence of maggots inside Resident 1 ' s mouth which occurred on 7/16/2023. The DON stated there was room for improvement and will be more pro-active with regards to providing Resident 1 with adequate oral care. A review of the facility ' s policy and procedure titled, Activities of Daily Living, last revised on 1/1/2020, indicated that residents who are unable to carry out ADLs independently will receive the assistance necessary to maintain good personal and oral hygiene. A review of the facility ' s policy and procedure titled, Oral Care, last revised on 11/1/2017, indicated it is the policy of the facility to ensure all residents receive appropriate oral care on a daily basis. The policy and procedure also indicated it is the responsibility of each staff member within the nursing department to ensure good oral care for each resident. 2. A review of Resident 2 ' s Admission Record indicated Resident 2 was admitted on [DATE] with diagnoses that included subarachnoid hemorrhage (bleeding in the space that surrounds the brain), tracheostomy and gastrostomy. A review of Resident 2 ' s MDS dated [DATE] indicated Resident 2 had severely impaired cognition. The MDS also indicated Resident 2 was completely dependent on staff for all ADLS. A review of Resident 2 ' s dental Mobile Dental notes indicated Resident 2 ' s last dental exam was on 7/30/2021. During an interview with the Medical Records Director (MRD) on 8/8/2023 at 12:44 p.m., the MRD stated Resident 2 did not have any dental exam visits in 2022 and 2023. The MRD stated based on the records, the last dental exam Resident 2 had was in 2021. During an interview with the DON on 8/8/2023 at 3:45 p.m., when asked how come Resident 2 had not been seen by a dentist since 2021, the DON stated the facility dropped the ball. The DON stated every resident should be seen by the dentist at least yearly and as needed. A review of Resident 3 ' s Admission Record indicated Resident 3 was admitted on [DATE], with diagnoses that included metabolic encephalopathy (brain damage or loss of brain function that is caused by an illness or condition), tracheostomy and gastrostomy. A review of Resident 3 ' s MDS dated [DATE] indicated Resident 3 had severely impaired cognition. The MDS also indicated Resident 3 was completely dependent on staff for all ADLs. A review of Resident 3 ' s dental Mobile Dental notes indicated Resident 3 ' s last dental exam was on 5/14/2021. During an interview with the MRD on 8/8/2023 at 12:44 p.m., the MRD stated Resident 3 did not have any dental exams in 2022 and 2023. The MRD stated based on the records, the last dental exam Resident 3 had was in 2021. During an interview with the DON on 8/8/2023 at 3:45 p.m., when asked how come Resident 3 had not been seen by a dentist since 2021, the DON stated the facility dropped the ball. The DON stated every resident should be seen by the dentist at least yearly and as needed. A review of the facility ' s policy and procedure titled, Dental Services, last revised on 11/1/2017, indicated it is the policy of the facility to refer and/or assist residents to obtain dental services as indicated for routine and emergency dental care including making appointments for the residents. Routine services include but are not limited to: i. Annual inspections ii. Dental cleaning, fillings and x-ray as needed. iii. Minor dental plate adjustments iv. Smoothing of broken teeth

Based on observation, interview, and record review the facility failed to protect one of three sampled resident's (Resident 1) right to be free from neglect (the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress) by: 1. Failing to ensure that facility staff identified Resident 1's central venous catheter (CVC-a tube placed in a large vein [blood vessel that carries blood to the heart] also known as a central line, to give fluids, blood, medications or to do medical tests which includes taking blood when a resident needs to have blood test) upon admission on 4/5/2022 and readmission on 5/28/2022. 2. Failing to ensure that facility staff provided the necessary care and treatment for Resident 1's CVC which included routine inspection (daily and as needed), flushing (injecting a solution into the tube to keep it from getting clogged or blocked) and dressing changes (a transparent [clear] protective cover placed over the tube to be changed every seven days in order to prevent infection) from the resident's admission on 4/5/2022 to 4/11/2023. 3. Failing to ensure Licensed Vocational Nurse 1 (LVN 1) and Licensed Vocational Nurse 2 (LVN 2) notified a Registered Nurse (RN) supervisor of Resident 1's CVC when the line was first identified. 4. Failing to ensure LVN 1 acted on and reported Resident 1's concerns and requests regarding the resident's CVC being left without a dressing. 5. Failing to ensure LVN 1 and Certified Nursing Assistant 1 (CNA) did not provide treatments outside of their scope and practice when LVN 1 and CNA 1 applied dressings to Resident 1's CVC. These deficient practices had the potential to place Resident 1 at risk for sepsis (the body's extreme response to an infection. Sepsis is a life-threatening medical emergency) from a central line-associated bloodstream infection (CLABSI- a serious infection that occurs when germs [usually bacteria or viruses] enter the bloodstream through the central line). On 4/17/2023 at 3:49 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ-a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility's failure to ensure staff did not act negligently towards Resident 1, when they failed to provide the necessary care and treatment for the resident's CVC line which included routine inspection, flushing and dressing changes from admission on 4/5/2022 to 4/11/2023. On 4/19/2023 at 1:40 p.m., the ADM provided an IJ Removal Plan which included the following summarized actions: I. Resident 1's CVC to his right upper chest (RUC) was assessed for complications, patency (the line is open and not blocked) and dressing change by the RN Supervisor on 4/11/2023. II. The Licensed Nurse notified Resident 1's primary care physician of the resident's CVC line on 4/11/2023 and obtained orders for routine central line dressing changes and monitoring. III. On 4/17/2023, the DON audited the facility for intravenous catheters (IV catheter- a thin plastic tube inserted into a vein using a needle). There were two (2) residents with central lines, two (2) residents with Peripherally Inserted Central Catheter lines (PICC lines- tube that is inserted into a vein in the upper arm and guided (threaded) into a large vein above the heart) and one (1) resident with a peripheral line (a tube that is placed through the skin into a vein, usually in the hand, elbow, or foot) identified. Resident 2, who was admitted on [DATE], was identified with no orders for PICC line use/maintenance. On 4/17/23, PICC line orders were obtained from Resident 2's physician. A care plan was initiated on 4/17/23 for management of PICC line for Resident 2. IV. DON in-serviced nursing staff, including licensed nurses and certified nurse assistants, on 4/17/2023, on the facility policy and procedures Abuse Prohibition/Neglect to include providing necessary care and services to ensure residents who receive intravenous (IV- within a vein) therapy (IV therapy- a way to give fluids, medicine, nutrition, or blood directly into the blood stream through a vein) are assessed and monitored for intravenous line patency and complications. V. The Admission Nurse for Resident 1 was in-serviced on 4/17/23 on performing a full body assessment (examining, measuring, or monitoring the resident's body) upon admission. VI. The Treatment Nurse responsible for assessing Resident 1 was in-serviced on 4/17/23 on performing a full body assessment for new admissions and indicate any lines such as IV lines. VII. Resident 1's care plan was reviewed and revised by the Interdisciplinary Team (IDT- a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident) to reflect Resident 1's current care and service interventions for his CVC on 4/17/2023. VIII. The DON in-serviced the licensed nurses on 4/17/2023 regarding central line access care including weekly dressing changes and routine assessments for any complications and patency, full body assessments, completion of treatments and documentation in the medical record of services provided for residents with intravenous lines. IX. The DON in-serviced each licensed nurse on 4/17/23 regarding understanding the standard of practice (a set of guidelines) for assessment of central lines and all other intravenous access sites for complications and patency. X. On 4/17/2023, the DON/ Designee in-serviced licensed staff (RN Supervisors and LVNs) regarding the facility's policy and procedures for parenteral (describes any drug administration other than by mouth) IV fluids including assessment and monitoring of intravenous sites for patency and complications as ordered by the physician. On 4/19/2023 at 2:03 p.m., while onsite and after verifying the facility's full implementation of the IJ removal plan, the SSA accepted the IJ Removal Plan and removed the IJ in the presence of the ADM and DON. Findings: 1. A review of Resident 1's Admission Record indicated the facility admitted the resident on 4/5/2022 and readmitted the resident on 5/28/2022 with diagnoses that included sepsis, left leg below the knee amputation (BKA-removal by surgery of a limb (arm or leg) or other body part because of injury or disease), end stage renal disease (ESRD, a medical condition in which the kidneys stop functioning) and dependence on renal dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working). A review of Resident 1's History and Physical, dated 6/2/2022, indicated the resident had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS - an assessment and screening too) dated 4/12/2022, indicated the resident had the ability to understand others and had the ability to make himself understood. The MDS further indicated the resident required extensive staff assistance with transfers, dressing, and personal hygiene. Further review of Resident 1's Minimum Data Set (MDS - an assessment and screening too) dated 4/13/2023, indicated the resident had the ability to understand others and had the ability to make himself understood. The MDS further indicated the resident required extensive staff assistance with transfers, dressing, and personal hygiene. A review of Resident 1's General Acute Care Hospital (GACH) record titled Diagnostic Imaging report dated 3/31/2022, indicated that the resident had the follow central line inserted on 3/30/2022: a) Right intrajugular tunneled CVC (a thin tube that is placed under the skin in the internal jugular vein [IJV- vein under the collarbone] allowing long-term access to the vein). A review of Resident 1's Physician Orders indicated orders for the following: a) Body check upon returning to facility, every evening shift; every Monday, Wednesday, and Friday, dated 4/28/2022 and discontinued on 5/24/2022 b) Body check to be performed upon Resident 1's return to facility, every day shift; every Monday, Wednesday, and Friday, dated 5/30/2022. c) IV central line active therapy orders: dressing change every seven days and as needed, remove old dressing, using sterile technique (technique used to prevent contamination of a site with microbes [bacteria], preventing infection), site cleanse with a chlorhexidine gluconate solution (a cleaning product that helps eliminate germs and bacteria) or povidone-iodine (a solution used on the skin to treat or prevent skin infection) as needed, every day shift every Sunday, dated 4/11/2023. d) IV central lines: flush each lumen (line) with 10 cubic centimeters (cc-a unit of measurement for liquids) with normal saline (solution used to clear the contents of a central line) before and after medication administration every shift, dated 4/11/2023. During a review of Resident 1's GACH Discharge to Skilled Nursing Facility (SNF) Summary and Transfer Orders, dated 4/5/2022 indicated Resident 1 with a five (5) french (fr- unit of measure) single lumen (one line) CVC placement on 3/30/2022. During an observation and interview on 4/14/2023 at 3:45 p.m., Resident 1 was observed lying in bed inside his room. Resident 1 stated, while tearful, that he had a CVC that the facility was not taking care of. Resident 1 pull up the right side of his t-shirt and observed was a purple, single lumen CVC sutured (held in place with stiches) to the resident's RUC. The CVC was covered with a chlorhexidine gluconate protective disk (a small circular dressing placed over the insertion site of a CVC to help reduce local infections) with a transparent dressing dated 4/11/2023. Resident 1 stated that the dressing currently on his CVC was the first dressing the facility applied since his admission on 4/5/2022. Resident 1 stated he had been asking the facility nurses to cover his CVC since his admission on 4/5/2022, but nothing was being done. Resident 1 stated that facility nursing staff would place a dressing or a plastic bag over his CVC during shower times, but all other times the CVC remained uncovered. Resident 1 stated his CVC line on his RUC goes to his heart and he is worried about infections. During an interview and record review on 4/14/2023 at 4:40 p.m., Registered Nurse 1 (RN 1) reviewed Resident 1's medical records including all face sheets, history and physical, physician orders, progress notes, care plans and skin assessments from 4/5/2022 to 4/14/2023. RN 1 stated that there was no documented evidence that the facility was aware or treated Resident 1's CVC prior to 4/11/2023. RN 1 stated she was not aware of Resident 1's CVC until 4/10/2023. RN 1 stated that Resident 1 had informed her that he had the CVC for over a year. During an interview and record review on 4/17/2023 at 9:00 a.m. with Treatment Nurse 1 (TN 1), Resident 1's Wound Weekly Monitoring Assessments, dated 4/6/2022 and 5/30/2023 documented by TN 1 were reviewed. TN 1 stated that when residents are admitted to the facility, the admitting nurse completes a full body skin assessment to identify any catheter lines such as CVCs. TN 1 stated that after the admitting nurse completes her full body assessment, the treatment nurse is to complete another full body assessment. TN 1 reviewed Resident 1's Wound Weekly Monitoring Assessments, dated 4/6/2022 and 5/30/2022 and stated there was no documented evidence that indicated Resident 1 had a RUC CVC. TN 1 stated that she completed a body check for Resident 1 on 4/6/2022 and 5/30/2022 but stated that she never saw Resident 1's CVC until 4/11/2023. During an interview on 4/17/2023 at 10:10 a.m. with the DON, DON stated that she was unaware that Resident 1 had the CVC until the resident informed her on 4/11/2023. The DON stated that Resident 1 could have potentially developed an infection and become septic (a life-threatening condition that arises with the body's response to an infection) from the CVC on his RUC that was not provided the necessary care to prevent infection such as applying dressing to the CVC and monitoring the CVC for signs and symptoms of infection. During a concurrent interview and record review on 4/17/2023 at 12:00 p.m. with the DON, Resident 1's Wound and Weekly Monitoring Assessment forms dated 4/6/2022 and 5/30/2022 were reviewed. The DON stated that there was no documented evidence of Resident 1's RUC CVC on the Wound and Weekly Monitoring Assessment forms. The DON stated the licensed nurses were not doing their job because the licensed nurses either did not assess Resident 1's skin thoroughly since the nurses did not know the resident had a CVC to his RUC, or the licensed nurses did not document the presence of the RUC CVC. The DON stated if the licensed nurses were really conducting a full body assessment on Resident 1, then the licenses nurses would have identified Resident 1's CVC. The DON stated that the licenses nurse's failure to conduct a thorough body assessment on Resident 1 resulting in the resident's CVC being untreated and monitored for over one year could be considered neglect because the facility failed to provide the needed care and treatment for Resident 1's CVC placing the resident at continued risk for infection. A review of the facility policy and procedure titled, Admission Assessment, last reviewed 1/18/2023, indicated licensed nursing staff will complete an admission assessment for residents upon admission to the facility. The comprehensive assessment will consider factors pertaining to medical, behavioral, and social needs of the resident. The assessment process must include direct and indirect observation and communication with the residents, as well as communication with licensed and non-licensed direct care staff members on all shifts. Assessment findings may necessitate communication with attending physician for treatment or care orders. A review of the facility policy and procedure titled, Skin Assessment, last revised 3/2023, indicated the purpose of the policy was to provide guidelines for routine assessment of resident's skin to maintain skin integrity and promote healing in accordance with standard of care practices. The licensed nurse completes a head-to-toe skin assessment (process of examining entire skin for abnormalities) of the resident's skin during the admission process. The licensed nurse completes routine weekly assessments. Skin integrity should be assessed for pressure related discoloration or breakdown from positioning or use of medical devices applied for therapeutic purposes. The licensed nurse documents assessment findings in the resident's medical record weekly following completion of the skin assessment. Injurious or at-risk areas are documented on a change in condition form and reported to the primary physician for further instruction. A review of the facility policy and procedure titled, Accuracy of Assessments, last reviewed 1/18/2023, indicated the facility ensures each resident receives an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas and are knowledgeable about the resident's status, needs, strengths, and areas of decline. A review of the facility policy and procedure titled, Abuse Prevention and Prohibition Program, last reviewed 1/18/2023, indicated the program was designed to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements. Each resident has the right to be free from mistreatment, neglect, and abuse. The facility has zero tolerance for abuse, neglect, and mistreatment. Staff must not permit anyone to engage in abuse, neglect, and mistreatment, or deprivation of goods necessary to attain or maintain physical, mental, and psychosocial well-being. The facility is committed to protecting residents from abuse by anyone including staff from other agencies serving residents. The facility provides covered individuals with training to enable the identification of the following signs and symptoms of potential physical neglect: poor hygiene, inadequate provision of care and caregiver indifference to resident's personal care and needs. 2. During an interview on 4/17/2023 at 9:45 a.m., CNA 1 stated that Resident 1 already had his CVC to his RUC when she first started caring for him six months ago. CNA 1 stated that Resident 1's CVC was left uncovered without a dressing during the time she cared for the resident. During an interview and record review on 4/17/2023 at 10:10 a.m. with the DON, Resident 1's medical records from 4/5/2022 to 4/17/2023 were reviewed. DON stated there was no documented evidence of a physician orders for Resident 1's CVC care that should have included central line dressing changes, central line flushing, or monitoring for signs and symptoms of infection prior to 4/11/2023. The DON stated she assessed Resident 1's CVC on 4/11/2023 and at the time it was not covered. During an interview and on 4/17/2023 at 10:45 a.m., the Nurse Practitioner (NP) stated that it was concerning that Resident 1 had a CVC without a dressing or monitoring being done because the CVC places Resident 1 at increased risk for infections. NP stated that the facility should have conducted a full physical assessment of Resident 1 upon admission that included a full skin check. The NP stated that the facility should have been able to identify Resident 1's CVC during their full skin check During an interview on 4/17/2023 at 11:20 a.m., LVN 1 stated she had cared for Resident 1 since his admission to the facility on [DATE]. LVN 1 stated that she has seen Resident 1's CVC on his right upper chest without a dressing for a couple of months. LVN 1 stated she notified the registered nurse to assess and monitor Resident 1's CVC. LVN 1 stated there were no orders for dressing changes or monitoring for Resident 1's CVC to his RUC prior to 4/11/2023. During a concurrent interview and record review on 4/17/2023 at 12:00 p.m. with the DON, Resident 1's Wound and Weekly Monitoring Assessment forms from 4/6/2022 to 4/12/2023 were reviewed. The DON stated that there was no documented evidence of Resident 1's RUC CVC on the Wound and Weekly Monitoring Assessment forms. The DON stated the facility's procedure for skin assessments is that they are done by a licensed nurse and documented on a resident's admissions and weekly forms because it is important to find wounds or anything new on the skin. The DON stated the nurses were not doing their job because the nurses either did not assess Resident 1's skin since nurses did not know the resident had a CVC to his RUC, or the nurses did not document the presence of the RUC CVC. The DON stated that licensed nurses should have done a full body assessment as ordered by the physician on 4/28/2022 and again on 5/30/2022 which was three times a week after Resident 1's hemodialysis (HD- a process where a machine filters the waste from your body because your kidneys have failed) treatments. The DON stated if the licensed nurses were really doing Resident 1's full body assessment as ordered, then the licenses nurses would have detected Resident 1's CVC. The DON stated that the licenses nurse's failure to identify and conduct a thorough body assessment on Resident 1 could be considered neglect because the facility failed to provide the needed care and treatment for Resident 1's CVC placing the resident at continued risk for infection. During an interview on 4/17/2023 at 12:28 p.m., LVN 1 stated that a resident's central lines needed to be monitored, flushed, and have weekly dressing changes. LVN 1 stated Resident 1 could have been harmed because the resident's CVC could have gotten infected. During a concurrent interview and record review on 4/18/2023 at 11:12 a.m., Registered Nurse 2 (RN 2) reviewed Resident 1's GACH Discharge to Skilled Nursing Facility Summary and Transfer Orders dated 4/5/2022 and stated that the summary indicated Resident 1 was admitted to the facility with the CVC on his RUC in place. RN 2 stated that the admitting nurse should have done a skin assessment on Resident 1 upon admission on 4/5/22 and 5/28/22 to identify any central lines such as Resident 1's CVC. RN 2 stated that the summary provided to the facility indicating that Resident 1 had a CVC in place should have alerted the admitting nurses of the presence of Resident 1's CVC. RN 2 stated TN 1 should have also performed a head-to-toe assessment on Resident 1 on admission and readmission and should have been able to identify Resident 1's CVC. RN 2 stated TN 1 should have performed weekly skin assessments on Resident 1 and had multiple opportunities to identify the resident's CVC. RN 2 stated central lines need dressings to keep them covered, secure, and safe. RN 2 stated a central line goes into the heart and you do not want germs and bacteria getting in there due to the risk of infection. RN 2 stated an LVN should be able to identify a central line and should notify the RNs. RN 2 stated if an RN was notified of a CVC, she should have assessed the resident, looked for documentation, then notified the physician for clarification and orders. RN 2 stated there were multiple missed opportunities to identify Resident 1's CVC that included the admitting nurse on 4/5/2022 and 5/28/2022, TN 1 upon admission on 4/5/2022 and 5/28/2022, treatment nurses conducting weekly skin assessments, and licensed nurses doing weekly and as ordered by the physician skin assessments. RN 2 stated that it was negligent that the facility did not identify Resident 1's CVC despite the resident telling facility staff of its presence. RN 2 stated it was negligent that the facility failed to provide Resident 1 with the needed care and treatment for the resident's CVC. A review of the facility policy and procedure titled, Dressing and Injection Cap Change of Central Venous Access Devices (devices that are inserted into the body through a vein, also known as CVC), last reviewed 1/18/2023, indicated an occlusive dressing (an air- and water-tight medical dressing ) shall always be maintained over the central venous access site to reduce the risk of infection to the insertion or exit site and surrounding area of central venous access devices. Transparent Semipermeable Membrane (TSM, a dressing that allows visualization of the insertion site, and provides stabilization and protection from microorganisms) are the dressing of choice for all central catheters. Gauze dressings are only used with the initial dressing application at the time of catheter insertion and needs to be changed within 24 hours. Routine central catheter dressing changes shall be done every seven days and as needed using a TSM type dressing. During every dressing change, facility staff is to document concerns, site problems or any amount of the catheter out of the skin before the insertion into the skin. Only qualified staff shall do a dressing and cap change. To be considered qualified, the RN or IV certified LVN shall have return demonstrated skills with another qualified RN. If a chlorhexidine gluconate protective disk was used, remove after seven days from the day it was placed. Label with a dressing to indicate the type of device, time and date of dressing change, initials of the RN performing the procedure. Document the site appearance, ease of blood return, ease of flush and suture stability. Document in the IV Medication Administration Record the dressing change, securement device change, cap change for all lumens, flush for all lumens, any amount of catheter out of the skin before the insertion site and the arm circumference. Notify the MD of any complications and document notification of the MD. Check the patient's chart to confirm the insertion report and chest X-ray (special pictures of the inside of your body) report confirm tip placement are there. A review of the facility policy and procedure titled, Flushing of Central Venous Access Devices, last reviewed 1/18/2023, indicated flushing of central venous access devices shall be performed by an RN after each infusion, blood draw, per flushing guidelines, or as ordered by the attending physician. The solutions and volumes to be used for flushing shall be ordered by the attending physician. Document in the nurse's notes the condition of the resident's skin, the presence of any sutures or type of securement device, the presence of any redness, edema (swelling), drainage, or unusual complaints of pain. Document on the treatment record the number of lumens, the flushing, arm circumference, site checks and any amount of exposed catheter. A review of the facility policy and procedure titled, Abuse Prevention and Prohibition Program, last reviewed 1/18/2023, indicated the program was designed to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements. Each resident has the right to be free from mistreatment, neglect, and abuse. The facility has zero tolerance for abuse, neglect, and mistreatment. Staff must not permit anyone to engage in abuse, neglect, and mistreatment, or deprivation of goods necessary to attain or maintain physical, mental, and psychosocial well-being. The facility is committed to protecting residents from abuse by anyone including staff from other agencies serving residents. The facility provides covered individuals with training to enable the identification of the following signs and symptoms of potential physical neglect: poor hygiene, inadequate provision of care and caregiver indifference to resident's personal care and needs. 3. During an interview on 4/17/2023 at 11:20 a.m., LVN 1 stated she had cared for Resident 1 since his admission to the facility on [DATE]. LVN 1 stated she did not know Resident 1 had a CVC until the end of 2022. LVN 1 stated licensed vocational nurses do not provide care for central lines, and that it was the registered nurse's responsibility to provide care for the central lines. LVN 1 stated she notified the registered nurse to assess and monitor Resident 1's CVC, but she does not remember who she notified or what they said. During an interview on 4/17/2023 at 1:00 p.m., Resident 1 stated that there was a day he spoke with LVN 1 about his CVC and that it needed to be covered, to which LVN 1 informed the resident that she would speak with the RN Supervisors, but nobody came. During a concurrent interview and record review with LVN 1 on 4/19/2023 at 9:11 a.m., Resident 1's medical records from 4/5/2022 to 4/19/2023 were reviewed. LVN 1 stated that she did not document that Resident 1's CVC had been identified in the resident's medical records. LVN 1 stated that there was no documented evidence in Resident 1's medical records from 4/5/2022 to 4/19/2023 to indicate that LVN 1 had notified an RN regarding Resident 1's CVC. LVN 1 stated that since there was no documented evidence of her informing the RNs, it means that it was not done, and she had not informed the RNs of Resident 1's CVC. During an interview on 4/19/2023 at 10:38 a.m., LVN 2 stated that he was aware that Resident 1 had a CVC on his RUC, and during the times he observed the CVC, it was not covered or dressed. LVN 2 stated he did not inform any other facility staff of the presences of Resident 1's CVC. LVN 2 stated he should have checked Resident 1's physician orders to ensure there were orders for treatment and care for Resident 1's CVC when he observed the line uncovered without a dressing. LVN 2 stated he could not recall why he did not inform an RN regarding Resident 1's CVC. LVN 2 stated that he was under the impression that the facility was already aware that Resident 1 had a CVC. LVN 2 stated he should have questioned why Resident 1's CVC would be uncovered and that he should have reported his findings up the chain of command (reporting to your supervisor). During an interview with the DON on 4/19/2023 at 11:25 a.m., DON stated that LVN 1 acted negligently because LVN 1 was aware of Resident 1's CVC including the risk associated with having a CVC such as infection, but LVN 1 did not follow up with an RN Supervisors or the DON. A review of the facility policy and procedure titled, Dressing and Injection Cap Change of Central Venous Access Devices (devices that are inserted into the body through a vein, also known as CVC), last reviewed 1/18/2023, indicated an occlusive dressing (an air- and water-tight medical dressing ) shall always be maintained over the central venous access site to reduce the risk of infection to the insertion or exit site and surrounding area of central venous access devices. Transparent Semipermeable Membrane (TSM, a dressing that allows visualization of the insertion site, is breathable, and provides stabilization and protection from microorganisms) are the dressing of choice for all central catheters. Gauze dressings are only used with the initial dressing application at the time of catheter insertion and needs to be changed within 24 hours. Routine central catheter dressing changes shall be done every seven days and as needed using a TSM type dressing. During every dressing change, facility staff is to document concerns, site problems or any amount of the catheter out of the skin before the insertion into the skin. Only qualified staff shall do a dressing and cap change. To be considered qualified, the RN or IV certified LVN shall have return demonstrated skills with another qualified RN. If a chlorhexidine gluconate protective disk was used, remove after seven days from the day it was placed. Label with a dressing to indicate the type of device, time and date of dressing change, initials of the RN performing the procedure. Document the site appearance, ease of blood return, ease of flush and suture stability. Document in the IV Medication Administration Record the dressing change, securement device change, cap change for all lumens, flush for all lumens, any amount of catheter out of the skin before the insertion site and the arm circumference. Notify the Medical Doctor (MD) of any complications and document notification of the MD. Check the patient's chart to confirm the insertion report and chest X-ray report confirm tip placement are there. A review of the facility policy and procedure titled, Abuse Prevention and Prohibition Program, last reviewed 1/18/2023, indicated the program was designed to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements. Each resident has the right to be free from mistreatment, neglect, and abuse. The facility has zero tolerance for abuse, neglect, and mistreatment. Staff must not permit anyone to engage in abuse, neglect, and mistreatment, or deprivation of goods necessary to attain or maintain physical, mental, and psychosocial well-being. The facility is committed to protecting residents from abuse by anyone including staff from other agencies serving residents. The facility provides covered individuals with training to enable the identification of the following signs and symptoms of potential physical neglect: poor hygiene, inadequate provision of care and caregiver indifference to resident's personal care and needs. 4. During an interview on 4/17/2023 at 11:20 a.m., LVN 1 stated she had cared for Resident 1 since his admission to the facility on [DATE]. LVN 1 stated she did not know Resident 1 had a CVC until around the end of 2022. LVN 1 stated that she continued to see Resident 1's CVC on his right upper chest without a dressing for a couple of months. LVN 1 stated that around the beginning of January 2023, Resident 1 had asked her on multiple occasions why he had the CVC and why was it not removed. During an interview on 4/17/2023 at 12:00 p.m., the DON stated that when R[TRUNCATED]

Based on observation, interview, and record review the facility failed to monitor and provide central venous catheter (CVC-a tube placed in a large vein [blood vessel that carries blood to the heart] also known as a central line, to give fluids, blood, medications or to do medical tests) line care for one of three sampled residents (Resident 1) by: 1. Failing to ensure that facility staff identified Resident 1's central venous catheter upon admission on 4/5/2022 and readmission on 5/28/2022. 2. Failing to ensure that facility staff provided the necessary care and treatment for Resident 1's CVC on the right upper chest (RUC) which included routine inspection (daily and as needed), flushing (injecting a solution into the tube to keep it from getting clogged or blocked) and dressing changes (a transparent [clear] protective cover placed over the tube to be changed every seven days in order to prevent infection) from the resident's admission on 4/5/2022 to 4/11/2023. 3. Failing to ensure Licensed Vocational Nurse 1 (LVN 1) and Licensed Vocational Nurse 2 (LVN 2) notified a Registered Nurse (RN) supervisor of Resident 1's CVC when the line was first identified. 4. Failing to ensure LVN 1 acted on and reported Resident 1's concerns and requests regarding the resident's CVC being left without a dressing. 5. Failing to ensure LVN 1 and Certified Nursing Assistant 1 (CNA) 1 did not provide treatments outside of their scope and practice when LVN 1 and CNA 1 applied dressings to Resident 1's CVC. These deficient practices had the potential to place Resident 1 at risk for sepsis (the body's extreme response to an infection. Sepsis is a life-threatening medical emergency) from a central line-associated bloodstream infection (CLABSI- a serious infection that occurs when germs [usually bacteria or viruses] enter the bloodstream through the central line). On 4/17/2023 at 3:49 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ-a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility's failure to provide CVC line care to Resident 1 from 4/5/2022 to 4/11/2023. On 4/19/2023 at 1:40 p.m., the ADM provided an IJ Removal Plan which included the following summarized actions: I. Resident 1's CVC to his right upper chest (RUC) was assessed for complications, patency (the line is open and not blocked) and dressing change by the RN Supervisor on 4/11/2023. II. The Licensed Nurse notified Resident 1's primary care physician of the resident's CVC line on 4/11/2023 and obtained orders for routine central line dressing changes and monitoring. III. On 4/17/2023, the DON audited the facility for intravenous catheters (IV catheter- a thin plastic tube inserted into a vein using a needle). There were two (2) residents with central lines, two (2) residents with Peripherally Inserted Central Catheter lines (PICC lines- tube that is inserted into a vein in the upper arm and guided (threaded) into a large vein above the heart) and one (1) resident with a peripheral line (a tube that is placed through the skin into a vein, usually in the hand, elbow, or foot) identified. Resident 2, who was admitted on [DATE], was identified with no orders for PICC line use/maintenance. On 4/17/23, PICC line orders were obtained from Resident 2's physician. A care plan was initiated on 4/17/23 for management of PICC line for Resident 2. IV. DON in-serviced nursing staff, including licensed nurses and certified nurse assistants, on 4/17/2023, on the facility policy and procedures including providing the necessary care and services to ensure residents who receive intravenous (IV- within a vein) therapy (IV therapy- a way to give fluids, medicine, nutrition, or blood directly into the blood stream through a vein) are assessed and monitored for intravenous line patency and complications. V. The Admission Nurse for Resident 1 was in-serviced on 4/17/23 on performing a full body assessment (examining, measuring, or monitoring the resident's body) upon admission. VI. The Treatment Nurse responsible for assessing Resident 1 was in-serviced on 4/17/23 on performing a full body assessment for new admissions and indicate any lines such as IV lines. VII. Resident 1's care plan was reviewed and revised by the Interdisciplinary Team (IDT- a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident) to reflect Resident 1's current care and service interventions for his CVC on 4/17/2023. VIII. The DON in-serviced the licensed nurses on 4/17/2023 regarding central line access care including weekly dressing changes and routine assessments for any complications and patency, full body assessments, completion of treatments and documentation in the medical record of services provided for residents with intravenous lines. IX. The DON in-serviced each licensed nurse on 4/17/23 regarding understanding the standard of practice (a set of guidelines) for assessment of central lines and all other intravenous access sites for complications and patency. X. On 4/17/2023, the DON/ Designee in-serviced licensed staff (RN Supervisors and LVNs) regarding the facility's policy and procedures for parenteral (describes any drug administration other than by mouth) IV fluids including assessment and monitoring of intravenous sites for patency and complications as ordered by the physician. On 4/19/2023 at 2:03 p.m., while onsite and after verifying the facility's full implementation of the IJ removal plan, the SSA accepted the IJ Removal Plan and removed the IJ in the presence of the ADM and DON. Findings: 1. A review of Resident 1's Admission Record indicated the facility admitted the resident on 4/5/2022 and readmitted the resident on 5/28/2022 with diagnoses that included sepsis, left leg below the knee amputation (BKA-removal by surgery of a limb (arm or leg) or other body part because of injury or disease), end stage renal disease (ESRD, a medical condition in which the kidneys stop functioning) and dependence on renal dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working). A review of Resident 1's History and Physical, dated 6/2/2022, indicated the resident had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS - an assessment and screening too) dated 4/12/2022, indicated the resident had the ability to understand others and had the ability to make himself understood. The MDS further indicated the resident required extensive staff assistance with transfers, dressing, and personal hygiene. Further review of Resident 1's Minimum Data Set (MDS - an assessment and screening too) dated 4/13/2023, indicated the resident had the ability to understand others and had the ability to make himself understood. The MDS further indicated the resident required extensive staff assistance with transfers, dressing, and personal hygiene. A review of Resident 1's General Acute Care Hospital (GACH) record titled Diagnostic Imaging report dated 3/31/2022, indicated that the resident had the following central line inserted on 3/30/2022: a) Right intrajugular (in the internal jugular vein [IJV- vein under the collarbone]) tunneled CVC (when a portion of the central line goes under the skin). A review of Resident 1's Physician Orders indicated orders for the following: a) Body check upon returning to facility, every evening shift; every Monday, Wednesday, and Friday, dated 4/28/2022 and discontinued on 5/24/2022 b) Body check to be performed upon Resident 1's return to facility, every day shift; every Monday, Wednesday, and Friday, dated 5/30/2022. c) IV central line active therapy orders: dressing change every seven days and as needed, remove old dressing, using sterile technique (technique used to prevent contamination of a site with microbes [bacteria], preventing infection), site cleanse with a chlorhexidine gluconate solution (a cleaning product that helps eliminate germs and bacteria) or povidone-iodine (a solution used on the skin to treat or prevent skin infection) as needed, every day shift every Sunday, dated 4/11/2023. d) IV central lines: flush each lumen (line) with 10 cubic centimeters (cc-a unit of measurement for liquids) with normal saline (solution used to clear the contents of a central line) before and after medication administration every shift, dated 4/11/2023. During a review of Resident 1's GACH Discharge to Skilled Nursing Facility (SNF) Summary and Transfer Orders, dated 4/5/2022 indicated Resident 1 with a five (5) french (fr- unit of measure) single lumen (one line) CVC placement on 3/30/2022. During an observation and interview on 4/14/2023 at 3:45 p.m., Resident 1 was observed by surveyor lying in bed inside his room. Resident 1 stated, while tearful, that he had a CVC that the facility was not taking care of. Resident 1 pull up the right side of his t-shirt and observed by surveyor was a purple, single lumen CVC sutured (held in place with stiches) to the resident's RUC. The CVC was covered with a chlorhexidine gluconate protective disk (a small circular dressing placed over the insertion site of a CVC to help reduce local infections) with a transparent dressing dated 4/11/2023. Resident 1 stated that the dressing currently on his CVC was the first dressing the facility applied since his admission on 4/5/2022. Resident 1 stated he had been asking the facility nurses to cover his CVC since his admission on 4/5/2022, but nothing was being done. Resident 1 stated that facility nursing staff would place a dressing or a plastic bag over his CVC during shower times, but all other times the CVC remained uncovered. Resident 1 stated his CVC line on his RUC goes to his heart and he is worried about infections. During an interview and record review on 4/14/2023 at 4:40 p.m., Registered Nurse 1 (RN 1) reviewed Resident 1's medical records including face sheet, history and physical, admission assessment, physician orders, progress notes, skin assessments, and care plans from 4/5/2022 to 4/14/2023. RN 1 stated that there was no documented evidence that the facility was aware or treated Resident 1's CVC prior to 4/11/2023. RN 1 stated she was not aware of Resident 1's CVC until 4/10/2023. RN 1 stated that Resident 1 had informed her that he had the CVC for over a year. During an interview and record review on 4/17/2023 at 9:00 a.m. with Treatment Nurse 1 (TN 1), Resident 1's Wound Weekly Monitoring Assessments, dated 4/6/2022 and 5/30/2023 documented by TN 1 were reviewed. TN 1 stated that after the admitting nurse completes her full body assessment, the treatment nurse is to complete another full body assessment. TN 1 reviewed Resident 1's Wound Weekly Monitoring Assessments, dated 4/6/2022 and 5/30/2023 and stated there was no documented evidence that indicated Resident 1 had a RUC CVC. TN 1 stated that she completed a body assessment for Resident 1 on 4/6/2022 and 5/30/2022 but stated that she never saw Resident 1's CVC until 4/11/2023. During an interview on 4/17/2023 at 10:10 a.m. with the DON, DON stated that she was unaware that Resident 1 had the CVC until the resident informed her on 4/11/2023. The DON stated that Resident 1 could have potentially developed an infection and become septic (a life-threatening condition that arises with the body's response to an infection) from the CVC on his RUC that was not provided the necessary care to prevent infection such as applying dressing to the CVC and monitoring the CVC for signs and symptoms of infection. During a concurrent interview and record review on 4/17/2023 at 12:00 p.m. with the DON, Resident 1's Wound and Weekly Monitoring Assessment forms dated 4/6/2022 and 5/30/2022 were reviewed by the DON and surveyor. The DON stated that there was no documented evidence of Resident 1's RUC CVC on any of the Wound and Weekly Monitoring Assessment forms. The DON stated the licensed nurses were not doing their job because the licensed nurses either did not assess Resident 1's skin thoroughly since the nurses did not know the resident had a CVC to his RUC, or the licensed nurses did not document the presence of the RUC CVC. The DON stated if the licensed nurses were really conducting a full body assessment on Resident 1, then the licenses nurses would have identified Resident 1's CVC. The DON stated that the licenses nurse's failure to conduct a thorough body assessment on Resident 1 resulting in the resident's CVC being untreated and monitored for over one year, placed the resident at continued risk for infection due to the facility not providing the needed care and treatment for the resident's CVC. A review of the facility policy and procedure titled, Admission Assessment, last reviewed 1/18/2023, indicated licensed nursing staff will complete an admission assessment for residents upon admission to the facility. The comprehensive assessment will consider factors pertaining to medical, behavioral, and social needs of the resident. The assessment process must include direct and indirect observation and communication with the residents, as well as communication with licensed and non-licensed direct care staff members on all shifts. Assessment findings may necessitate communication with attending physician for treatment or care orders. A review of the facility policy and procedure titled, Skin Assessment, last revised 3/2023, indicated the purpose of the policy was to provide guidelines for routine assessment of resident's skin to maintain skin integrity and promote healing in accordance with standard of care practices. The licensed nurse completes a head-to-toe skin assessment (process of examining entire skin for abnormalities) of the resident's skin during the admission process. The licensed nurse completes routine weekly assessments. Skin integrity should be assessed for pressure related discoloration or breakdown from positioning or use of medical devices applied for therapeutic purposes. The licensed nurse documents assessment findings in the resident's medical record weekly following completion of the skin assessment. Injurious or at-risk areas are documented on a change in condition form and reported to the primary physician for further instruction. A review of the facility policy and procedure titled, Accuracy of Assessments, last reviewed 1/18/2023, indicated the facility ensures each resident receives an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas and are knowledgeable about the resident's status, needs, strengths, and areas of decline. 2. During an interview on 4/17/2023 at 9:45 a.m., CNA 1 stated that Resident 1 already had his CVC to his RUC when she first started caring for him six months ago. CNA 1 stated that Resident 1's CVC was left uncovered without a dressing during the time she cared for the resident. During an interview and record review on 4/17/2023 at 10:10 a.m. with the DON, Resident 1's medical records from 4/5/2022 to 4/17/2023 were reviewed. DON stated there was no documented evidence of a physician orders for Resident 1's CVC care that should have included central line dressing changes, central line flushing, or monitoring for signs and symptoms of infection prior to 4/11/2023. The DON stated she assessed Resident 1's CVC on 4/11/2023 and at the time it was not covered. During an interview and on 4/17/2023 at 10:45 a.m., the Nurse Practitioner (NP) stated that it was concerning that Resident 1 had a CVC without a dressing or monitoring being done because the CVC places Resident 1 at increased risk for infections. NP stated that the facility should have conducted a full physical assessment of Resident 1 upon admission that included a full skin check. The NP stated that the facility should have been able to identify Resident 1's CVC during their full skin check. During an interview on 4/17/2023 at 11:20 a.m., LVN 1 stated she had cared for Resident 1 since his admission to the facility on [DATE]. LVN 1 stated she has seen Resident 1's CVC on his right upper chest without a dressing for a couple of months. LVN 1 stated she notified the registered nurse to assess and monitor Resident 1's CVC. LVN 1 stated there were no orders for dressing changes or monitoring for Resident 1's CVC to his RUC prior to 4/11/2023. During a concurrent interview and record review on 4/17/2023 at 12:00 p.m. with the DON, Resident 1's Wound and Weekly Monitoring Assessment forms from 4/6/2022 to 4/12/2023 were reviewed. The DON stated that there was no documented evidence of Resident 1's RUC CVC on the Wound and Weekly Monitoring Assessment forms. The DON stated the facility's procedure for skin assessments is that they are done by a licensed nurse and documented on a resident's admissions and weekly forms because it is important to find wounds or anything new on the skin. The DON stated the nurses were not doing their job because the nurses either did not assess Resident 1's skin since nurses did not know the resident had a CVC to his RUC, or the nurses did not document the presence of the RUC CVC. The DON stated that licensed nurses should have done a full body assessment as ordered by the physician on 4/28/2022 and again on 5/30/2022 which was three times a week after Resident 1's hemodialysis (HD- a process where a machine filters the waste from your body because your kidneys have failed) treatments. The DON stated if the licensed nurses were really doing Resident 1's full body assessment as ordered, then the licenses nurses would have detected Resident 1's CVC. The DON stated that the licenses nurse's failure to identify or conduct a thorough body assessment on Resident 1 could be considered neglect because the facility failed to provide the needed care and treatment for Resident 1's CVC placing the resident at continued risk for infection. During an interview on 4/17/2023 at 12:28 p.m., LVN 1 stated that a resident's central lines needed to be monitored, flushed, and have weekly dressing changes. LVN 1 stated Resident 1 could have been harmed because the resident's CVC could have gotten infected. During a concurrent interview and record review on 4/18/2023 at 11:12 a.m., Registered Nurse 2 (RN 2) reviewed Resident 1's GACH Discharge to Skilled Nursing Facility Summary and Transfer Orders dated 4/5/2022 and stated that the summary indicated Resident 1 was admitted to the facility with the CVC on his RUC in place. RN 2 stated that the admitting nurse should have done a skin assessment on Resident 1 upon admission on 4/5/22 and 5/28/22 to identify any central lines such as Resident 1's CVC. RN 2 stated that the summary provided to the facility should have alerted the admitting nurses of the presence of Resident 1's CVC. RN 2 stated TN 1 should have also performed a head-to-toe assessment on Resident 1 on admission and readmission and should have been able to identify the CVC. RN 2 stated TN 1 should have performed weekly skin assessments on Resident 1 and had multiple opportunities to identify the resident's CVC. RN 2 stated central lines need dressings to keep them covered, secure, and safe. RN 2 stated a central line goes into the heart and you do not want germs and bacteria getting in there due to the risk of infection. RN 2 stated an LVN should be able to identify a central line and should notify the RNs. RN 2 stated if an RN was notified of a CVC, an RN should have assessed the resident, looked for documentation, then notified the physician for clarification and orders. RN 2 stated there were multiple missed opportunities to identify Resident 1's CVC that included the admitting nurse on 4/5/2022 and 5/28/2022, TN 1 upon admission on 4/5/2022 and 5/28/2022, treatment nurses conducting weekly skin assessments, and licensed nurses doing weekly and as ordered by the physician skin assessments. A review of the facility policy and procedure titled, Dressing and Injection Cap Change of Central Venous Access Devices (devices that are inserted into the body through a vein, also known as CVC), last reviewed 1/18/2023, indicated an occlusive dressing (an air- and water-tight medical dressing ) shall always be maintained over the central venous access site to reduce the risk of infection to the insertion or exit site and surrounding area of central venous access devices. Transparent Semipermeable Membrane (TSM, a dressing that allows visualization of the insertion site, and provides stabilization and protection from microorganisms) are the dressing of choice for all central catheters. Gauze dressings are only used with the initial dressing application at the time of catheter insertion and needs to be changed within 24 hours. Routine central catheter dressing changes shall be done every seven days and as needed using a TSM type dressing. During every dressing change, facility staff is to document concerns, site problems or any amount of the catheter out of the skin before the insertion into the skin. Only qualified staff shall do a dressing and cap change. To be considered qualified, the RN or IV certified LVN shall have return demonstrated skills with another qualified RN. If a chlorhexidine gluconate protective disk was used, remove after seven days from the day it was placed. Label with a dressing to indicate the type of device, time and date of dressing change, initials of the RN performing the procedure. Document the site appearance, ease of blood return, ease of flush and suture stability. Document in the IV Medication Administration Record the dressing change, securement device change, cap change for all lumens, flush for all lumens, any amount of catheter out of the skin before the insertion site and the arm circumference. Notify the MD of any complications and document notification of the MD. Check the patient's chart to confirm the insertion report and chest X-ray (special pictures of the inside of your body) report confirm tip placement are there. A review of the facility policy and procedure titled, Flushing of Central Venous Access Devices, last reviewed 1/18/2023, indicated flushing of central venous access devices shall be performed by an RN after each intermittent infusion, blood draw, per flushing guidelines, or as ordered by the attending physician. The solutions and volumes to be used for flushing shall be ordered by the attending physician. Document in the nurse's notes the condition of the resident's skin, the presence of any sutures or type of securement device, the presence of any redness, edema (swelling), drainage, or unusual complaints of pain. Document on the treatment record the number of lumens, the flushing, arm circumference, site checks and any amount of exposed catheter. 3. During an interview on 4/17/2023 at 11:20 a.m., LVN 1 stated she had cared for Resident 1 since his admission to the facility on [DATE]. LVN 1 stated she did not know Resident 1 had a CVC until the end of 2022. LVN 1 stated licensed vocational nurses do not provide care for central lines, and that it was the registered nurse's responsibility to provide care for the central lines. LVN 1 stated she notified the registered nurse to assess and monitor Resident 1's CVC, but she does not remember who she notified or what they said. During an interview on 4/17/2023 at 1:00 p.m., Resident 1 stated that there was a day (resident unable to recall exact date) he spoke with LVN 1 about his CVC and that it needed to be covered, to which LVN 1 informed the resident that she would speak with the RN Supervisors, but nobody came. During a concurrent interview and record review with LVN 1 on 4/19/2023 at 9:11 a.m., Resident 1's medical records including face sheet, history and physical, admission assessment, physician orders, progress notes, skin assessments, and care plans from 4/5/2022 to 4/19/2023 were reviewed. LVN 1 stated that she did not document that Resident 1's CVC had been identified in the resident's medical records. LVN 1 stated that there was no documented evidence in Resident 1's medical records from 4/5/2022 to 4/19/2023 to indicate that LVN 1 had notified an RN regarding Resident 1's CVC. LVN 1 stated that since there was no documented evidence of her informing the RNs, it means that it was not done, and she had not informed the RNs of Resident 1's CVC. During an interview on 4/19/2023 at 10:38 a.m., LVN 2 stated that he was aware that Resident 1 had a CVC on his RUC, and during the times he observed the CVC, it was not covered or dressed. LVN 2 stated he did not inform any other facility staff of the presences of Resident 1's CVC. LVN 2 stated he should have checked Resident 1's physician orders to ensure there were orders for treatment and care for Resident 1's CVC when he observed the line uncovered without a dressing. LVN 2 stated he could not recall why he did not inform an RN regarding Resident 1's CVC. LVN 2 stated that he was under the impression that the facility was already aware that Resident 1 had a CVC. LVN 2 stated he should have questioned why Resident 1's CVC would be uncovered and that he should have reported his findings up the chain of command (reporting to your supervisor). A review of the facility policy and procedure titled, Dressing and Injection Cap Change of Central Venous Access Devices (devices that are inserted into the body through a vein, also known as CVC), last reviewed 1/18/2023, indicated an occlusive dressing (an air- and water-tight medical dressing) shall always be maintained over the central venous access site to reduce the risk of infection to the insertion or exit site and surrounding area of central venous access devices. Transparent Semipermeable Membrane (TSM, a dressing that allows visualization of the insertion site, is breathable, and provides stabilization and protection from microorganisms) are the dressing of choice for all central catheters. Gauze dressings are only used with the initial dressing application at the time of catheter insertion and needs to be changed within 24 hours. Routine central catheter dressing changes shall be done every seven days and as needed using a TSM type dressing. During every dressing change, facility staff is to document concerns, site problems or any amount of the catheter out of the skin before the insertion into the skin. Only qualified staff shall do a dressing and cap change. To be considered qualified, the RN or IV certified LVN shall have return demonstrated skills with another qualified RN. If a chlorhexidine gluconate protective disk was used, remove after seven days from the day it was placed. Label with a dressing to indicate the type of device, time and date of dressing change, initials of the RN performing the procedure. Document the site appearance, ease of blood return, ease of flush and suture stability. Document in the IV Medication Administration Record the dressing change, securement device change, cap change for all lumens, flush for all lumens, any amount of catheter out of the skin before the insertion site and the arm circumference. Notify the Medical Doctor (MD) of any complications and document notification of the MD. Check the patient's chart to confirm the insertion report and chest X-ray report confirm tip placement are there. 4. During an interview on 4/17/2023 at 11:20 a.m., LVN 1 stated she had cared for Resident 1 since his admission to the facility on [DATE]. LVN 1 stated she did not know Resident 1 had a CVC until around the end of 2022. LVN 1 stated that she continued to see Resident 1's CVC on his right upper chest without a dressing for a couple of months. LVN 1 stated that around the beginning of January 2023, Resident 1 had asked her on multiple occasions why he had the CVC and why was it not removed. During an interview on 4/17/2023 at 12:00 p.m., the DON stated that when Resident 1 complained to LVN 1 that the facility was not treating or caring for his CVC, LVN 1 should have notified the RN Supervisor. The DON stated LVN 1 did not provide the care Resident 1 needed because she left the resident's CVC uncovered and did not notify the RN Supervisors. During an interview on 4/17/2023 at 1 p.m., Resident 1 stated that he spoke with LVN 1 about his CVC and that it needed to be covered. Resident 1 stated that LVN 1 informed him that she would speak with the supervisors, but nobody came back. Resident 1 stated the facility absolutely did not provide good care and it made him feel scared because they were supposed to know how to take care of his CVC. During an interview on 4/19/2023 at 8:58 a.m., CNA 1 stated she talked with LVN 1 regarding Resident 1's CVC and how she was worried that the line was uncovered during his showers and that the resident wanted it covered. CNA 1 stated she spoke with LVN 1 on multiple occasions regarding covering Resident 1's CVC. During an interview 4/19/2023 at 9:12 a.m., LVN 1 stated she thought about Resident 1's CVC every day that she worked. yet she did not follow up with the RN Supervisors when Resident 1's CVC remained uncovered and untreated. During an interview on 4/19/2023 at 11:25 a.m. the DON stated LVN 1 should have addressed Resident 1's concerns and complaints regarding his CVC. The DON stated if LVN 1 knew about the CVC, LVN 1 should have followed up with the RN supervisor. DON stated that because LVN 1 did not follow up with an RN, no monitoring or treatment was done for Resident 1's CVC. The DON stated LVN 1 knew the adverse effects associated with having a CVC and she should have followed up with Resident 1's concerns of having his CVC left untreated. DON stated that LVN 1 did not follow up with an RN Supervisors or the DON so that orders to monitor and provide the necessary treatment to Resident 1's CVC could be obtained. A review of the facility policy and procedure titled, Skin Assessment, last revised 3/2023, indicated the purpose of the policy was to provide guidelines for routine assessment of resident's skin to maintain skin integrity and promote healing in accordance with standard of care practices. The licensed nurse completes a head-to-toe skin assessment (process of examining entire skin for abnormalities) of the resident's skin during the admission process. The licensed nurse completes routine weekly assessments. Skin integrity should be assessed for pressure related discoloration or breakdown from positioning or use of medical devices applied for therapeutic purposes. The licensed nurse documents assessment findings in the resident's medical record weekly following completion of the skin assessment. Injurious or at-risk areas are documented on a change in condition form and reported to the primary physician for further instruction. 5. During an interview on 4/19/2023 at 8:58 a.m., CNA 1 stated she gave Resident 1 a shower approximately once a week and covered the resident's CVC on his RUC herself. CNA 1 stated she had previously spoken with LVN 1 regarding Resident 1's CVC and how she was worried that the CVC was uncovered during his shower. CNA 1 stated that she informed LVN 1 that Resident 1 wanted his CVC covered. CNA 1 stated that LVN 1 instructed her to cover Resident 1's CVC with the dressings provided by the family. CNA 1 stated she knew she should not cover Resident 1's CVC herself as it is outside her scope of practice, but she covered Resident 1's CVC because LVN 1 did not do it. CNA 1 stated she had spoken with LVN 1 a couple of times regarding Resident 1's need to have his CVC covered during his shower. During an interview on 4/19/2023 at 9:11 a.m., LVN 1 stated that she had reported Resident 1's CVC to an RN Supervisor but was unable to recall who. LVN 1 stated that to her knowledge, the RN Supervisors did not assess Resident 1 CVC. LVN 1 stated that when the RN did not assess Resident 1's CVC, LVN 1 would cover the resident's CVC with a gauze dressing. LVN 1 stated covering a CVC was not within her scope of practice and she was aware of this fact when she covered Resident 1's CVC. LVN 1 stated she covered Resi[TRUNCATED]

Based on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 1), was kept free from neglect (a situation in which not enough care or attention is provided to someone or something) when facility staff failed to call paramedics (person trained to give emergency medical care to people who are injured or ill) when the resident first exhibited signs and symptoms of decompensating (a sudden worsening of a resident ' s medical condition) as evidence by a blood pressure of ,d+[DATE] millimeters of mercury (mmHg-unit of measure, normal blood pressure is ,d+[DATE]mmHg); Oxygen Saturation level (O2 sat- the amount of oxygen in the blood) of 77 percent (%-unit of measure; normal level is 95% or higher); pulse (heart rate) of 111 beats per minute (BPM; normal range is 60 to 100 bpm); and respiration (beathing) rate of 26 breaths per minute (normal range is 16 to 20 breaths per minute) on [DATE] at 6:30 a.m. As a result, Resident 1 ' s decompensating condition was not immediately treated, and 911 (telephone number used to request for emergency medical assistance) was not called until 7:56 a.m. when the oncoming shift nurse (Registered Nurse 2 [RN 2]) went to assess the resident during her morning rounds (when the nurse first checks on all their assigned resident at the start of their shift). RN 2 noted that Resident 1 was in distress. Facility staff then initiated the transfer of Resident 1 to General Acute Care Hospital (GACH) via 911. While at the emergency department (ER- department within the GACH for residents requiring immediate medical care) of the GACH, Resident 1 expired (died ) on [DATE] at 10:19 a.m. while GACH staff were attempting to draw laboratory blood test (a test done on a sample of blood to determine overall health). On [DATE] at 6:09 p.m., the State Survey Agency called an Immediate Jeopardy (IJ-a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Assistant Facility Administrator (AFA) and the Director of Nursing (DON) due to the facility's failure to ensure staff did not act negligently towards Resident 1, who exhibited a decline in overall health condition, when they did not immediately call 911. On [DATE] at 11:11 a.m., the Facility Administrator (FA) provided an IJ Removal Plan which included the following summarized actions: 1. On [DATE], the Director of Nursing began immediate in-servicing of the RN Supervisor and Licensed Vocational Nurse (LVN) assigned to Resident 1 on [DATE], on the facility's policies and procedures regarding neglect. 2. The DON began immediate in-servicing of licensed staff (RN Supervisors and LVNs) scheduled on [DATE]. Director of Nursing/Designee continued to in-service licensed staff until [DATE] on the facility's policies and procedures regarding neglect. One LVN will be in-serviced on [DATE] upon his return from his leave. 3. The DON audited 127 residents for changes of condition. There were 23 of 127 residents identified on [DATE], who were currently being monitored and managed for active changes in conditions. 4. RN Supervisor for each shift will continue to monitor and assess the 23 residents with change of condition for a minimum of 72 hours or until condition has resolved. 5. Effective [DATE], under the guidance and direction of each resident's Primary Care Physician (PCP) or designee, the RN Supervisors implemented resident-directed care and treatment interventions, consistent with the residents' goals and preferences to address the changes. 6. The DON and RN Supervisors reviewed and revised resident care plans effective [DATE] to address the changes in condition and to ensure continued care and services to maintain their highest practicable outcomes. 7. The RN Supervisor for each shift shall inform the resident, the resident's physician and the resident's representative when there are changes involving life threatening conditions to ensure residents receive the necessary staff, supplies, services, policies, training, or staff supervision and oversight to meet their needs 8. The Interdisciplinary Team (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of the resident) reviewed all changes in condition effective [DATE] and continued to review daily the 23 resident's change in condition to ensure required notifications, interventions, care planning and immediacy of interventions to reduce the potential for further decline in health to the extent possible. On [DATE] at 4:21 p.m., while onsite and after verifying the facility ' s full implementation of the IJ removal plan, the State Survey Agency accepted the IJ Removal Plan and removed the Immediate Jeopardy in the presence of the DON and Director of Staff Development (DSD). Findings: A review of Resident 1 ' s face sheet (admission record) indicated that the resident was admitted on [DATE] with diagnoses including hypertension (high blood pressure [BP-a measure of the force that your heart uses to pump blood around your body]), diabetes mellitus type II (DM Type II- an impairment in the way the body regulates and uses glucose [sugar]) and thrombocythemia (platelet [disc-shaped piece of cell that is found in the blood] disorder in which one ' s body produces too many platelets). A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool) dated [DATE], indicated that the resident had intact cognition (ability to think and make decisions). The MDS also indicated that the resident needed extensive assistance from staff with mobility, transfer, toilet use, dressing, and personal hygiene. A review of Resident 1 ' s Physician Orders for Life-Sustaining Treatment (POLST-form that gives residents control over their end-of-life-care) dated [DATE] indicated the resident was under the order of Do Not Resuscitate (DNR- if found pulseless or breathless, medical staff is not to perform cardiopulmonary resuscitation [CPR - an emergency life-saving procedure that is done when someone's breathing or heartbeat has stopped]) with Selective Treatment (a goal of treating a medical condition without invasive [aggressive] medical procedures, such as the use of ventilators [machine that helps you breathe or breathes for you] or major surgery). The POLST was signed by the physician and Resident 1 on [DATE]. A review of Resident 1 ' s Change of Condition (COC) Assessment Form completed by Registered Nurse 4 (RN 4) dated [DATE] and timed at 8:46 a.m., indicated that on [DATE] at around 6:30 a.m., Resident 1 complained of shortness of breath (SOB). The form indicated that Resident 1 ' s initial vital signs (measurements of the body's most basic functions) were as follows: 1. Blood pressure was ,d+[DATE] mmHg. 2. O2 sat- was at 77 %. The COC form indicated that facility staff elevated Resident 1 ' s legs (elevating ones legs above the heart allows the blood to circulate back to the heart without fighting gravity) and provided the resident with supplemental oxygen (treatment in which a tank of oxygen is used to give oxygen to people with breathing problems) of five (5) liters (L-unit of measure) via nasal canula (a device that has two prongs and sits below the nose that delivers oxygen directly into one ' s nostrils). The form further indicated that upon reassessment, Resident 1 ' s vital signs were as follows: 1. Pulse was 111 bpm 2. Respiration rate was 26 breaths per minute 3. Blood Pressure of ,d+[DATE] mmHg 4. Temperature of 97.3 Degrees Fahrenheit ( F-unit of measure; normal temperature range is 97 to 99 F) 5. O2 sat 94% The COC form further indicated that Resident 1 was noted with bloody urine from in and out catheterization (a tube is inserted in a person ' s bladder to drain urine). The COC indicated that a message was left with Resident 1 ' s physician. RN 4 documented that the facility received a call back with instructions to transfer Resident 1 via 911 which was called at around 8:00 a.m. The form indicated that paramedics came and took over the care of Resident 1 at 8:05 a.m., assessed the resident and left the facility with Resident 1 to GACH ER at 8:13 a.m. A review of Resident 1 ' s Paramedic Patient Care Report, dated [DATE], indicated that Paramedics were called by the facility at 7:56 a.m. and arrived at the facility at 8:02 a.m. The form indicated that Resident 1 was found to have low O2 Sat levels of 77% at approximately 6:30 a.m. and was provided with supplemental oxygen. The form indicated that there was minimal improvement to Resident 1, and as a result the facility contacted 911 services. The report indicated that upon the Paramedic ' s arrival to the facility, Resident 1 had an O2 sat of 78%. The record further indicated that Resident 1 was noted to be in a moderate level of distress with the chief complaint being shortness of breath. A review of the GACH ' s Daily Focus Assessment Report, dated [DATE], indicated that on [DATE] at 8:39 a.m., Resident 1 was admitted in the emergency department with labored breathing (having a hard time breathing), slurred speech, hypothermia (dangerously low body temperature), oriented (level of awareness) to self and place, and unable to complain of pain. The Daily Focus Assessment Report further indicated that Resident 1 was noted with tenderness (pain) on palpation (feeling with the fingers or hands) of abdomen. The record indicated that when GACH staff was attempting to draw blood for laboratory testing, Resident 1 was noted to no longer be breathing and was pulseless. The GACH physician was made aware, and Resident 1 was pronounced dead on [DATE] at 10:19 a.m. On [DATE] 10:04 a.m., during an interview, Registered Nurse 5 (RN 5) stated that on [DATE], Resident 1 was under her direct care. RN 5 stated that at approximately 6:30 a.m. on [DATE], she checked Resident 1 ' s blood pressure and O2 Sat levels and noted that Resident 1 ' s blood pressure reading was ,d+[DATE] mmHg with an O2 sat level at 77%. RN 5 stated that due to the resident ' s hypotension (low blood pressure), the resident ' s legs were elevated. RN 5 stated that Resident 1 was also started on oxygen at five (5) liters per min (LPM- unit of measurement) via nasal cannula. RN 5 stated that Resident 1 ' s O2 sat had increased to 94% and the blood pressure increased to ,d+[DATE] mmHg. RN 5stated that she did not monitor Resident 1 any further. RN 5 stated that Resident 1 should have been transferred to the GACH with their initial blood pressure of ,d+[DATE] mmHg. RN 5 stated that 911 should have been called immediately as Resident 1 was in noted distress. RN 5 stated that she considered questioning Registered Nurse 4 (RN 4) who was the RN supervisor, if the resident needed to be transferred via 911. RN 5 stated that because the facility nurses did not immediately call 911, there was a delay in transferring Resident 1 to the GACH. RN 5 stated that if Resident 1 was transferred to the GACH sooner, there is a possibility that the resident would still be alive. On [DATE] at 9:25 p.m., during an interview, Licensed Vocational Nurse 3 (LVN 3) stated that on [DATE] at approximately 6:30 a.m., RN 4 and RN 5 called her to Resident 1 ' s room. LVN 3 stated that upon entering the resident ' s room, Resident 1 was complaining of abdominal pain. LVN 3 stated that RN 4 and RN 5 were having difficulty with obtaining Resident 1 ' s blood pressure because the machine was not getting a reading. LVN 3 stated that Resident 1 appeared to be in distress. LVN 3 stated that she informed RN 4 and RN 5 that Resident 1 needed to be transferred to the GACH as Resident 1 continued to have unrelieved pain. LVN 3 stated that if facility staff had called 911 right away, there would be a possibility that Resident 1 would still be alive. On [DATE] at 5:25 p.m., during an interview, RN 4 stated that she was the RN Supervisor on [DATE]. RN 4 stated that at around 6:30 a.m., she was called by RN 5 to Resident 1 ' s room because the resident had a blood pressure reading of ,d+[DATE] mmHg and an O2 sat level of 77%. RN 4 indicated that Resident 1 was also complaining of abdominal pain, so she asked RN 5 and LVN 3 to perform an in and out catheterization, which revealed that Resident 1 had hematuria (blood in the urine). RN 4 stated that after Resident 1 ' s blood pressure and O2 sat levels improved, she then left a message with Resident 1 ' s physician regarding the COC. RN 4 stated that at 8:46 a.m., she received a call back from the on-call RN informing her that Resident 1 needed to be transferred to the GACH via 911. RN 4 stated that RN 2 had already assessed Resident 1, and the resident had already been transferred to the GACH before receiving the call. RN 4 stated that she should have called 911 when Resident 1 ' s health condition first declined at 6:30 a.m. so that the resident could have been transferred to the GACH sooner. RN 4 stated that she did not call 911 immediately because she was first waiting to receive a call back from Resident 1 ' s physician. RN 4 stated that calling 911 could have possibly saved Resident 1 ' s life. During an interview on [DATE] at 12:06 p.m., Registered Nurse 2 (RN 2) stated that on [DATE], she was the oncoming morning shift (7:00 a.m. to 3:30 p.m.) nurse supervisor. RN 2 stated that on [DATE], she arrived at the facility at approximately 7:45 a.m. RN 2 stated that RN 4 informed her that Resident 1 had experienced a COC at 6:30 a.m. that same morning. RN 2 stated that immediately after being told of Resident 1 ' s COC, she rushed into Resident 1 ' s room. RN 2 stated she had asked RN 4 if 911 had been called, to which RN 4 indicated that she did not call 911 because the resident had a code status of Do Not Resuscitate (DNR). RN 2 stated that she corrected RN 4 that Resident 1 had a code status of DNR with selective treatment. RN 2 stated that she informed RN 4 that 911 needed to be called immediately as Resident 1 appeared to be in distress. RN 2 stated that after 911 was called for Resident 1, paramedics arrived at the facility and Resident 1 was transferred to the GACH. RN 2 stated that Resident 1 should have been transferred to the GACH when the resident first exhibited signs and symptoms of desaturation (low levels of oxygen in the blood), hypotension, rapid respiratory rate (taking more than 20 breaths per minute; normal range is 10 to 20 breaths per minute), and tachycardia (heart rate greater than 100 beats per minute). RN 2 stated that RN 4 apologized to her for not calling 911 for Resident 1. RN 2 stated that there was a greater chance of saving a resident ' s life if emergency treatment had been given as soon as possible. On [DATE] at 2:57 p.m., during an interview with the DON, DON stated that on [DATE] at 6:30 a.m., licensed nurses should have immediately called 911 if Resident 1 exhibited signs and symptoms of desaturation, hypotension, and tachycardia so that the resident could have gotten the help and care he needed. On [DATE] at 12:40 p.m., during a follow up interview with RN 2, RN 2 stated that she was familiar with Resident 1 because the resident resided in the facility for a long period of time. RN 2 stated that when she arrived on shift on [DATE] at approximately 7:45 a.m. she was informed by RN 4 that Resident 1 had a change in condition. RN 2 stated that she immediately went to Resident 1 ' s room and noted that the resident looked different. RN 2 stated that the resident looked pale (having less color than usual) in color and was complaining of abdominal pain. RN 2 stated that within minutes of being in the room with Resident 1, she could tell that the resident needed emergent transfer to the GACH. RN 2 stated that it was important to call 911 because the resident was in distress. RN 2 stated that if they waited for orders to transfer the resident via an ambulance (non-emergency transport to the GACH), the ambulance would refuse transportation of Resident 1 due to the resident ' s condition being unstable. RN 2 stated the reason 911 needed to be called is so that the resident can be transferred to the GACH immediately. On [DATE] at 1:38 p.m., during a follow up interview and concurrent record review with the DON, Resident 1 ' s Change of Condition form dated [DATE] at 8:46 a.m. was reviewed. DON stated that from her investigation of the event that occurred on [DATE] regarding Resident 1 ' s change of condition at 6:30 a.m., that the resident was stabilized and did not require emergent transfer to the GACH. The DON reviewed Resident 1 ' s COC dated [DATE] time at 8:46 a.m. and confirmed that while Resident 1 ' s blood pressure had improved to ,d+[DATE] mmHg and the O2 sat levels had improved to 94% on five (5) L via nasal cannula, the resident still had an elevated heart rate of 111 and an elevated respiratory rate of 26. DON stated that if she was the nurse caring for Resident 1, she would have re-assessed and re-evaluated Resident 1 because the resident ' s vital signs were outside of the normal range. When the DON was asked if Resident 1 had been reassessed or re-evaluated, the DON stated, I know my nurses. The DON stated that her nurses reassessed Resident 1. When the DON was asked if there was documented evidence that Resident 1 had been reassessed to ensure the resident ' s condition had been stabilized, DON stated that there was no documented evidence that the resident had become stable during the shift and that she cannot prove the nurses reassessed or reevaluated the resident because they did not document. On [DATE] at 2:17 p.m. during a follow up interview and concurrent record review with RN 5, Resident 1 ' s Change of Condition form dated [DATE] at 8:46 a.m. was reviewed. RN 5 stated that on [DATE] at approximately 6:30 a.m. she obtained a blood pressure of ,d+[DATE] mmHg and on O2 sat level of 77% for Resident 1. RN 5 stated she took a full set of initial vital signs for Resident 1 at 6:30 a.m. which included their temperature, pulse rate, and respiratory rate, but was unable to find documented evidence when looking through Resident 1 ' s medical record. RN 5 stated that after they elevated Resident 1 ' s legs and provided the resident with supplemental oxygen, the residents blood pressure improved to ,d+[DATE] mmHg and the O2 sat levels had improved to 94% on five (5) L via nasal cannula. RN 5 reviewed Resident 1 ' s COC dated [DATE] at 8:46 a.m. and stated that she was the one who obtain Resident 1 ' s vital signs that showed an elevated heart rate of 111 bpm and an elevated respiratory rate of 26 breaths per minute. RN 5 confirmed that a heart rate of 111 and a respiratory rate of 26 was not normal. RN 5 stated that even though Resident 1 ' s vital signs were not normal, she did not reassess the resident to ensure the resident ' s condition had stabilized. RN 5 stated that her assessment of Resident 1 ' s condition was that the resident was stable and did not require emergent transfer to the GACH. When asked how RN 5 was able to determine if Resident 1 was stable if the resident ' s vital signs were outside the normal range, and RN 5 had admitted to not reassessing or reevaluating the resident, RN 5 stated that based on what she saw, the resident was not in distress and did not need to be transferred to the GACH. When RN 5 was asked how come she indicated in her previous interview that Resident 1 appeared to be in distress, and she questioned if RN 4 was going to transfer the resident to the GACH, RN 5 stated that she does not recall making that statement. When RN 5 was asked if Resident 1 ' s elevated heart rate and respiratory rated needed to be reassessed, RN 5 stated she should have reassessed the resident. When asked if Resident 1 was provided with the care needed, RN 5 stated that she did not provide the resident with the care needed. RN 5 stated that she should have reassessed the resident because the resident was not stable and did not have stable vital signs. RN 5 stated that Resident 1 had just recovered from hypotension, and desaturation, but she failed to continue to monitor the resident to follow up with the elevated heart rate and respiratory rate. RN 5 stated that neglect is when a resident is in need, and the staff can provide that need but does not. RN 5 stated that she did not provide the care needed by Resident 1 when she did not reassess or re-evaluate the resident. RN 5 stated she should have reassessed the resident because the vital signs were still not within normal range, and because she did not reassess, she was not able to ensure the resident was stable. When asked if she acted neglectful by not reassessing or re-evaluating Resident 1 during his COC on [DATE] at 6:30 a.m., RN 5 stated Yes it was neglectful. A review of the facility ' s policy and procedure, titled, Change of Condition Notification, revised [DATE], indicated that if the resident deteriorates, the resident ' s symptoms are serious, and the most rapid intervention available by a physician would place the resident in great jeopardy, the facility is to call 911 for transport to hospital. A review of the facility ' s policy and procedure, titled, Abuse Prevention and Prohibition Program, revised [DATE], indicated that: 1. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property. Resident assessments and care planning are performed to monitor resident needs. The facility provides covered individuals with training to enable the identification of the following signs and symptoms of potential resident abuse and neglect including leaving someone unattended who needs supervision.

Based on interview and record review, the facility failed to immediately call the paramedics (person trained to give emergency medical care to people who are injured or ill) for one of three sampled residents (Resident 1), when the resident first exhibited signs and symptoms of decompensating (a sudden worsening of a resident ' s medical condition) as evidence by a blood pressure of ,d+[DATE] millimeters of mercury (mmHg-unit of measure, normal blood pressure is ,d+[DATE]mmHg); Oxygen Saturation level (O2 sat- the amount of oxygen in the blood) of 77 percent (%-unit of measure; normal level is 95% or higher); pulse (heart rate) of 111 beats per minute (BPM; normal range is 60 to 100 bpm); and respiration (beathing) rate of 26 breaths per minute (normal range is 16 to 20 breaths per minute) on [DATE] at 6:30 a.m. As a result, Resident 1 ' s decompensating condition was not immediately treated, and 911 (telephone number used to request for emergency medical assistance) was not called until 7:56 a.m. when the oncoming shift nurse (Registered Nurse 2 [RN 2]) went to assess the resident during her morning rounds (when the nurse first checks on all their assigned resident at the start of their shift). RN 2 noted that Resident 1 was in distress. Facility staff then initiated the transfer of Resident 1 to General Acute Care Hospital (GACH) via 911. While at the emergency department (ER- department within the GACH for residents requiring immediate medical care) of the GACH, Resident 1 expired (died ) on [DATE] at 10:19 a.m. while GACH staff were attempting to draw laboratory blood test (a test done on a sample of blood to determine overall health). On [DATE] at 6:09 p.m., the State Survey Agency called an Immediate Jeopardy (IJ-a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Assistant Facility Administrator (AFA) and the Director of Nursing (DON) due to the facility's failure to ensure staff immediately called 911 for Resident 1, who exhibited signs and symptoms of decline in overall health condition. On [DATE] at 11:11 a.m., the DON provided an IJ Removal Plan which included the following summarized actions: 1. On [DATE], the DON in-serviced the Registered Nurse (RN) Supervisor and Licensed Vocational Nurse (LVN) assigned to Resident 1 on the night of [DATE] on the facility's policies and procedures regarding changes in condition. 2. On [DATE], the Director of Nursing/ Designee began immediate in-servicing of the facility's licensed staff (RN Supervisors and LVNs) regarding the facility's policy and procedures regarding changes in condition. All available licensed staff have been in-serviced as of [DATE]. 3. On [DATE], the Director of Nursing began immediate in-servicing of the facility's licensed staff (RN Supervisors and LVNs), regarding understanding the code status (type of emergent treatment a person would or would not receive) of residents who experience changes in condition and how their code status will impact interventions implemented to address the specific changes. 4. On [DATE], the Director of Nursing audited the facility's 127 residents for changes of condition. There were 23 out of 127 residents identified as currently being monitored and managed for active changes in condition. 5. Effective [DATE], the RN Supervisor for each shift will continue to monitor and assess the 23 residents with change of condition (COC- a deterioration in health) for a minimum of 72 hours or until condition has resolved to ensure all needed care or services to address the residents' well-being are provided for in collaboration with their primary care physician or designees. 6. Effective [DATE], under the guidance and direction of each resident's Primary Care Physician (PCP) or designee, the RN Supervisors implemented resident-directed care and treatment interventions, consistent with the residents' goals and preferences to address the changes. 7. The Interdisciplinary Team (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of the resident) reviewed all changes in condition effective [DATE] and continued to review daily the 23 resident's change in condition to ensure required notifications, interventions, care planning and immediacy of interventions to reduce the potential for further decline in health to the extent possible. 8. Following completion of code status education on [DATE], the Director of Nursing validated licensed nurses ' competency of change in condition, code status and how it impacts interventions. 9. The facility's policy and procedure on change of condition will be added to the new hire orientation checklist effective [DATE] and will be part of the annual competency program. 10. Director of Nursing or designee will discuss during morning stand up meeting regarding residents identified with any new or on-going changes of condition to ensure their needs are being met. 11. The Director of Nursing, Director of Staff Development (DSD), Assistant Director of Nursing (ADON), or designee will provide clinical oversight and will evaluate and supervise all staff through clinical rounds every shift to identify non-compliance with change of condition protocols. On [DATE] at 4:21 p.m., while onsite and after verifying the facility ' s full implementation of the IJ removal plan, the State Survey Agency accepted the IJ Removal Plan and removed the Immediate Jeopardy in the presence of the DON and DSD. Findings: A review of Resident 1 ' s face sheet (admission record) indicated that the resident was admitted on [DATE] with diagnoses including hypertension (high blood pressure [BP-a measure of the force that your heart uses to pump blood around your body]), diabetes mellitus type II (DM Type II- an impairment in the way the body regulates and uses glucose [sugar]) and thrombocythemia (platelet [disc-shaped piece of cell that is found in the blood] disorder in which one ' s body produces too many platelets). A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool) dated [DATE], indicated that the resident had intact cognition (ability to think and make decisions). The MDS also indicated that the resident needed extensive assistance from staff with mobility, transfer, toilet use, dressing, and personal hygiene. A review of Resident 1 ' s Physician Orders for Life-Sustaining Treatment (POLST-form that gives residents control over their end-of-life-care) dated [DATE] indicated the resident was under the order of Do Not Resuscitate (DNR- if found pulseless or breathless, medical staff is not to perform cardiopulmonary resuscitation [CPR - an emergency life-saving procedure that is done when someone's breathing or heartbeat has stopped]) with Selective Treatment (a goal of treating a medical condition without invasive [aggressive] medical procedures, such as the use of ventilators [machine that helps you breathe or breathes for you] or major surgery). The POLST was signed by the physician and Resident 1 on [DATE]. A review of Resident 1 ' s Change of Condition (COC) Assessment Form completed by Registered Nurse 4 (RN 4) dated [DATE] and timed at 8:46 a.m., indicated that on [DATE] at around 6:30 a.m., Resident 1 complained of shortness of breath (SOB). The form indicated that Resident 1 ' s initial vital signs (measurements of the body's most basic functions) were as follows: 1. Blood pressure was ,d+[DATE] mmHg. 2. O2 sat- was at 77 %. The COC form indicated that facility staff elevated Resident 1 ' s legs (elevating ones legs above the heart allows the blood to circulate back to the heart without fighting gravity) and provided the resident with supplemental oxygen (treatment in which a tank of oxygen is used to give oxygen to people with breathing problems) of five (5) liters (L-unit of measure) via nasal canula (a device that has two prongs and sits below the nose that delivers oxygen directly into one ' s nostrils). The form further indicated that upon reassessment, Resident 1 ' s vital signs were as follows: 1. Pulse was 111 bpm 2. Respiration rate was 26 breaths per minute 3. Blood Pressure of ,d+[DATE] mmHg 4. Temperature of 97.3 Degrees Fahrenheit ( F-unit of measure; normal temperature range is 97 to 99 F) 5. O2 sat 94% The COC form further indicated that Resident 1 was noted with bloody urine from in and out catheterization (a tube is inserted in a person ' s bladder to drain urine). The COC indicated that a message was left with Resident 1 ' s physician. RN 4 documented that the facility received a call back with instructions to transfer Resident 1 via 911 which was called at around 8:00 a.m. The form indicated that paramedics came and took over the care of Resident 1 at 8:05 a.m., assessed the resident and left the facility with Resident 1 to GACH ER at 8:13 a.m. A review of Resident 1 ' s Paramedic Patient Care Report, dated [DATE], indicated that Paramedics were called by the facility at 7:56 a.m. and arrived at the facility at 8:02 a.m. The form indicated that Resident 1 was found to have low O2 Sat levels of 77% at approximately 6:30 a.m. and was provided with supplemental oxygen. The form indicated that there was minimal improvement to Resident 1, and as a result the facility contacted 911 services. The report indicated that upon the Paramedic ' s arrival to the facility, Resident 1 had an O2 sat of 78%. The record further indicated that Resident 1 was noted to be in a moderate level of distress with the chief complaint being shortness of breath. A review of the GACH ' s Daily Focus Assessment Report, dated [DATE], indicated that on [DATE] at 8:39 a.m., Resident 1 was admitted in the emergency department with labored breathing (having a hard time breathing), slurred speech, hypothermia (dangerously low body temperature), oriented (level of awareness) to self and place, and unable to complain of pain. The Daily Focus Assessment Report further indicated that Resident 1 was noted with tenderness (pain) on palpation (feeling with the fingers or hands) of abdomen. The record indicated that when GACH staff was attempting to draw blood for laboratory testing, Resident 1 was noted to no longer be breathing and was pulseless. The GACH physician was made aware, and Resident 1 was pronounced dead on [DATE] at 10:19 a.m. On [DATE] 10:04 a.m., during an interview, Registered Nurse 5 (RN 5) stated that on [DATE], Resident 1 was under her direct care. RN 5 stated that at approximately 6:30 a.m. on [DATE], she checked Resident 1 ' s blood pressure and O2 Sat levels and noted that Resident 1 ' s blood pressure reading was ,d+[DATE] mmHg with an O2 sat level at 77%. RN 5 stated that due to the resident ' s hypotension (low blood pressure), the resident ' s legs were elevated. RN 5 stated that Resident 1 was also started on oxygen at five (5) liters per min (LPM- unit of measurement) via nasal cannula. RN 5 stated that Resident 1 ' s O2 sat had increased to 94% and the blood pressure increased to ,d+[DATE] mmHg. RN 5stated that she did not monitor Resident 1 any further. RN 5 stated that Resident 1 should have been transferred to the GACH with their initial blood pressure of ,d+[DATE] mmHg. RN 5 stated that 911 should have been called immediately as Resident 1 was in noted distress. RN 5 stated that she considered questioning Registered Nurse 4 (RN 4) who was the RN supervisor, if the resident needed to be transferred via 911. RN 5 stated that because the facility nurses did not immediately call 911, there was a delay in transferring Resident 1 to the GACH. RN 5 stated that if Resident 1 was transferred to the GACH sooner, there is a possibility that the resident would still be alive. On [DATE] at 9:25 p.m., during an interview, Licensed Vocational Nurse 3 (LVN 3) stated that on [DATE] at approximately 6:30 a.m., RN 4 and RN 5 called her to Resident 1 ' s room. LVN 3 stated that upon entering the resident ' s room, Resident 1 was complaining of abdominal pain. LVN 3 stated that RN 4 and RN 5 were having difficulty with obtaining Resident 1 ' s blood pressure because the machine was not getting a reading. LVN 3 stated that Resident 1 appeared to be in distress. LVN 3 stated that she informed RN 4 and RN 5 that Resident 1 needed to be transferred to the GACH as Resident 1 continued to have unrelieved pain. LVN 3 stated that if facility staff had called 911 right away, there would be a possibility that Resident 1 would still be alive. On [DATE] at 5:25 p.m., during an interview, RN 4 stated that she was the RN Supervisor on [DATE]. RN 4 stated that at around 6:30 a.m., she was called by RN 5 to Resident 1 ' s room because the resident had a blood pressure reading of ,d+[DATE] mmHg and an O2 sat level of 77%. RN 4 indicated that Resident 1 was also complaining of abdominal pain, so she asked RN 5 and LVN 3 to perform an in and out catheterization, which revealed that Resident 1 had hematuria (blood in the urine). RN 4 stated that after Resident 1 ' s blood pressure and O2 sat levels improved, she then left a message with Resident 1 ' s physician regarding the COC. RN 4 stated that at 8:46 a.m., she received a call back from the on-call RN informing her that Resident 1 needed to be transferred to the GACH via 911. RN 4 stated that RN 2 had already assessed Resident 1, and the resident had already been transferred to the GACH before receiving the call. RN 4 stated that she should have called 911 when Resident 1 ' s health condition first declined at 6:30 a.m. so that the resident could have been transferred to the GACH sooner. RN 4 stated that she did not call 911 immediately because she was first waiting to receive a call back from Resident 1 ' s physician. RN 4 stated that calling 911 could have possibly saved Resident 1 ' s life. During an interview on [DATE] at 12:06 p.m., Registered Nurse 2 (RN 2) stated that on [DATE], she was the oncoming morning shift (7:00 a.m. to 3:30 p.m.) nurse supervisor. RN 2 stated that on [DATE], she arrived at the facility at approximately 7:45 a.m. RN 2 stated that RN 4 informed her that Resident 1 had experienced a COC at 6:30 a.m. that same morning. RN 2 stated that immediately after being told of Resident 1 ' s COC, she rushed into Resident 1 ' s room. RN 2 stated she had asked RN 4 if 911 had been called, to which RN 4 indicated that she did not call 911 because the resident had a code status of Do Not Resuscitate (DNR). RN 2 stated that she corrected RN 4 that Resident 1 had a code status of DNR with selective treatment. RN 2 stated that she informed RN 4 that 911 needed to be called immediately as Resident 1 appeared to be in distress. RN 2 stated that after 911 was called for Resident 1, paramedics arrived at the facility and Resident 1 was transferred to the GACH. RN 2 stated that Resident 1 should have been transferred to the GACH when the resident first exhibited signs and symptoms of desaturation (low levels of oxygen in the blood), hypotension, rapid respiratory rate (taking more than 20 breaths per minute; normal range is 10 to 20 breaths per minute), and tachycardia (heart rate greater than 100 beats per minute). RN 2 stated that RN 4 apologized to her for not calling 911 for Resident 1. RN 2 stated that there was a greater chance of saving a resident ' s life if emergency treatment had been given as soon as possible. On [DATE] at 2:57 p.m., during an interview with the DON, DON stated that on [DATE] at 6:30 a.m., licensed nurses should have immediately called 911 if Resident 1 exhibited signs and symptoms of desaturation, hypotension, and tachycardia so that the resident could have gotten the help and care he needed. On [DATE] at 12:40 p.m., during a follow up interview with RN 2, RN 2 stated that she was familiar with Resident 1 because the resident resided in the facility for a long period of time. RN 2 stated that when she arrived on shift on [DATE] at approximately 7:45 a.m. she was informed by RN 4 that Resident 1 had a change in condition. RN 2 stated that she immediately went to Resident 1 ' s room and noted that the resident looked different. RN 2 stated that the resident looked pale (having less color than usual) in color and was complaining of abdominal pain. RN 2 stated that within minutes of being in the room with Resident 1, she could tell that the resident needed emergent transfer to the GACH. RN 2 stated that it was important to call 911 because the resident was in distress. RN 2 stated that if they waited for orders to transfer the resident via an ambulance (non-emergency transport to the GACH), the ambulance would refuse transportation of Resident 1 due to the resident ' s condition being unstable. RN 2 stated that the reason 911 needed to be called, was so that the resident could be transferred to the GACH immediately. On [DATE] at 1:38 p.m., during a follow up interview and concurrent record review with the DON, Resident 1 ' s Change of Condition form dated [DATE] at 8:46 a.m. was reviewed. DON stated that from her investigation of the event that occurred on [DATE] regarding Resident 1 ' s change of condition at 6:30 a.m., that the resident was stabilized and did not require emergent transfer to the GACH. The DON reviewed Resident 1 ' s COC dated [DATE] time at 8:46 a.m. and confirmed that while Resident 1 ' s blood pressure had improved to ,d+[DATE] mmHg and the O2 sat levels had improved to 94% on five (5) L via nasal cannula, the resident still had an elevated heart rate of 111 and an elevated respiratory rate of 26. DON stated that if she was the nurse caring for Resident 1, she would have re-assessed and re-evaluated Resident 1 because the resident ' s vital signs were outside of the normal range. When the DON was asked if Resident 1 had been reassessed or re-evaluated, the DON stated, I know my nurses. The DON stated that her nurses reassessed Resident 1. When the DON was asked if there was documented evidence that Resident 1 had been reassessed to ensure the resident ' s condition had been stabilized, DON stated that there was no documented evidence that the resident had become stable during the shift and that she cannot prove the nurses reassessed or reevaluated the resident because they did not document. On [DATE] at 2:17 p.m. during a follow up interview and concurrent record review with RN 5, Resident 1 ' s Change of Condition form dated [DATE] at 8:46 a.m. was reviewed. RN 5 stated that on [DATE] at approximately 6:30 a.m. she obtained a blood pressure of ,d+[DATE] mmHg and on O2 sat level of 77% for Resident 1. RN 5 stated she took a full set of initial vital signs for Resident 1 at 6:30 a.m. which included their temperature, pulse rate, and respiratory rate, but was unable to find documented evidence when looking through Resident 1 ' s medical record. RN 5 stated that after they elevated Resident 1 ' s legs and provided the resident with supplemental oxygen, the residents blood pressure improved to ,d+[DATE] mmHg and the O2 sat levels had improved to 94% on five (5) L via nasal cannula. RN 5 reviewed Resident 1 ' s COC dated [DATE] at 8:46 a.m. and stated that she was the one who obtain Resident 1 ' s vital signs that showed an elevated heart rate of 111 bpm and an elevated respiratory rate of 26. RN 5 confirmed that a heart rate of 111 and a respiratory rate of 26 was not normal. RN 5 stated that even though Resident 1 ' s vital signs were not normal, she did not reassess the resident to ensure the resident ' s condition had stabilized. RN 5 stated that her assessment of Resident 1 ' s condition was that the resident was stable and did not require emergent transfer to the GACH. When asked how RN 5 was able to determine if Resident 1 was stable if the resident ' s vital signs were outside the normal range, and RN 5 had admitted to not reassessing or reevaluating the resident, RN 5 stated that based on what she saw, the resident was not in distress and did not need to be transferred to the GACH. When RN 5 was asked how come she indicated in her previous interview that Resident 1 appeared to be in distress, and she questioned if RN 4 was going to transfer the resident to the GACH, RN 5 stated that she does not recall making that statement. When RN 5 was asked if Resident 1 ' s elevated heart rate and respiratory rated needed to be reassessed, RN 5 stated she should have reassessed the resident. When asked if Resident 1 was provided with the care needed, RN 5 stated that she did not provide the resident with the care needed. RN 5 stated that she should have reassessed the resident because the resident was not stable and did not have stable vital signs. RN 5 stated that Resident 1 had just recovered from hypotension, and desaturation, but she failed to continue to monitor the resident to follow up with the elevated heart rate and respiratory rate. RN 5 stated that she did not provide the care needed by Resident 1 when she did not reassess or re-evaluate the resident. RN 5 stated she should have reassessed the resident because the vital signs were still not within normal range, and because she did not reassess, she was not able to ensure the resident was stable. A review of the facility ' s policy and procedure, titled, Change of Condition Notification, revised [DATE], indicated: 1. That if the resident deteriorates, the resident ' s symptoms are serious, and the most rapid intervention available by a physician would place the resident in great jeopardy, the facility is to call 911 for transport to hospital. 2. That a COC is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains. Clinically important means a deviation that, without intervention, may result in complications or death. A review of the facility ' s policy and procedure titled, Emergency Care-General, revised [DATE], indicated that for Emergency - Serious but Not Life Threatening, staff is to summon help and request that someone call 911 if indicated. The resident's vital signs including blood pressure, pulse, respirations, and temperature is to be documented.

Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 261), who was at risk for pain and distress related to [CONDITION(S)] (when the protective cartilage that cushions the ends of the bones wears down over time resulting in pain), received pain management in accordance with professional standards of practice, the facility's policy and the comprehensive person-center care plan by failing to implement the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice caused Resident 261 to experience severe untreated pain (pain rated at seven [7] or higher out of 10, on a pain scale from zero [0] to 10, where 10 is the worst possible pain) on 2/5/2022 and 2/14/2022 when the pain medication was not administered as ordered. Findings: A. A review of Resident 261's Admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 261`s History and Physical dated 2/6/2022, indicated that the resident had the capacity to understand and make decisions. The History and Physical further indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 261`s Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 261's Care Plan titled The resident at risk of pain . dated 2/7/2022 indicated that the resident will display a decrease in behaviors of inadequate pain control. Interventions indicated to administer analgesia (pain medications) as per orders. During an interview on 2/16/22 at 10:29 a.m., Resident 261 stated that she was admitted to the facility on [DATE] at approximately 10:00 a.m. Resident 261 stated that she takes [MEDICATION(S)] 5/325 mg for her knee pain due to her [CONDITION(S)]. Resident 261 stated that on 2/5/2022 she informed her nurse that she was suffering from pain and requested for her [MEDICATION(S)] 5-325mg. Resident 261 stated that the nurse informed her that they were awaiting delivery of her [MEDICATION(S)] 5-325mg. Resident 261 stated she had to wait till the following day on 2/6/2022 before she was given her first dose of [MEDICATION(S)] 5-325 mg. Resident 261 stated she had to endure pain rated at 10 while she was waiting for her [MEDICATION(S)] 5-325 mg. Resident 261 stated that she was in tears due to her untreated pain. A review of facility's Pharmacy Delivery Sheet for Resident 261's [MEDICATION(S)] 5-325 mg dated 2/5/2022, indicated a delivery of 28 tablets which was received by the facility at 11:35 p.m. A review of Resident 261`s Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 02/16/22 at 3:37 p.m., the Director of Nursing (DON) stated that if the facility does not currently have a specific medication for a new admission, the staff can call the pharmacy to get authorization to obtain the medication from the facility's automated medication dispensing system (machine that stores medication to be used during emergent situations such as when a significant medication has not yet been delivered to the facility). During an interview on 2/17/2022 at 3:32 p.m. with Licensed Vocational Nurse 8 (LVN 8), LVN 8 stated that on 2/5/2022 Resident 261 had informed him that she was having knee pain. LVN 8 stated that he was unable to administer [MEDICATION(S)] 5-325 mg to Resident 261 because the resident was a new admission and the pharmacy had not yet delivered their ordered medication. LVN 8 stated that he did not know that the facility utilized an automated medication dispensing system where he could have obtained a dose of [MEDICATION(S)] 5/325 mg for Resident 261 while the pharmacy had not yet delivered the resident's medication. LVN 8 further stated that if a resident is not medicated for pain, the resident could then suffer. During an interview on 2/18/2022 at 8:15 a.m. with the Assistant Director of Nursing (ADON), ADON stated that the facility does carry doses of [MEDICATION(S)] 3/325 mg inside their automated medication dispensing system. ADON stated that on 2/5/2022, doses of [MEDICATION(S)] were available in the automated medication dispensing system. B. A review of Resident 261`s Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 261`s Refill Order Details, dated 2/14/2022 at 10:17 a.m., indicated a request to refill the resident's prescription for [MEDICATION(S)] 5-325 mg. A review of facility's Pharmacy Delivery Sheet for Resident 261's [MEDICATION(S)] 5-325 mg dated 2/14/2022, indicated a delivery of 35 tablets which was received by the facility at 7:00 p.m. A review of Resident 261's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 02/16/22 at 10:29 a.m., Resident 261 stated that on 02/14/2022 sometime before 12:00 p.m., when she asked the nurse for her prescribed [MEDICATION(S)] 5-325 mg, they informed her that they had ran out of her pain medication. Resident 261 stated that she once again had to wait for pharmacy to deliver her medication. Resident 261 stated that the pharmacy did not deliver the medication until around 8:00 p.m. Resident 261 stated that the prolonged untreated pain caused her to cry out. During an interview on 2/17/2022 at 3:32 p.m. with LVN 8, LVN 8 stated that on 2/14/2022, Resident 261 had informed him that she was having knee pains. LVN 8 stated he was unable to administer [MEDICATION(S)] 5-325 mg to the resident because the medication was not available. LVN 8 stated that he made sure that Resident 261's [MEDICATION(S)] 5-325 mg refill was ordered. LVN 8 stated that he did not know that the facility utilized an automated medication dispensing system where he could have obtained a dose of [MEDICATION(S)] 5/325 mg for Resident 261 while the pharmacy had not yet delivered the refill of the resident's medication. During an interview on 2/18/2022 at 12:46 p.m. with Certified Occupational Therapy Assistant (COTA), COTA stated that she provides physical therapy exercises to Resident 261. COTA stated that on 2/14/2022 at approximately 10:30 a.m., Resident 261 complained to her of knee pain. COTA stated that Resident 261 informed her that the facility had run out of her prescribed pain medication of [MEDICATION(S)] 5-325 mg. COTA stated she observed Resident 261 breathing heavily, appearing to be overwhelmed by not having any pain medications. COTA stated that she informed the nurses that Resident 261 needed pain medication. A review of Resident 261`s Physical Therapy (PT) Treatment Encounter Notes dated 2/14/2022 indicated that multiple visits had to be made to Resident 261 to initiate therapy treatment due to reports of pain. The note further indicated that the facility was unable to premedicated the resident for pain due to the prescription medication running out. A review of Resident 261's Care Plan titled The resident at risk of pain . dated 2/7/2022 indicated that the resident will not have an interruption in normal activities due to pain. Interventions indicated to administer analgesia (pain medications) as per orders. During an interview on 2/16/22 at 3:37 p.m., the Director of Nursing (DON) stated that medication refills for residents should be placed when there is around three to four days' worth of remaining medication doses. The DON added that if the facility does not currently have the medication, the staff can call the pharmacy to get authorization to obtain the medication from the facility's automated medication dispensing system (machine that stores medication to be used during emergent situations such as when a significant medication has not yet been delivered to the facility). DON stated that residents will suffer in pain if not timely medicated. During an interview on 2/18/2022 at 8:15 a.m. with the Assistant Director of Nursing (ADON), ADON stated that the facility does carry doses of [MEDICATION(S)] 3/325 mg inside their automated medication dispensing system. ADON stated that on 2/14/2022, doses of [MEDICATION(S)] were available in the automated medication dispensing system. A review of the facility`s undated policy and procedure, titled Pain Management, indicated that facility staff is responsible for helping the resident attain or maintain their highest level of well-being to prevent or manage the resident`s pain. A review of the facility`s undated policy and procedure, titled Medication-Administration, indicated that medication will be administered by a Licensed Nurse per the order of an Attending Physician or licensed independent practitioner. The time and dose of the drug or treatment administered to the resident will be recorded in the resident`s individual medication record by the person who administers the drug or treatment. A review of the facility`s undated policy and procedure, titled Medication-Administration, indicated that medication will be administered by a Licensed Nurse per the order of an Attending Physician or licensed independent practitioner. The time and dose of the drug or treatment administered to the resident will be recorded in the resident`s individual medication record by the person who administers the drug or treatment. A review of the facility`s undated policy and procedure, titled Medication Ordering and Receiving from Pharmacy, indicated that emergency pharmacy service is available on a 24-hour basis. Emergency needs for medication are met by the facility`s emergency medication supply or by special order from the pharmacy. The pharmacy supplies emergency medications including emergency drugs, antibiotics, controlled substances, products for infusion in limited quantities in portable, sealed containers in compliance with applicable state regulations.

Based on observation, interview, and record review, the facility failed to prevent an avoidable injury - a fracture to Resident A's left humerus (upper arm bone) for 1 of 1 sample residents by failing to: 1. Use a mechanical lift (device that assists to safely transfer a resident from one surface to another) to transfer Resident A, who required extensive physical assistance for transfers, from a bed to a wheelchair. 2. Use a two-person physical assist to safely transfer Resident A from a bed to a wheelchair as indicated on the Minimum Data Set (MDS - a comprehensive assessment and screening tool), and develop a care plan for transfer care and service needs based on the assessment, to reduce the risk of an accident. This failure resulted in Resident A sustaining a fracture of the left humerus during a transfer, due to not using a mechanical lift, from a bed to a wheelchair. Resident A had associated severe pain, and required the administration of Norco (a controlled narcotic pain medicine used to treat moderate to severe pain), and placed the resident at risk for side effects, such as constipation. Findings: On January 13, 2016, the Department received a Complaint (CA 340) that alleged, on November 27, 2015, Resident A sustained a fracture of her shoulder. The Department initiated an investigation on January 25, 2016. According to the admission record review, Resident A was initially admitted to the skilled nursing facility (SNF) on December 23, 2013, and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of Restorative Nursing Program Referral care plan dated September 1, 2015, indicated Resident A was totally dependent for transfers due to generalized weakness of both upper and lower extremities. There was no method of transfer indicated on the care plan. A review of the Minimum Data Set (MDS - a comprehensive assessment and screening and care planning tool), dated September 14, 2015, indicated Resident A had moderately impaired cognitive skills for daily-decision making, and required two-person extensive physical assistance (staff provide weight-bearing support) with transfers. Resident A required 1 person extensive physical assistance for dressing, eating, toileting, and personal hygiene. There was no care plan developed to address a method of transfer in order to meet Resident A's transfer needs. A review of the Incident Report Progress Notes dated November 30, 2015, regarding a November 27, 2015, incident, indicated Resident A stated CNA 1 twisted her arm (during the transfer), but the resident was not able to state how. Fifteen minutes after the transfer, and after eating lunch, Family Member 1 notified Charge Nurse 1 about the pain of the left shoulder, and that the resident was not able to move her arm during eating. The progress notes indicated Physician 1 was notified and ordered a stat (immediately), complete x-ray of the left shoulder. A review of Resident A's x-ray report, dated November 27, 2015, at 2:36 pm, indicated Resident A had an impacted (bone ends are driven into each other) humeral neck fracture injury (a broken bone of the upper arm at the shoulder). A review of the facility's Concern/Grievance Reporting form dated December 30, 2015, indicated on November 27, 2015, at 12 pm, Resident A was noted to have a pain rating level of 6 out of 10 (using a pain rating scale of 1 being the least amount of pain, and 10 being the worst possible pain), of the left shoulder. Charge Nurse 1 stated Resident A was transferred from the bed to the wheelchair using a standing machine (a device used to assist in transferring a resident from a sitting to a standing position). A review of Physician 1's progress notes dated November 27, 2015 at 3:11 pm, indicated Resident A complained of shoulder pain, had an impacted humeral neck fracture, had a sling applied and was referred to an orthopedic specialist (physician specializing in bone-related conditions). A review of the Physician 2 ' s progress notes, dated December 4, 2015, at 11:10 am, indicated Resident A, had shoulder pain with movement, had a shoulder immobilizer applied and the plan was to treat the resident non-operatively (without surgery), and ordered non-weight bearing (place no weight on the injured body part) of the left upper arm. A review of the Routine Visit dated December 4, 2015, at 3:12 pm, with Nurse Practitioner 1, indicated she met with Resident A and FM 1, before the resident's orthopedic appointment. FM 1 stated the resident's pain (due to the preventable fracture), was not controlled with the current Norco 5-325 milligrams (mg) one tablet (tab) by mouth every four hours as needed for severe pain. FM 1 and Resident A agreed to a higher dose of Norco (7.5- 325 mg one tab by mouth every six hours as needed for moderate to severe pain) for the resident's severe pain. A review of Resident A's SNF Medication Administration Records (MAR), Controlled Medication Count Sheet, and the Nurses Progress Notes, of November and December 2015, indicated the following use of pain medication: Date Time/Shift Pain Level Medication November 2 to 27, 2015 N/A No Pain None November 27, 2015 Evening 7 None November 27, 2015 Night 5 None November 28, 2015 826am 8 Norco 5-325 mg one tab November 28, 2015 1143pm 5 Tylenol 500 mg two tabs November 29, 2015 0400am 0 Norco 5-325 mg one tab November 29, 2015 1538pm 5 Tylenol 500 mg two tabs November 30, 2015 1200am 6 Norco 5-325 mg one tab November 30, 2015 1102 am 6 Tylenol 500 mg two tabs November 30, 2015 430pm 6 Norco 5-325 mg one tab December 1, 2015 500am 5 Norco 5-325 mg one tab December 1, 2015 800pm 8 Norco 5-325 mg one tab December 2, 2015 1108am 9 Norco 5-325 mg one tab December 2, 2015 1710pm 6 Norco 5-325 mg one tab December 3, 2015 646am 6 Norco 5-325 mg one tab December 3, 2015 1113 am 0 Tylenol 500 mg two tabs December 3, 2015 1422pm 8 Norco 5-325 mg one tab December 4, 2015 0830am 7 Norco 5-325 mg one tab and Tylenol 500 mg two tabs December 4, 2015 500pm 0 Norco 5-325 mg one tab Resident A had physician's orders [REDACTED]. There was a new order for Norco 7.5-325 mg by mouth twice a day. And, Norco 7.5-325 mg by mouth every 6 hours, if needed. Do not exceed a total of 6 tablets of Norco in 24 hours. However, Resident A did not receive the increase in pain medication to control her pain until December 7, 2015. Date Time/Shift Pain Level Medication December 5, 2015 900am 6 Norco 5-325 mg one tab December 5, 2015 500pm 0 Norco 5-325 mg one tab December 6, 2015 900am 5 Norco 5-325 mg one tab December 6, 2015 500pm 5 Norco 5-325 mg one tab December 7, 2015 900am 6 Norco 7.5-325 mg one tab December 7, 2015 400pm 0 Norco 7.5-325 mg one tab December 8, 2015 100am 0 Norco 7.5-325 mg one tab December 8, 2015 900am 5 Norco 7.5-325 mg one tab December 8, 2015 500pm 6 Norco 7.5-325 mg one tab December 9, 2015 900am 6 Norco 7.5-325 mg one tab December 9, 2015 500pm 0 Norco 7.5-325 mg one tab December 10, 2015 900am 6 Norco 7.5-325 mg one tab December 10, 2015 500pm 8 Norco 7.5-325 mg one tab Resident A received pain medication for a pain severity level rating of up to 8, indicating she had severe pain at times, from the preventable fracture on November 27, 2015, into February 2016. The MAR after December 10, 2015, indicated Resident A continued to receive Norco 7.5-325 mg at least twice a day through February 1, 2016, as ordered. On February 4, 2016 at 12:30 p.m., during an interview with the administrator he stated CNA 1, who provided care to Resident A on November 27, 2015, was a new employee and was not knowledgeable about Resident A's transfer needs and had never worked with the resident before. On February 4, 2016, at 12:30 p.m., during an interview with the Director of Nurses (DON), she stated Resident A had weak lower extremities (legs) and could not bear weight (stand). The DON stated that the standing machine placed more pressure on the upper extremities (arms and shoulders) which Resident A could not tolerate, and caused the fracture of her left arm. The DON stated the mechanical lift should have been used to move Resident A instead of the standing machine. The DON when asked, was unable to provide a plan of care with interventions that specified the type of mechanical device and/or method to use when transferring Resident A from bed to chair or wheelchair. The DON stated two staff members should be present when using the standing machine and the mechanical lift to transfer a resident from bed to wheelchair. The DON stated CNA 1 was the only staff present when using the standing machine to transfer Resident A from bed to wheelchair. On February 9, 2016, at 2:55 p.m., during an interview, Resident A's family member (FM 2) stated FM 1 witnessed CNA 1 enter Resident A's room alone (on November 27, 2015). No other staff entered the room to assist CNA 1 with transferring Resident A. An attempt was made to phone interview CNA 1 on March 10, 2016, at 3:45 p.m., and on March 15, 2016, at 5:28 p.m. CNA 1 stated he no longer worked for the facility, and was not cooperative with the interview. A review of the 2011 Operation Manual for Care Lifts and Care Stands (standing machine) indicated, on page 3: The Medicare Stand was designed specifically for assisting your patients to a standing position. Because the Stand is an assistive device, it should only be used with patients that can bear the requisite amount of weight as determined by your facility. It also requires that patients possess more advanced motor skills than for the Medicare Lift. It is important to first determine the appropriateness of this piece of equipment for a particular patient. A review of the facility ' s policy and procedure for the transfer of residents dated July 1, 2015, indicated the purpose is to provide the form of transfer best suited to the residents ' needs and to maintain safety during the procedure. Mechanical lift procedures are used on any resident unable to independently pivot (bear weight to turn) or transfer.