Every finding on record at The Springs Post-Acute

Based on observation, interview, and record review, the facility did not meet standards of quality when licensed staff failed to follow or clarify physician medication orders for three of three residents (Residents 54, 97, and 76):1. For Resident 54, facility failed to separate the administration of Ferrous Sulfate and Minocycline to prevent medication interactions.2. For Residents 54, 97, and 76 facility failed ensure enteral feeding was ordered held before and after administration of phenytoin via gastrostomy tube.This deficient practice had the potential for medication or food interactions which could result in decrease in antibiotic effectiveness for Resident 54 and for Residents 54, 97, and 76 potential to result in seizure activity, decline in resident's condition, or hospitalization. Findings:1. During a medication administration (pass) observation in Station 2, at Medication Cart (Med Cart) C on 4/22/2026 at 8:24 AM with a Licensed Vocational Nurse (LVN) 9, LVN 9 prepared a total of 13 medications that included the following four (4) medications for Resident 54: a. 7.5 ml of Ferrous Sulfate Liquid 220 mg/5 ml (330 mg total) poured out into a medication cupb. 15 ml of Multivitamins with Minerals Liquid was poured out into a medication cup without shaking the medication bottle prior to pouringc. Eight (8) ml of Phenytoin Oral Suspension 125 mg/ 5 ml (200 mg total) was poured into a medication cup without shaking the medication bottle prior to pouringd. Two tablets of Minocycline 50 mg (100 mg total) was crushed and placed into a medication cup During a medication administration (pass) observation on 4/22/2026 at 9:08 AM with LVN 9, after preparing the medications LVN 9 entered Resident 54's room, turned off the enteral feeding pump, checking g-tube placement, providing initial water flush, administered each medication that included but was not limited to Ferrous Sulfate, Minocycline, and Phenytoin. LVN 9 immediately after medication administration via g-tube turned back on Resident 54's enteral feeding pump.During a review of Resident 54's admission record, the admission record indicated Resident 54 was admitted to the facility 7/12/2023 and readmitted on [DATE] with diagnoses that included seizures Idiopathic epilepsy (a neurological disorder characterized by recurrent, unprovoked seizures, from unknown causes), epileptic syndromes with seizures of localized onset (seizures starting in one brain region), anemia (low red blood cells), Encounter for attention to gastrostomy, and dependence on respiratory (ventilator-a machine that helps a person breathe) status. During a review of Resident 54's Order Summary Report (OSR) for the month of April 2026, the OSR indicated active medication orders for: a. Enteral Feed Order every shift Enteral: Hold feeding one (1) hour before and one (1) hour after administration of medication that has a drug/nutrient interaction such as Dilantin (phenytoin), dated 2/3/2026.b. Phenytoin Oral Suspension 100 milligram (mg, unit of measurement mass) per 4 milliliters (ml, unit of measurement volume), give 8 ml via g-tube two times a day for diagnosis of seizure (8ml = 200 mg), dated 2/3/2026c. Ferrous Sulfate Liquid 220 mg/ 5 ml, give 7.5 ml via g-tube one time a day for diagnosis of anemia (7.5 ml = 330 mg). Give with food, dated 2/3/2026.d. Minocycline Oral Tablet 100 mg, give one (1) tablet via g-tube two times a day for s/p (status post/ after) lesion removal ([MOHS surgery] [NAME] Micrographic Surgery, surgical technique used to treat skin cancer, thin layers of cancer-containing skin are progressively removed and examined until only cancer-free tissue remains) of the L-side (left side) of nose for 14 days, dated 4/16/2026.During a review of Resident 54's April 2026 Medication Administration Record (MAR) indicated by documentation and licensed nurses initials that Resident 54 was administered Ferrous Sulfate and Minocycline daily at the schedule 9 AM administration time for 18 days between 4/5/2026 through 4/18/2026.During an interview with the Director of Nursing (DON) on 04/22/2026 at 12:05 PM, the DON stated there was a potential interactions between ferrous sulfate and Minocycline and should not be given together, because iron binds to minocycline. During a telephone interview on 4/22/2026 at 2:35 PM, with Pharm 1 in the presence of the DON, Pharm 1 stated Resident 54's minocycline and ferrous sulfate should be separated as the two medications affect the absorption of each other.During a telephone interview on 4/22/2026 at 2:56 PM with facility's dispensing pharmacist (Pharm 2) in the presence of the DON, Pharm 2 stated Resident 54's ferrous sulfate was not on the resident's profile. Pharm 2 stated Resident 54's minocycline 100 mg twice a day should not be given together with ferrous sulfate.2a. During a concurrent observation, interview, and record review on 4/22/2026 at 9:43 AM with LVN 9 stated that he was not sure if the g-tube feeding should be started immediately after administering phenytoin. LVN 9 reviewed Resident 54's phenytoin order and stated the order does not give instructions to hold feeding. During a concurrent interview and record review on 4/22/2026 at 9:56 AM with the Director of Nursing (DON) in the presence of LVN 9, the DON stated that enteral feeding must be held one hour before and one hour after administration of phenytoin. The DON stated the information to hold enteral feeding was not included on the physician order or on the prescription label to guide the nurse during medication administration. During a concurrent interview and record review on 4/22/2026 at 10:43 AM with the DON, the DON reviewed residents on Dilantin via g-tube and stated the facility have three residents on Dilantin, Resident 54, Resident 97, and Resident 76. The DON stated he will have to communicate to the medication nurses to hold the g-tube feeding before and after Dilantin administration by at least an hour.During a telephone interview on 4/22/2026 at 10:36 AM with the facility's Consultant Pharmacist (Pharm 1) in the presence of the DON. Pharm 1 stated enteral feeding should be held between one to two hours before and after phenytoin administration for better medication absorption and effectiveness. Pharm 1 stated enteral feeding may cause the phenytoin not to be absorbed well, may not be as effective, and the phenytoin level may not be therapeutic to be the most effective and the resident may need more phenytoin to reach an effective level for seizure control.2b. During a review of Resident 97's admission record, the admission record indicated Resident 97 was admitted to the facility 7/8/2023 and readmitted on [DATE] with diagnoses that included seizures, epilepsy, and encounter for attention to gastrostomy. During a review of Resident 97's Order Summary Report (OSR) for the month of April 2026, the OSR indicated active medication orders for: a. Enteral Feed Order every shift Enteral: Hold feeding one (1) hour before and one (1) hour after administration of medication that has a drug/nutrient interaction such as Dilantin (phenytoin), dated 4/16/2026.b. Phenytoin Oral Suspension 100 mg/4 ml, give 8 ml via g-tube three times a day related to epilepsy (8ml = 200 mg). Shake Suspension Well, dated 4/17/2026 During a review of Resident 97's Dilantin (phenytoin) laboratory results with a collection and report date of 2/24/2026, indicated Dilantin result as 7.0 micrograms (mcg, unit of measurement mass)/ml with reference range of 10.0 mcg/ml - 20.0 mcg/ml and was flagged as low (L).During a concurrent record review and interview on 4/22/2026 at 10:43 AM with the DON, Resident 97's current physician order for Dilantin was reviewed. The DON stated for Resident 97 there was no parameter on the order to hold enteral feeding before and after Dilantin administration. 2c. During a review of Resident 76's admission record, the admission record indicated Resident 76 was admitted to the facility 3/13/2017 and readmitted on [DATE] with diagnoses that included seizures, coma (a state of deep unconsciousness in which a person cannot be awakened), and encounter for attention to gastrostomy During a review of Resident 76's Order Summary Report (OSR) for the month of April 2026, the OSR indicated active medication orders for Phenytoin Oral Suspension 125 mg/ 5 ml, give 4 ml via g-tube three times a day for seizures (4 ml = 100 mg), dated 1/27/2026During a concurrent record review and interview on 4/22/2026 at 11:09 AM with the DON, Resident 76's current physician order for Dilantin was reviewed. The DON stated for Resident 76 there was no order to hold enteral feeding before and after Dilantin administration. During an interview on 4/22/2026 at 11:11 AM, with the DON, the DON reviewed and provided a drug reference titled, Management of phenytoin with enteral tube feeding, dated 11/2012, published by Mental Health Clinician, that indicated phenytoin absorption is reduced when given concomitantly with tube feeding to such an extent that phenytoin serum levels may be reduced as much as 50 % to 75 %, leaving the patient at risk for seizures.Ideally, the feeds should be held one to two hours before or after each phenytoin dose with adequate tube flushes before and after phenytoin administration.During a review of the facility's Policy and Procedures (P&P) titled, Administering Medications, dated 4/2019, the P&P indicated to provide safe administration of medications for residents in the facility. The P&P indicated, Medications are administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include:a. Enhancing optimal therapeutic effect of the medicationb. Preventing potential medication or food interactions. During a review of the facility's P&P titled, Administering Medication through an Enteral Tube, dated 11/2018, the P&P indicated, Check compatibility with feeding tube formula:a. If the resident is on continuous tube feedings and the medication(s) are to be given on an empty stomach and/or are associated with medication-feeding formula incompatibility, stop the feeding at least 30 minutes prior to medication administration and restart at least 30 minutes after medication administrationb. Recommended timeframes between medication and enteral formula administration should be determined by manufacturers of these products, or specified in the order.

Based on observation, interview and record review the facility failed to establish and maintain an implementation for prevention and control program (IPCP) to maintain safety and sanitary for two out of two sampled residents by failing to: Report an outbreak of scabies (a contagious skin condition caused by tiny insects called mites that infest and irritate your skin by intense itching, inflammation, and red patches) to the local health Department after 2 residents (Residents 66 and Resident 87) had rashes with severe itching and tested positive for skin scraping (a quick, minimally invasive diagnostic procedure used to sample the outer layer of skin, usually with a scalpel blade, to detect fungal infections (using [NAME]) or parasites like scabies/mites (using mineral oil) under a microscope. for scabies, which affected their quality of life, while being treated for suspected scabies. Perform disinfection of the mattress, pillows, bedside equipment, and floors after permethrin cream used for scabies prevention treatment for Residents 66 and 87. Ensure Resident 36 and Resident 39 who are exhibiting symptoms of suspected scabies were placed on contact isolation (used to prevent disease from spreading) and ensure the facility protocol for scabies was followed. These deficient practices placed all residents, staff, vendors, and visitors at risk to acquire and be exposed to the scabies infection. Findings: a. During a review of Resident 87's admission Record, admission Record indicated Resident 66 was admitted on [DATE] with diagnoses including hypertension (high blood pressure) diabetes mellitus (DM- high blood glucose), acute respiratory failure with hypoxia . During a review of Resident 87's Minimum Data Set (MDS- a resident assessment) dated 2/8/26, MDS indicated, Resident 66 has no speech, and with short term and long-term memory problem. The MDS indicated Resident 87 is dependent on all activities of daily living (ADL's). During a review of Resident 87's Skin Scraping for scabies dated 1/20/26, it indicated positive for sarcoptes scabiei (microscopic, parasitic mite that burrows into the upper layer of human skin to live and lay eggs, causing a contagious skin infestation known as scabies). During a review of Resident 66's admission Record, the admission Record indicated, Resident 66 was admitted on [DATE] with diagnoses including hemiplegia (complete paralysis) and hemiparesis (weakness) following unspecified cerebrovascular disease affecting right dominant side, acute respiratory failure with hypoxia (dangerous condition where body tissues do not receive enough oxygen), cardiac arrest (life-threatening emergency where the heart abruptly stops beating and pumping blood), pneumothorax (collapsed lung), acute embolism (thrombus or foreign substance that breaks off and travels through the bloodstream, getting lodged in a smaller vessel) and thrombosis (stationary clot formed in a vein or artery) of unspecified deep veins of right lower extremity. During a review of Resident 66's MDS dated [DATE], MDS indicated Resident 66 has no speech, with short term memory problem and long-term memory problem. The MDS indicated Resident 66 is dependent with staff on all ADL's. During a review of Resident 66's Skin Scraping for scabies dated 2/28/26, it indicated positive for sarcoptes scabiei (microscopic, parasitic mite that burrows into the upper layer of human skin to live and lay eggs, causing a contagious skin infestation known as scabies). During a review of a Resident 66's Dermatologist (a medical practitioner specializing in the diagnosis and treatment of skin disorders) Visit Note dated 3/3/26, Resident 66 was seen for a chief complaint of a rash located throughout the body, rash is itchy, red, scaly and moderate in severity, has had this rash for weeks, pertinent history includes difficulty sleeping at night due to itch, it indicated Dermatologist prescribed ivermectin ( prescription medication used to treat human infections caused by parasitic worms (strongyloidiasis, onchocerciasis) and external parasites like head lice and scabies)and permethrin cream ( prescription topical medication used primarily to treat scabies by killing Sarcoptes scabiei mites and their egg), apply from neck down to the toes, leave for 12 hours then rinse, repeat once a week x 4 weeks, and perform skin scraping. During a record review of the undated line listing (a table that contains key information about each case in an outbreak), the line list indicated on 1/16/2026 Resident 87 has positive skin scraping. The line list indicated that on 2/25/2026 Resident 66 tested positive for skin scraping of scabies which is within the 4-8 weeks of incubation period. During a concurrent interview and record review conducted on 4/23/2026 at 9:00 a.m. with the Infection Preventionist Nurse (IPN), the IPN stated that a report was not made to the agency because there were not yet two positive residents to qualify as an outbreak. The IPN stated they had been waiting for a response from the Local Public Health Department, but no response was received until March 2026. The IPN stated that the report should have been submitted when two residents tested positive on 2/25/2026. The IPN stated that the agency must be notified so it can visit the facility and ensure appropriate measures are being taken to contain the spread of infection. The IPN stated that the report should have been made sooner. The IPN stated that the process for the application of the permethrin cream is that applied at nighttime then showered in the morning to remove the cream. The housekeeping will clean the room including bagging the belongings while providing showers to the residents. During a concurrent record review and interview conducted on 4/23/2026 at 9:50 a.m. with the Housekeeping Supervisor (HS), the HS stated that a complete log of deep cleaning for rooms occupied by affected residents, as well as for shower rooms, was not maintained. The HS stated that the regular deep-cleaning schedule was followed and no additional deep-cleaning procedures were performed. The HS also stated that there was no documentation indicating that the linens or personal belongings of Resident 66 or Resident 87 had been bagged or deep cleaned. During an interview conducted on 4/23/2026 at 11:00 a.m. with the Director of Nursing (DON), the DON stated that the first positive case occurred on 1/20/2026 and the second positive case on 2/25/2026. The DON explained that two positive cases within this timeframe constitute an outbreak. The DON stated that the facility failed to report the positive case identified in 02/2026 and stated that it is essential to report when two positive cases occur within a 4-6-week incubation period. During a review of Resident 36's admission Record, the admission Record indicated Resident 36 was admitted on [DATE] with diagnoses including acute respiratory failure (a life-threatening, sudden inability of the lungs to oxygenate the blood or remove carbon dioxide), malignant neoplasm of endometrium (cancer of the uterine lining), dependence on ventilator (machine that helps residents breathe), congestive heart failure (the heart cannot pump blood efficiently), chronic kidney failure, anemia (blood disorder where the body lacks sufficient healthy red blood cells). During a review of Resident 36's MDS dated [DATE], MDS indicated, Resident 36 has no speech, moderate hearing difficulty, The MDS indicated that Resident 36 dependent on ADLs with staff. During a review of Resident 36's Situation, Background, Assessment, and Recommendation (SBAR-a communication framework) or Change of Condition (COC) dated 3/16/26, SBAR indicated, rash on left shoulder: during morning care, noted rash like eruptions on left shoulder, dry and scaly, with redness and scant serous exudate, complaining of itchiness SBAR also indicated to perform skin scraping. During a review of Resident 36's Dermatology Progress Notes dated 4/13/26, Derma Notes indicated, diagnosis of dermatitis unspecified gen body, treatment: permethrin and ivermectin, topical steroids, and skin scraping. There is no documented contact precaution while there is a suspicious rash on 3/16/26. During a review of Resident 36's Physician Orders dated 4/14/26, Physician Orders indicated, rash: dermatitis unspecified on generalized body; monitor and assess once a day for any changes in appearance, there is no documented contact isolation. During a review of Resident 39's admission Record on 4/20/26, admission Record indicated, Resident 39 was admitted on [DATE] with diagnoses including acute and chronic respiratory failure, epilepsy (recurrent, unprovoked seizures), DM. During a review of Resident 39's MDS dated [DATE], the MDS indicated Resident 39 has no speech, cognitive skills for daily decision making is severely impaired and dependent with ADL's. During a review of Resident 39's SBAR or COC dated 3/27/26, SBAR indicated, rash like eruption on left side trunk during morning care noted rash like eruption on left side trunk, raised red and dark brown patches and scattered red spots with no drainage, some are raised and pimple like. During a review of Resident 39's Dermatology Notes dated 4/13/26, Derma Notes indicated, diagnosis of dermatitis unspecified gen body, treatment includes permethrin, ivermectin, oral steroids, topical steroids, and skin scraping, no contact precaution order for a generalized body rash. During a concurrent record review and interview on 4/23/26 at 9:00 a.m. of Resident 39 and 36's Physician's order and SBAR with IPN, IPN stated, Resident 39 was not placed on contact precaution when rash was identified on 3/27/26. The IPN stated it should have been on contact isolation to prevent the spread of infection to other residents or staff. During an interview on 4/23/2026 at 11:20 a.m. with the DON, the DON stated that contact precautions are implemented when a contagious disease is suspected in order to prevent transmission. The DON stated that they remain actively involved and proactive in monitoring infections reported within the facility to prevent the spread of disease. The DON stated that he was not aware that there was no physician order in place for the initiation of contact precautions when there is a suspected rash.During a review of the facility's Policy and Procedure (P&P), titled Infection Prevention Quality Control Plan, reviewed October 2022, Standard precautions will be used in the care of all residents in all situations regardless of suspected or confirmed presence of infectious disease . Transmission-based Precautions will be used whenever measures more stringent than Standard Precautions are needed to prevent the spread of infection. During a review of facility's P&P on Scabies Identification, Treatment and Environmental Cleaning, reviewed August 2022, P&P indicated, incubation period can be 2-6 weeks before onset of itching for persons with no previous exposure. Affected residents should remain on Contact Precautions. Treatment with Permethrin leave cream on for at least 8 hours but no more than 12 hours and then shower or bathe the resident in warm water, soaping the body completely, rinsing and drying well. Environmental Control: Typical Scabies 1. Place residents with typical scabies on contact precautions during the treatment period, Environmental Control: Crusted/Atypical Scabies: Maintain contact precautions until treatment is complete and/or resident is determined (by dermatologist or primary care provider) to be scabies-free.

Based on observation, interview, and record review, the facility failed to ensure three of three residents (Resident 54, 97, and 76) were free of a significant medication error (any preventable error in medication administration that can result in resident discomfort, jeopardizing health and safety, or requiring medical intervention) by failing to:1. Ensure Resident 54 was not administered interacting medications, Ferrous Sulfate and Minocycline together for 18 days, between 4/5/2026 through 4/22/20262. Ensure Resident 54, Resident 97, and Resident 76 enteral feeding was turned off one hour before and after g-tube administration of Dilantin (phenytoin) to prevent the potential for feeding and phenytoin interaction in accordance with the physician's enteral feeding order and the facility's policy and procedures (P&P) titled, Administering Medication through an Enteral Tube and Administering Medicationsnot administered or had the potential to be administered via g-tube concomitantly Dilantin (phenytoin) with enteral feeding which increased the risk for interactions and uncontrolled seizure by lowering the effectiveness of phenytoin These deficient practices increased the risk that Residents 54, 97 and 76 experience adverse reactions (negative effects from medication), that include slow infection healing for Resident 54 and increased risk for uncontrolled seizures, that could lead to a decline in the residents' condition, harm, or hospitalization for Residents 54, 97, and 76. Findings:1. During a medication administration (pass) observation in Station 2, at Medication Cart (Med Cart) C on 4/22/2026 at 8:24 AM with a Licensed Vocational Nurse (LVN) 9, LVN 9 prepared a total of 13 medications that included the following four (4) medications for Resident 54: a. 7.5 ml of Ferrous Sulfate Liquid 220 mg/5 ml (330 mg total) poured out into a medication cupb. 15 ml of Multivitamins with Minerals Liquid was poured out into a medication cup without shaking the medication bottle prior to pouringc. Eight (8) ml of Phenytoin Oral Suspension 125 mg/ 5 ml (200 mg total) was poured into a medication cup without shaking the medication bottle prior to pouringd. Two tablets of Minocycline 50 mg (100 mg total) was crushed and placed into a medication cup During a medication administration (pass) observation on 4/22/2026 at 9:08 AM with LVN 9, LVN 9 put on personal protective equipment (PPE, gown and gloves), used alcohol based hand sanitizer (ABHS), and entered Resident 54's room, turned off the enteral feeding pump, after checking g-tube placement, providing initial water flush, administered each medication separately that included but was not limited to Ferrous Sulfate, Minocycline, and Phenytoin, and then LVN 9 turned back on the enteral feeding pump.During a review of Resident 54's admission record, the admission record indicated Resident 54 was admitted to the facility 7/12/2023 and readmitted on [DATE] with diagnoses that included seizures Idiopathic epilepsy (a neurological disorder characterized by recurrent, unprovoked seizures, from unknown causes), epileptic syndromes with seizures of localized onset (seizures starting in one brain region), anemia (low red blood cells), hemiplegia (severe or complete loss of strength or paralysis on one side of the body) affecting right dominant side, Encounter for attention to gastrostomy, and dependence on respiratory (ventilator-a machine that helps a person breathe) status. During a review of Resident 54's Minimum Data Set (MDS - a resident assessment tool), dated 1/13/2026, the MDS indicated Resident 54's cognitive skills (thought process and ability to reason or make decisions) to make self-understood or to understand others that the resident was rarely or never understood or understandable.During a review of Resident 54's History and Physical (H&P), dated 2/4/2026, the H&P indicated Resident 54 does not have the capacity to understand and make decisions. During a review of Resident 54's Care Plans (CP), revised on 4/8/2026, indicated: The CP focus indicated Resident 54 was at risk for seizure activity. The CP indicated that Resident 54 will remain seizure free and will remain free from injury related to seizure. The CP interventions indicated to administer medications as ordered and monitor for any adverse effect: Dilantin.The CP focus indicated Resident 54 has infection related to diagnosis: Status post lesion removal. The CP indicated that Resident 54 will have infection resolved upon completion of anti-infective therapy as evidence by absence of signs and symptoms of infection. The CP interventions indicated to assess and document therapeutic effects of medication: Minocycline Oral Tablet 100 mg.During a review of Resident 54's Order Summary Report (OSR) for the month of April 2026, the OSR indicated active medication orders for: a. Enteral Feed Order every shift Enteral: Hold feeding one (1) hour before and one (1) hour after administration of medication that has a drug/nutrient interaction such as Dilantin (phenytoin), dated 2/3/2026.b. Phenytoin Oral Suspension 100 milligram (mg, unit of measurement mass) per 4 milliliters (ml, unit of measurement volume), give 8 ml via g-tube two times a day for diagnosis of seizure (8ml = 200 mg), dated 2/3/2026c. Ferrous Sulfate Liquid 220 mg/ 5 ml, give 7.5 ml via g-tube one time a day for diagnosis of anemia (7.5 ml = 330 mg). Give with food, dated 2/3/2026.d. Minocycline Oral Tablet 100 mg, give one (1) tablet via g-tube two times a day for s/p (status post/ after) lesion removal ([MOHS surgery] [NAME] Micrographic Surgery, surgical technique used to treat skin cancer, thin layers of cancer-containing skin are progressively removed and examined until only cancer-free tissue remains) of the L-side (left side) of nose for 14 days, dated 4/16/2026.During a review of Resident 54's April 2026 Medication Administration Record (MAR) indicated by documentation and licensed nurses initials that Resident 54 was administered Ferrous Sulfate and Minocycline daily at the schedule 9 AM administration time for 18 days between 4/5/2026 through 4/18/2026.During an interview with the Director of Nursing (DON) on 04/22/2026 at 12:05 PM, the DON stated there was a potential interactions between ferrous sulfate and Minocycline and should not be given together, because iron binds to minocycline. During a telephone interview on 4/22/2026 at 2:35 PM, with Pharm 1 in the presence of the DON, Pharm 1 stated Resident 54's medication was reviewed in the beginning, when medications are dispensed in the pharmacy will show interactions and the dispensing pharmacy will let the facility know regarding drug interactions. Pharm 1 stated minocycline and ferrous sulfate should be separated as the two medications affect the absorption of each other.During a telephone interview on 4/22/2026 at 2:56 PM with facility's dispensing pharmacist (Pharm 2) in the presence of the DON, Pharm 2 stated Resident 54's ferrous sulfate was not on the resident's profile. Pharm 2 stated Resident 54's minocycline 100 mg twice a day should not be given together with ferrous sulfate.2a. During a concurrent observation, interview, and record review on 4/22/2026 at 9:43 AM with LVN 9, Resident 54's physician orders for phenytoin and enteral feed were reviewed. LVN 9 stated all done with medication pass and stated restarting Resident 54's enteral feeding. LVN 9 was observed pressing the restart button on the enteral feeding pump. LVN 9 stated that he was not sure if the g-tube feeding should be started immediately after administering phenytoin. LVN 9 reviewed Resident 54's phenytoin order and stated the order does not give instructions to hold feeding. LVN 9 reviewed Resident 54's enteral feed order and stated that the enteral feed order indicated to hold feeding, but the physician order and prescription label did not include the instructions to hold feeding before or after administering phenytoin. During a concurrent interview and record review on 4/22/2026 at 9:56 AM with the Director of Nursing (DON) in the presence of LVN 9, the DON stated that enteral feeding must be held one hour before and one hour after administration of phenytoin. The DON stated the information to hold enteral feeding was not included on the physician order or on the prescription label to guide the nurse during medication administration. The DON stated the enteral feeding is held to improve the absorption of phenytoin and to prevent a drug/nutrient interaction with phenytoin. The DON stated if the phenytoin level is low, may trigger a seizure in Resident 54. The DON stated that a seizure could cause resident injury, a change of condition and hospitalization. The DON stated that Resident 54's physician Enteral Feeding order indicated to hold tube feeding for one hour before and after administration of medication that has a drug/nutrient interaction such as Dilantin (phenytoin). During a telephone interview on 4/22/2026 at 10:36 AM with the facility's Consultant Pharmacist (Pharm 1) in the presence of the DON. Pharm 1 stated enteral feeding should be held between one to two hours before and after phenytoin administration for better medication absorption and effectiveness. Pharm 1 stated enteral feeding may cause the phenytoin not to be absorbed well, may not be as effective, and the phenytoin level may not be therapeutic to be the most effective and the resident may need more phenytoin to reach an effective level for seizure control.During a concurrent interview and record review on 4/22/2026 at 10:43 AM with the DON, the DON reviewed residents on Dilantin via g-tube and stated the facility have three residents on Dilantin, Resident 54, Resident 97, and Resident 76. The DON stated he will have to communicate to the medication nurses to hold the g-tube feeding before and after Dilantin administration by at least an hour.2b. During a review of Resident 97's admission record, the admission record indicated Resident 97 was admitted to the facility 7/8/2023 and readmitted on [DATE] with diagnoses that included seizures, epilepsy, and encounter for attention to gastrostomy. During a review of Resident 97's MDS, dated [DATE], the MDS indicated Resident 97's cognitive skills to make self-understood or to understand others that the resident was rarely or never understood or understandable.During a review of Resident 97's H&P, dated 4/17/2026, the H&P indicated Resident 97 has the capacity to understand and make decisions. During a review of Resident 97's Order Summary Report (OSR) for the month of April 2026, the OSR indicated active medication orders for: a. Enteral Feed Order every shift Enteral: Hold feeding one (1) hour before and one (1) hour after administration of medication that has a drug/nutrient interaction such as Dilantin (phenytoin), dated 4/16/2026.b. Phenytoin Oral Suspension 100 mg/4 ml, give 8 ml via g-tube three times a day related to epilepsy (8ml = 200 mg). Shake Suspension Well, dated 4/17/2026During a review of Resident 97's Care Plans (CP), initiated on 4/18/2026, the CP focus indicated Resident 97 has a seizure disorder related to epilepsy. The CP indicated that Resident 97 will remain seizure free and will remain free from injury related to seizure activity. The CP interventions indicated to give medications as ordered. Monitor/document for effectiveness and side effects. Phenytoin Oral Suspension.During a review of Resident 97's Dilantin (phenytoin) laboratory results with a collection and report date of 2/24/2026, indicated Dilantin result as 7.0 micrograms (mcg, unit of measurement mass)/ml with reference range of 10.0 mcg/ml - 20.0 mcg/ml and was flagged as low (L).During a concurrent record review and interview on 4/22/2026 at 10:43 AM with the DON, Resident 97's current physician order for Dilantin was reviewed. The DON stated for Resident 97 there was no parameter on the order to hold enteral feeding before and after Dilantin administration. 2c. During a review of Resident 76's admission record, the admission record indicated Resident 76 was admitted to the facility 3/13/2017 and readmitted on [DATE] with diagnoses that included seizures, coma (a state of deep unconsciousness in which a person cannot be awakened), and encounter for attention to gastrostomy During a review of Resident 76's MDS, dated [DATE], the MDS indicated Resident 76's was in a comatose state.During a review of Resident 76's H&P, dated 5/15/2025, the H&P indicated Resident 76 does not have the capacity to understand and make decisions. During a review of Resident 76's Order Summary Report (OSR) for the month of April 2026, the OSR indicated active medication orders for Phenytoin Oral Suspension 125 mg/ 5 ml, give 4 ml via g-tube three times a day for seizures (4 ml = 100 mg), dated 1/27/2026During a review of Resident 76's Care Plans (CP), revised on 3/24/2026, the CP focus indicated Resident 76 is at risk for seizure activity. The CP indicated that Resident 76 will remain seizure free and will remain free from injury related to seizure. The CP interventions indicated to administer medications as ordered and monitor for any adverse effects. phenytoinDuring a concurrent record review and interview on 4/22/2026 at 11:09 AM with the DON, Resident 76's current physician order for Dilantin was reviewed. The DON stated for Resident 76 there was no order to hold enteral feeding before and after Dilantin administration. During an interview on 4/22/2026 at 11:11 AM, with the DON, the DON reviewed and provided a drug reference titled, Management of phenytoin with enteral tube feeding, dated 11/2012, published by Mental Health Clinician, that indicated phenytoin absorption is reduced when given concomitantly with tube feeding to such an extent that phenytoin serum levels may be reduced as much as 50 % to 75 %, leaving the patient at risk for seizures.Ideally, the feeds should be held one to two hours before or after each phenytoin dose with adequate tube flushes before and after phenytoin administration.During a review of the facility's Policy and Procedures (P&P) titled, Administering Medications, dated 4/2019, the P&P indicated to provide safe administration of medications for residents in the facility. The P&P indicated, Medications are administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include:a. Enhancing optimal therapeutic effect of the medicationb. Preventing potential medication or food interactions. During a review of the facility's P&P titled, Administering Medication through an Enteral Tube, dated 11/2018, the P&P indicated, Check compatibility with feeding tube formula:a. If the resident is on continuous tube feedings and the medication(s) are to be given on an empty stomach and/or are associated with medication-feeding formula incompatibility, stop the feeding at least 30 minutes prior to medication administration and restart at least 30 minutes after medication administrationb. Recommended timeframes between medication and enteral formula administration should be determined by manufacturers of these products, or specified in the order.

Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was less than five percent (%, unit of measurement). The facility had four medication errors out of a total of twenty-five opportunities resulting in an overall medication error rate of 16 %, affecting one of six residents (resident 54) observed during medication administration (pass). The medication errors noted for Resident 54 were as follows:1. Facility failed to separate and check compatibility (the ability to combine two medicines without interfering with the action of either) between Minocycline (antibiotic) and Ferrous Sulfate (iron supplement) before administering the two medications together via gastrostomy tube (g-tube: a feeding tube that's surgically placed into the stomach).2. Facility failed to hold enteral feeding (giving food or medication directly into the stomach through a tube in the abdomen) before and after phenytoin administration 3. Facility failed to follow manufacturer instructions to shake well phenytoin oral suspension and Multivitamin and Minerals Liquid prior to pouring a dose of each into medication cups for administration.These failures to administer medications in accordance with manufacturer's specifications and standards of practice placed Residents 54 at risk to experience significant medical complications including reduced seizure (a sudden, uncontrolled electrical disturbance in the brain), control, drug (medication) interactions (when two or more drugs affect each other's action or cause unexpected side effects), administration of less than the full therapeutic dose of medication, adverse reactions (undesired or harmful effects caused by medication), and hospitalization. Findings:During a review of Resident 54's admission record, the admission record indicated Resident 54 was admitted to the facility 7/12/2023 and readmitted on [DATE] with diagnoses that included seizures Idiopathic epilepsy (a neurological disorder characterized by recurrent, unprovoked seizures, from unknown causes), epileptic syndromes with seizures of localized onset (seizures starting in one brain region), anemia (low red blood cells), hemiplegia (severe or complete loss of strength or paralysis on one side of the body) affecting right dominant side, Encounter for attention to gastrostomy, and dependence on respiratory (ventilator-a machine that helps a person breathe) status. During a review of Resident 54's Minimum Data Set (MDS - a resident assessment tool), dated 1/13/2026, the MDS indicated Resident 54's cognitive skills (thought process and ability to reason or make decisions) to make self-understood or to understand others that the resident was rarely or never understood or understandable.During a review of Resident 54's History and Physical (H&P), dated 2/4/2026, the H&P indicated Resident 54 does not have the capacity to understand and make decisions. During a review of Resident 54's Care Plans (CP), revised on 4/8/2026, indicated:1. The CP focus indicated Resident 54 was at risk for seizure activity. The CP indicated that Resident 54 will remain seizure free and will remain free from injury related to seizure. The CP interventions indicated to administer medications as ordered and monitor for any adverse effect: Dilantin.2. The CP focus indicated Resident 54 has infection related to diagnosis: Status post lesion removal. The CP indicated that Resident 54 will have infection resolved upon completion of anti-infective therapy as evidence by absence of signs and symptoms of infection. The CP interventions indicated to assess and document therapeutic effects of medication: Minocycline Oral Tablet 100 mg.During a review of Resident 54's Order Summary Report (OSR) for the month of April 2026, the OSR indicated active medication orders for: 1. Enteral Feed Order every shift Enteral: Hold feeding one (1) hour before and one (1) hour after administration of medication that has a drug/nutrient interaction such as Dilantin (phenytoin), dated 2/3/2026.2. Phenytoin Oral Suspension 100 mg/4 ml, give 8 ml via g-tube two times a day for diagnosis of seizure (8ml = 200 mg), dated 2/3/2026.3. Ferrous Sulfate Liquid 220 milligrams (mg, unit of measurement mass) per 5 milliliters (ml, unit of measurement volume), give 7.5 ml via g-tube one time a day for diagnosis of anemia (7.5 ml = 330 mg). Give with food, dated 2/3/2026.4. Minocycline Oral Tablet 100 mg, give one (1) tablet via g-tube two times a day for s/p (status post/ after) lesion removal ([MOHS surgery] [NAME] Micrographic Surgery, surgical technique used to treat skin cancer, thin layers of cancer-containing skin are progressively removed and examined until only cancer-free tissue remains) of the L-side (left side) of nose for 14 days, dated 4/16/2026. During a medication administration (pass) observation in Station 2, at Medication Cart (Med Cart) C on 4/22/2026 at 8:24 AM with a Licensed Vocational Nurse (LVN) 9, LVN 9 prepared a total of 13 medications that included the following four (4) medications for Resident 54: 1. 7.5 ml of Ferrous Sulfate Liquid 220 mg/5 ml (330 mg total) poured out into a medication cup2. 15 ml of Multivitamins with Minerals Liquid was poured out into a medication cup without shaking the medication bottle prior to pouring3. Eight (8) ml of Phenytoin Oral Suspension 125 mg/ 5 ml (200 mg total) was poured into a medication cup without shaking the medication bottle prior to pouring4. Two tablets of Minocycline 50 mg (100 mg total) was crushed and placed into a medication cup During a medication administration (pass) observation on 4/22/2026 at 9:08 AM with LVN 9, LVN 9 put on personal protective equipment (PPE, gown and gloves), used alcohol based hand sanitizer (ABHS), and entered Resident 54's room, turned off the enteral feeding pump, after checking g-tube placement, providing initial water flush, administered each medication separately, and then turned back on the enteral feeding pump.During a concurrent observation, interview, and record review on 4/22/2026 at 9:43 AM with LVN 9, Resident 54's physician orders for phenytoin and enteral feed were reviewed. LVN 9 stated all done with medication pass and stated restarting Resident 54's enteral feeding. LVN 9 was observed pressing the restart button on the enteral feeding pump. LVN 9 stated that he was not sure if the g-tube feeding should be started immediately after administering phenytoin. LVN 9 reviewed Resident 54's phenytoin order and stated the order does not give instructions to hold feeding. LVN 9 reviewed Resident 54's enteral feed order and stated that the enteral feed order indicated to hold feeding, but the physician order and prescription label did not include the instructions to hold feeding before or after administering phenytoin. During a continued interview on 4/22/2026 at 9:48 AM with LVN 9, LVN 9 reviewed the manufacturer labels for phenytoin that indicated, Shake well before each use. LVN 9 reviewed the manufacturer's label for Multivitamin with Minerals Liquid that indicated, Shake well, LVN 9 stated that he forgot to shake well before pouring out of phenytoin oral suspension and Multivitamin with Minerals Liquid. During a concurrent interview and record review on 4/22/2026 at 9:56 AM with the Director of Nursing (DON) in the presence of LVN 9, the DON stated that enteral feeding must be held one hour before and one hour after administration of phenytoin. The DON stated the information to hold enteral feeding was not included on the physician order or on the prescription label to guide the nurse during medication administration. The DON stated the enteral feeding is held to improve the absorption of phenytoin and to prevent a drug/nutrient interaction with phenytoin. The DON stated if the phenytoin level is low, may trigger a seizure in Resident 54. The DON stated that a seizure could cause resident injury, a change of condition and hospitalization. The DON stated that Resident 54's physician Enteral Feeding order indicated to hold tube feeding for one hour before and after administration of medication that has a drug/nutrient interaction such as Dilantin (phenytoin). During a telephone interview on 4/22/2026 at 10:36 AM with the facility's Consultant Pharmacist (Pharm 1) in the presence of the DON. Pharm 1 stated enteral feeding should be held between one to two hours before and after phenytoin administration for better medication absorption and effectiveness. Pharm 1 stated enteral feeding may cause the phenytoin not to be absorbed well, may not be as effective, and the phenytoin level may not be therapeutic to be the most effective and the resident may need more phenytoin to reach an effective level for seizure control.During a telephone interview on 4/22/2026 at 2:56 PM with facility's dispensing pharmacist (Pharm 2) in the presence of the DON, Pharm 2 stated Resident 54's ferrous sulfate was not on the resident's profile. Pharm 2 stated Resident 54's minocycline 100 mg twice a day should not be given together with ferrous sulfate.During a review of the facility's Policy and Procedures (P&P) titled, Administering Medications, dated 4/2019, the P&P indicated to provide safe administration of medications for residents in the facility. The P&P indicated, Medications are administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include:a. Enhancing optimal therapeutic effect of the medicationb. Preventing potential medication or food interactions.During a review of the facility's P&P titled, Administering Medication through an Enteral Tube, dated 11/2018, the P&P indicated, Check compatibility with feeding tube formula:a. If the resident is on continuous tube feedings and the medication(s) are to be given on an empty stomach and/or are associated with medication-feeding formula incompatibility, stop the feeding at least 30 minutes prior to medication administration and restart at least 30 minutes after medication administration.b. Recommended timeframes between medication and enteral formula administration should be determined by manufacturers of these products, or specified in the order.During a review of manufacturer labeling provided by the facility for Dilantin, dated 2/2021, indicated, Drug Enteral Feeding/ Nutritional Preparation Interaction - Literature reports suggest that patients who have received enteral feeding preparations and/or related nutritional supplements have lower than expected phenytoin levels. It is therefore suggested that phenytoin not be administered concomitantly with an enteral feeding preparation. More frequent serum phenytoin level monitoring may be necessary in these patients. Cross Referenced: F760 and F658

Based on record review and interview, the facility failed to ensure that a licensed pharmacist performed a monthly medication regimen review (MRR, when a consultant pharmacist reviews and analyzes a resident's medication list, ensuring that the medications are appropriate, effective, and safe) to identify potential clinically significant medication issues, including drug interactions, for three of seven sampled residents (Residents 54, 97, and 76).This failure had the potential to result in unmonitored adverse drug reactions (undesired and harmful effects that occur because of medication, treatment, or procedure) and inappropriate medication usage for Residents 54, 97, and 76.Findings:1. During a review of Resident 54's admission record, the admission record indicated Resident 54 was admitted to the facility 7/12/2023 and readmitted on [DATE] with diagnoses that included seizures Idiopathic epilepsy (a neurological disorder characterized by recurrent, unprovoked seizures, from unknown causes), epileptic syndromes with seizures of localized onset (seizures starting in one brain region), anemia (low red blood cells), Encounter for attention to gastrostomy, and dependence on respiratory (ventilator-a machine that helps a person breathe) status. During a review of Resident 54's Order Summary Report (OSR) for the month of April 2026, the OSR indicated active medication orders for: a. Enteral Feed Order every shift Enteral: Hold feeding one (1) hour before and one (1) hour after administration of medication that has a drug/nutrient interaction such as Dilantin (phenytoin), dated 2/3/2026.b. Phenytoin Oral Suspension 100 milligram (mg, unit of measurement mass) per 4 milliliters (ml, unit of measurement volume), give 8 ml via g-tube two times a day for diagnosis of seizure (8ml = 200 mg), dated 2/3/2026c. Ferrous Sulfate Liquid 220 mg/ 5 ml, give 7.5 ml via g-tube one time a day for diagnosis of anemia (7.5 ml = 330 mg). Give with food, dated 2/3/2026.d. Minocycline Oral Tablet 100 mg, give one (1) tablet via g-tube two times a day for s/p (status post/ after) lesion removal ([MOHS surgery] [NAME] Micrographic Surgery, surgical technique used to treat skin cancer, thin layers of cancer-containing skin are progressively removed and examined until only cancer-free tissue remains) of the L-side (left side) of nose for 14 days, dated 4/16/2026.During a review of Resident 54's April 2026 Medication Administration Record (MAR) indicated by documentation and licensed nurses initials that Resident 54 was administered Ferrous Sulfate and Minocycline daily at the schedule 9 AM administration time for 18 days between 4/5/2026 through 4/18/2026.During a telephone interview on 4/22/2026 at 2:35 PM, with Pharm 1 in the presence of the DON, Pharm 1 stated Resident 54's minocycline and ferrous sulfate should be separated as the two medications affect the absorption of each other.During a telephone interview on 4/22/2026 at 2:56 PM with facility's dispensing pharmacist (Pharm 2) in the presence of the DON, Pharm 2 stated Resident 54's ferrous sulfate was not on the resident's profile. Pharm 2 stated Resident 54's minocycline 100 mg twice a day should not be given together with ferrous sulfate.During an interview on 4/23/2026 at 11:02 AM with the DON, the DON provided an Interim Medication Regiment Review for Resident 54. The DON stated was received from Pharm 1, the evening of 4/22/2026 with multiple recommendations, which included but was not limited to a recommendation to separate ferrous sulfate by two hours from minocycline. Pharm 1 documented a recommendation to give ferrous sulfate at 9 AM and minocycline at 11 AM. Pharm 1 indicated phenytoin may also affect the serum concentrations of acetaminophen, amlodipine, Keppra, lacosamide, or levothyroxine and dose adjustments may be necessary.During review on 4/23/2026 at 11:31 AM, Pharm 2 provided a documentation that indicated, I wanted to follow-up regarding the recent interaction identified between minocycline and ferrous sulfate. At the time of review, we were unable to detect this interaction because ferrous sulfate was not listed in the patient's profile.2. During a review of Resident 97's admission record, the admission record indicated Resident 97 was admitted to the facility 7/8/2023 and readmitted on [DATE] with diagnoses that included seizures, epilepsy, and encounter for attention to gastrostomy. During a review of Resident 97's Order Summary Report (OSR) for the month of April 2026, the OSR indicated active medication orders for: a. Enteral Feed Order every shift Enteral: Hold feeding one (1) hour before and one (1) hour after administration of medication that has a drug/nutrient interaction such as Dilantin (phenytoin), dated 4/16/2026.b. Phenytoin Oral Suspension 100 mg/4 ml, give 8 ml via g-tube three times a day related to epilepsy (8ml = 200 mg). Shake Suspension Well, dated 4/17/2026 During a review of Resident 97's Dilantin (phenytoin) laboratory results with a collection and report date of 2/24/2026, indicated Dilantin result as 7.0 micrograms (mcg, unit of measurement mass)/ml with reference range of 10.0 mcg/ml - 20.0 mcg/ml and was flagged as low (L).During a concurrent record review and interview on 4/22/2026 at 10:43 AM with the DON, Resident 97's current physician order for Dilantin was reviewed. The DON stated for Resident 97 there was no parameter on the order to hold enteral feeding before and after Dilantin administration. 3. During a review of Resident 76's admission record, the admission record indicated Resident 76 was admitted to the facility 3/13/2017 and readmitted on [DATE] with diagnoses that included seizures, coma (a state of deep unconsciousness in which a person cannot be awakened), and encounter for attention to gastrostomy During a review of Resident 76's Order Summary Report (OSR) for the month of April 2026, the OSR indicated active medication orders for Phenytoin Oral Suspension 125 mg/ 5 ml, give 4 ml via g-tube three times a day for seizures (4 ml = 100 mg), dated 1/27/2026During a concurrent record review and interview on 4/22/2026 at 11:09 AM with the DON, Resident 76's current physician order for Dilantin was reviewed. The DON stated for Resident 76 there was no order to hold enteral feeding before and after Dilantin administration. During a review of the facility binder for Consultant Pharmacist's Medication Regimen Review [MRR] for recommendations created between 1/2026 and 4/2026, the MRR indicated Resident 54, 97, and 76's names was listed among other residents as medications that were reviewed by the consultant pharmacist but did not show recommendations for enteral feeding and phenytoin medication instructions or identify drug interactions between Ferrous Sulfate and Minocycline for Resident 54 who was administered the medication 18 times between 4/5/2026 to 4/22/2026.During an interview and record review on 4/22/2026 at 10:27 AM with the DON, Resident 54, Resident 97, and Resident 76's Monthly Regimen Review, were reviewed for the months of January 2026, February 2026, and March 2026. The DON stated there was no documentation that the facility's pharmacist consultant made recommendations for the administration of phenytoin via g-tube.During a telephone interview on 4/22/2026 at 10:36 AM with the facility's Consultant Pharmacist (Pharm 1) in the presence of the DON. Pharm 1 stated enteral feeding should be held between one to two hours before and after phenytoin administration for better medication absorption and effectiveness. Pharm 1 stated enteral feeding may cause the phenytoin not to be absorbed well, may not be as effective, and the phenytoin level may not be therapeutic to be the most effective and the resident may need more phenytoin to reach an effective level for seizure control. Pharm 1 stated that no recommendations were made to the facility regarding holding the feeding before or after phenytoin administration. Pharm 1 stated should have documented the recommendation to hold enteral feeding before and after medication administration, especially for phenytoin. Pharm 1 stated the physician orders should have included to hold the enteral feeding before and after phenytoin administration for each resident receiving phenytoin. During a review of the facility's undated policy titled, Consultant Pharmacist Scope and Services, indicated, Their primary objective is to ensure medication safety, regulatory compliance, and optimal clinical outcomes through the following responsibilities:nCore Clinical Responsibilities: Medication Regimen Review (MRR): Conducts a comprehensive monthly review of every resident's medical chart and medication profile. They identify potential drug interactions, duplicate therapies, or improper dosing.During a review of the facility's policy titled, Medication Regimen Review, dated 12/2022, indicated, The consultant pharmacist identifies irregularities through a variety of sources including the resident's clinical record, pharmacy records, and other applicable documents. The facility shall make available to the pharmacist all appropriate records. In addition to reviewing pharmacy and clinical records (such as medication administration records [MAR]); prescribers' orders, progress notes of prescribers, nurses.Resident-specific irregularities resulting from or associated with medications are documented in the resident's active record and reported to the Director of Nursing, Medical Director and Attending Physician.

Based on observation, interview, and record review, the facility failed to ensure safe medication administration and accurate accountability of all controlled medications (medications with a high potential for abuse) for three of seven sampled residents (Resident 30, 50, and 58) reviewed during controlled medication storage inspection by failing to:A. Document the removal of Oxycodone with Acetaminophen (a pain medication combining oxycodone, an opioid, and acetaminophen, a non-opioid analgesic) for administration to Resident 30 on the Controlled Drug Record (CDR, a detailed record that tracks the receipt, administration, disposal, and inventory of controlled substances [use are regulated by law due to its potential for abuse, dependence, or harm]).B. Document the removal of Hysingla Extended Release (ER) (a long-acting opioid pain medication containing hydrocodone, used to manage severe pain requiring around-the-clock treatment) and Hydrocodone with Acetaminophen (a pain medication combining oxycodone, an opioid, and acetaminophen, a non-opioid analgesic) for Resident 50 on the CDR.C. Document the removal of Modafinil (a medication that promotes wakefulness) on the CDR. D. A Licensed Vocational Nurse (LVN) 3 did not sign the shift change audit (a brief review of medication and documentation at the end of a work shift) form in the presence of the outgoing nurse or covering nurse prior to taking possession Medication Cart (MedCart) 3 on Station 2. This deficient practice increased the risk for lack of controlled medication accountability. This failure created a discrepancy between Resident 30, 50, and 58's Medication Administration Record (MAR, a record of each medication given, including dosage, time, and the person administering) and the CDR on 4/22/2026. This failure increased the risk for the licensed nurses (in general) not to be able to readily identify controlled medication loss, drug diversion (illegal distribution or use of prescription drugs), or medication errors.Findings:During a concurrent medication storage area inspection, record review, and interview on 4/22/2026 between 12:46 PM through 1:12 PM on Station 1 at MedCart A, with LVN 10, the following controlled medication discrepancies were identified:A. During a review of Resident 30's admission record, the admission record indicated Resident 30 was admitted to the facility 3/4/2026 with diagnoses that included pain in right and left leg, low back pain, and chronic pain.During a review of Resident 30's Minimum Data Set (MDS - a resident assessment tool), dated 3/8/2026, the MDS indicated Resident 30's cognitive skills (thought process and ability to reason or make decisions) was intact. During a review of Resident 30's Order Summary Report (OSR) for the month of April 2026, the OSR indicated an active medication order for: -Oxycodone Acetaminophen 5 mg/325 mg, give 1 tablet by mouth every 12 hours as needed for Breakthrough Pain with s/p (after care following) laminectomy L3-L5 (a surgery to remove bone from the lower back in order to take pressure off nerves). NTE (not to exceed) three (3) g (gram, unit of measurement) per 24 hours of Acetaminophen. HOLD for RR (respiration rate, the number of breaths taken per minute) less than 12, order dated 3/10/2026.Resident 30's CDR and MAR for the Month of April 2026 were reviewed and documentation indicated the following for Resident 30:-MAR dated 4/22/2026, timed at 9:40 AM, indicated a dose of Oxycodone 5 milligram (mg, unit of measurement mass) with Acetaminophen 325 mg (5 mg/325 mg) was administered. The CDR documentation indicated the last dose removed was on 4/22/2026, timed at 9:42 AM with a remaining quantity of 14 tablets Medication Card for of Oxycodone with Acetaminophen 5 mg/325 mg indicated a remaining quantity of 13 creating a controlled medication discrepancy.LVN 10 stated that he did not document on the CDR the removal of Oxycodone with Acetaminophen 5 mg/325 mg for Resident 30 on 4/22/2026. LVN 10 stated, he should have documented the removal on the CDR to show how much medication was actually remaining, if the CDR is not accurate the licensed nurses would not know what happened.B1. During a review of Resident 50's admission record, the admission record indicated Resident 50 was admitted to the facility 10/10/2024 and readmitted on [DATE] with diagnoses that included aftercare following joint replacement surgery, Osteomyelitis (a bone infection), Rheumatoid arthritis (a disease that causes the body to attack the joints and make them swollen and painful), and muscle spasm.During a review of Resident 50's MDS, dated [DATE], the MDS indicated Resident 50's cognitive skills were intact. During a review of Resident 50's OSR for the month of April 2026, the OSR indicated an active medication order for: -Hysingla ER Oral Tablet ER 24 Hour Abuse-Deterrent 20 MG (Hydrocodone Bitartrate) Give 1 tablet by mouth two times a day for Dx: Chronic Pain (Hold if Resp Rate<12/Min) (Do Not Crush or Chew, Swallow Whole), order dated 2/5/2026-Hydrocodone-Acetaminophen 10 mg/ 325 mg, give 1 tablet by mouth as needed for BREAKTHROUGH PAIN (QID PRN) with multiple fractures, NTE 3G/24 HOURS OF Acetaminophen FROM ALL SOURCES. HOLD FOR RR < 12, order dated 3/30/2026 Resident 50's CDR and MAR for the Month of April 2026 were reviewed and documentation indicated the following for Resident 50:MAR dated 4/22/2026, timed at 12:00 PM, indicated a dose of Hysingla ER Tablet 20 mg was administered. The CDR documentation indicated that the last dose of Hysingla ER Tablet 20 mg removed was on 4/21/2026, timed at 2100 (9:00 PM) with a remaining quantity of five tablets. The Medication Card for Hysingla ER Tablet 20 mg indicated a remaining quantity of four tablets creating a controlled medication discrepancy.LVN 10 stated, I did not write it down. dose not recorded on controlled drug record for today, 4/22/2026.B2. Resident 50's CDR and MAR for the Month of April 2026 were reviewed and documentation indicated the following for Resident 50:MAR dated 4/22/2026, timed at 12:00 PM, indicated a dose of Hydrocodone with Acetaminophen 10 mg/325 mg CDR documentation indicated the last dose of Hydrocodone with Acetaminophen 10 mg/325 mg removed was on 4/22/2026, timed at 5:50 AM with a remaining quantity of 23 tablets Medication Card for of Hydrocodone with Acetaminophen 10 mg/325 mg indicated a remaining quantity of 22 tablets creating a controlled medication discrepancy.LVN 10 stated, not documenting on the CDR could lead to inaccurate documentation of controlled medications and miscommunication of what the facility has on hand, which could lead to drug diversion.C. During a review of Resident 58's admission record, the admission record indicated Resident 50 was admitted to the facility 4/11/2025 and readmitted on [DATE] with diagnoses that included Rheumatoid arthritis.During a review of Resident 50's MDS, dated [DATE], the MDS indicated Resident 58's cognitive skills moderately impaired. During a review of Resident 58's OSR for the month of April 2026, the OSR indicated an active medication order for: -Modafinil Oral Tablet 100 MG (Modafinil) Give 1 tablet by mouth one time a day for Narcolepsy (a sleep disorder that causes sudden and uncontrollable episodes of sleepiness), order dated 12/24/2025, Resident 58's CDR and MAR for the Month of April 2026 were reviewed and documentation indicated the following for Resident 58:MAR dated 4/22/2026, timed at 8:20 AM, indicated a dose of Modafinil 100 mg was administered, the CDR documentation did not indicate when a dose of Modafinil 100 mg was for administration to Resident 58. The quantity available indicated 14 out of 14 tablets remaining.The Medication Card for Modafinil 100 mg indicated a remaining quantity of 13 tablets creating a controlled medication discrepancy. LVN 10 stated, for Resident 58 there was no last administered dose documented on the resident's CDR form.During a concurrent record review and interview on 4/22/2026 between 1:38 PM to 1:53 PM, with a Registered Nurse Supervisor (RNS) 1, RNS 1 reviewed physician orders, CDR, MAR, and medication cards for Residents 30, 50, and 58's controlled medications. RNS 1 confirmed the discrepancies identified on 4/22/2026 between the CDR, MAR and medication cards for Resident 30, Resident 50, and Resident 58. RNS 1 stated there could be a discrepancy in the narcotic count, communication issues, medication errors, residents are at risk for getting the medication twice by accident or not receiving the medication at all and a potential for drug abuse. RNS 1 stated the licensed nurses must count the medication to ensure what is on the medication card matches what is on the controlled medication sheet and document the time they are giving the controlled medication. RNS 1 stated the licensed nurse should document on the CDR sheet immediately when they remove the medication it is like an imaginary automated dispensing machine in which you are counting the controlled medication upon removal and verifying the count is accurate before you administer the controlled medication to the resident. D. During a concurrent medication storage area inspection and interview on 4/22/2026 at 2:06 PM of Station 2 MedCart 3 with LVN 3, the Shift Change Narcotic Count Sheet for the month of 4/2026 was reviewed. The space for nurses' signature on the Narcotic Count Sheet oncoming On nurse from the 7 AM to 3 PM shift on 4/22/2026 was not initialed/signed. LVN 3 stated that she did not sign the Narcotic Count Sheet, because she thought the nurse (LVN 9) that was covering for her earlier had signed. LVN 3 stated that the incoming and outgoing nurses signing the Narcotic Count Sheet during shift change together means we counted the narcotic medications together and that there were no discrepancies. LVN 3 stated if the narcotic medications in the MedCart are not counted together the oncoming nurse should not take possession the MedCart in case something is missing and must ensure there are no narcotic medication discrepancies before taking over the medication cart.During an interview on 4/22/2026 at 2:15 PM with LVN 9, LVN 9 stated there was no licensed nurse present when he took possession of MedCart 3 on Station 2 and did not count with another nurse the narcotic medications and document on the Narcotic Count Sheet. During a review of the facility's policy and procedures (P&P) titled, Controlled Substances, dated 4/2019 indicated, Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift.Upon Administration: The nurse administering the medication is responsible for recording:(1) Name of the resident receiving the medication(2) Name, strength and dose of the medication(3) Time of administration(4) method of administration(5) quantity of the medication remaining; and(6) signature of nurse administering medicationAt the end of each shift:a. Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together b. Any discrepancies in the controlled substance count are documented and reported to the director of nursing services immediatelyc. The director of nursing services investigates all discrepancies in controlled medication reconciliation to determine the cause and identify any responsible parties, and reports the findings to the administratord. The director of nursing services consults with the provider pharmacy and the administrator to determine whether further legal actions is indicated.Policies and procedures for monitoring controlled medications to prevent loss, diversion or accidental exposure are periodically reviewed and updated by the director of nursing services and the consultant pharmacist.

Cross Reference to F688 Based on observation, interview, and record review, the facility failed to ensure Restorative Nursing Aide (nursing aide program that helps residents maintain any progress made after therapy intervention to maintain their function) 1 (RNA 1) was competent to provide RNA services to one of six sampled residents (Resident 44) by failing to ensure RNA 1 was competent to correctly identify and apply hand roll splints (device or apparatus used to support and immobilize a broken bone or impaired joint) to Resident 44's both hands in accordance with physician's orders and was qualified to modify the RNA splinting program. These failures had the potential to cause Resident 44 and residents receiving RNA services in the facility to experience pain, injury, skin breakdown (tissue damage caused by friction, shear, moisture, or pressure), ROM decline leading to contracture (loss of motion of a joint associated with stiffness and joint deformity) development, and a decline in physical functioning.Findings:During an observation on 4/20/2026 at 12:30 pm in Resident 44's room, Resident 44 was lying in bed, sleeping. Resident 44's both elbows were bent and resting on the chest. Resident 44 was holding a yellow and red colored ball in each hand.During an observation on 4/21/2026 at 1:44 p.m. of Resident 44's RNA session, in Resident 44's room, Resident 44 was sitting in a gerichair (reclining chair that allows someone to get out of bed and sit comfortably in different positions while fully supported) by the window with both elbows bent and resting on the chest, both wrists bent, and both hands positioned in fists. RNA 1 stated all of Resident 44's joints in both legs and both arms were tight and required increased time with exercises to help Resident 44 relax during range of motion (ROM, full movement potential of a joint) exercises. RNA 1 assisted with passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises to Resident 44's both shoulders, both elbows, and both legs. RNA 1 did not apply hand roll splints to Resident 44's both hands.During a review of Resident 44's admission Record, the admission Record indicated Resident 44 was admitted to the facility on [DATE] with diagnoses including anoxic brain injury (injury to the brain caused by lack of oxygen), functional quadriplegia (complete inability to move due to severe physical disability or medical condition), and contractures of the right knee and unspecified joints (where two bones meet).During a review of Resident 44's Minimum Data Set (MDS, a resident assessment tool), dated 3/20/2026, the MDS indicated Resident 44 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 44 was dependent (helper does all the effort) in hygiene, toileting, bathing, dressing, rolling to both sides, and transfers (moving from one place to another). The MDS indicated Resident 44 had functional limitations in ROM (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in both arms and both legs.During a review of Resident 44's Order Summary Report, the Order Summary Report indicated a physician's order, dated 7/31/2025, for RNA to apply hand rolls to Resident 44's both hands for six hours, five times a week.During a concurrent observation, interview and record review on 4/21/2026 at 11:05 am with RNA 1, RNA 1 reviewed Resident 44's RNA physician's orders, dated 7/31/2025, and confirmed Resident 44 had RNA orders for RNA to apply hand roll splints to Resident 44's both hands. RNA 1 stated a hand roll splint was rolled up gauze (thin, breathable cloth material often used to bandage wounds) obtained from the treatment nurse, not actual splints. RNA 1 confirmed she did not apply hand rolls to Resident 44's both hands as ordered because she forgot. RNA 1 returned to Resident 44's room and placed a yellow ball into each of Resident 44's hands after assisting with ROM exercises to Resident 44's both wrists and hands. RNA 1 stated she was supposed to put hand rolls in Resident 44's both hands according to the RNA order but could not find the treatment nurse and thought rolled up towels and balls were more appropriate because it helped manage Resident 44's hand hygiene and odor. RNA 1 stated she often placed rolled up towels, soft stress balls, and/or gauze rolls into Resident 44's hands depending on what was available to her at the time despite the RNA order being written specifically for hand roll splints. RNA 1 stated Resident 44's family member constantly brought various items from home to place into Resident 44's hands and left them in a bag at Resident 44's bedside. RNA 1 stated RNA 1 sometimes used the items brought into the facility by Resident 44's family member in place of the hand rolls without notifying the Director of Rehabilitation (DOR) or nursing because she thought the family preferred them. RNA 1 stated the Rehabilitation Department (Rehab) created and modified the RNA program as needed. RNA 1 stated the specific types of splints RNAs were supposed to carry out with the residents were written on the RNA order. RNA 1 stated RNAs were supposed to follow exactly what the RNA orders indicated and were not allowed to modify the RNA program because RNAs were not qualified to do so. RNA 1 stated the PT and OT were the only staff qualified to modify the RNA program because they had the training and qualifications to do so. RNA 1 stated she should have notified the Rehabilitation Department (Rehab) and/or a licensed nurse and waited for therapy to re-assess Resident 44 and modify the RNA program as appropriate if she wanted to modify the RNA program but did not. RNA 1 stated if RNAs did not follow the RNA program as ordered, did not know the differences in splint types, and modified the RNA program without the proper qualifications, it could potentially cause harm to the residents.During a concurrent interview and record review on 4/21/2026 at 2:09 pm with the Director of Rehabilitation (DOR), the DOR stated the Rehab created the RNA programs based on a resident's needs. The DOR stated RNAs were to carry out RNA orders, which included splint application as ordered. The DOR reviewed Resident 44's RNA physician's orders, dated 7/31/2026, and confirmed Resident 44 had RNA orders for the application of hand roll splints to Resident 44's both hands. The DOR stated hand rolls were cylindrical splints placed in the palm of a resident's hand and secured to the hand with an elastic strap. The DOR stated hand roll splints were used to help prevent contractures by keeping the hand in a proper position. The DOR stated if an order was written for RNA to apply hand roll splints to a resident's hands, it was expected the RNA apply the hand roll splint, not a gauze roll, towel roll, or ball. The DOR stated gauze rolls, towel rolls, and balls were not appropriate items to be placed in Resident 44's both hands as they were not assessed and recommended by Rehab and could potentially cause harm if placed into Resident 44's hands without a formal assessment. The DOR stated a licensed Occupational Therapist (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) and/or Physical Therapist (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) established and modified the RNA program as needed. The DOR stated specific splints were recommended for each individual resident based on the therapist's assessment and the resident's functional abilities and needs. The DOR stated RNAs were supposed to carry out the RNA program as ordered and could not modify the RNA program because they were not qualified to do so. The DOR stated if an RNA was not competent in the different splint types and modified the RNA program independently, it could potentially cause harm and injury to the residents in the facility.During an interview on 4/23/2026 at 11:13 am with the Director of Staff Development (DSD), the DSD stated she supervised the RNAs. The DSD stated the RNAs in the facility were Certified Nursing Assistants (CNA) with specialized training in RNA services. The DSD reviewed Resident 44's physician's order, dated 7/31/2025, and confirmed Resident 44 had an RNA order for RNA to apply hand rolls to Resident 44's both hands. The DSD stated hand rolls were cylindrical splints placed in the palm of a resident's hand and secured with elastic. The DSD stated gauze rolls, towel rolls, and balls were not hand rolls and should not be placed in Resident 44's both hands since the RNA order was for hand roll splints. The DSD stated RNAs were supposed to follow exactly what the RNA order indicated and could not deviate from the order or modify the RNA program because they were not qualified to do so. The DSD stated PT and/or OT were the only qualified staff who were able to modify an RNA program and must be notified if an RNA program required modification. The DSD stated if RNAs modified the RNA program independently and were not competent in the different types of splints as ordered, it could result in resident harm, injury, and functional decline. During an interview on 4/23/2026 at 1:53 pm with the Director of Nursing (DON), the DON stated the RNA treatment plan was determined by the licensed therapists and implemented by the RNAs as prescribed on the RNA order. The DON stated the RNAs were supposed to follow exactly what the RNA order indicated. The DON stated if an RNA program required modification, the RNA must notify a licensed nurse, PT, and/or OT who in turn would re-assess the resident and modify the RNA program if appropriate based on the resident's needs. The DON stated RNAs were not qualified and competent to modify an RNA program because they did not have the proper training and expertise. The DON stated if RNAs modified the RNA program independently, it could negatively impact the safety of the residents and staff in the facility. The DON stated it was important RNAs were competent in the types of splints ordered to ensure the correct splints were applied to a resident as incorrect splint application could result in injury and ROM decline. During a review of the facility's Policy and Procedure (P/P), titled Staffing, Sufficient and Competent Nursing, revised 8/2022, the P/P indicated the facility provided sufficient numbers of nursing staff with the appropriate skills and competency necessary to providing nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. During a review of the facility's undated Job Description titled, Restorative Nursing Aide (RNA), the Job Description indicated RNAs assisted the therapists in administering treatment plans to residents under the general supervision of the DON or assigned RNA lead. The Job Description indicated essential responsibilities and job functions of the RNA included ensuring equipment was used correctly and safely in performing resident care, providing therapists with observations, feedback, resident problems, risks to resident safety and resident feedback related to care and treatment responses, recognizing limits of training to avoid evaluation treatment and giving instructions and directions to resident/family in care and management of care, and referring questions and concerns relating to treatment goals, plans, assessments, and progress to the therapist(s).During a review of the facility's undated P/P titled, Splint Application, the P/P indicated a splint was a device that was placed on a resident's limb to help improve or correct performance or prevent further deformity. The P/P indicated therapy assessed the resident for the appropriate splint and set up a program for application. The P/P indicated the residents with splints would be monitored by RNAs or Certified Nursing Assistants under the supervision of a licensed nurse to ensure correct usage and optimal splint condition.

Based on observation, interview, and record review, the facility failed to provide services to improve or maintain range of motion (ROM, full movement potential of a joint) for one of six sampled residents (Residents 44) with ROM and mobility (ability to move) concerns by failing to: 1. Ensure Restorative Nursing Aide (nursing aide program that helps residents maintain any progress made after therapy intervention to maintain their function) 1 (RNA 1) provided passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises to Resident 44's both wrists and hands and applied splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) to Resident 44's both hands in accordance with physician's orders.2. Objectively measure Resident 44's ROM limitations in both hands during the Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Evaluation, dated 5/15/2025.3. Assess Resident 44's mobility during the Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation, dated 7/22/2025. These deficient practices had the potential for Resident 44 to experience a further decline in ROM resulting in worsening contractures (loss of motion of a joint associated with stiffness and joint deformity) and have a further decline in physical functioning. Findings:1. During an observation on 4/20/2026 at 12:30 pm in Resident 44's room, Resident 44 was lying in bed, sleeping. Resident 44's both elbows were bent and resting on the chest. Resident 44 was holding a yellow and red colored ball in each hand.During an observation on 4/21/2026 at 1:44 p.m. of Resident 44's RNA session, in Resident 44's room, Resident 44 was sitting in a geri-chair (reclining chair that allows someone to get out of bed and sit comfortably in different positions while fully supported) by the window with both elbows bent and resting on the chest, both wrists bent, and both hands positioned in fists. RNA 1 stated all of Resident 44's joints in both legs and both arms were tight and required increased time with exercises to help Resident 44 relax during ROM exercises. RNA 1 assisted with PROM exercises to Resident 44's both shoulders and both elbows. RNA 1 did not assist Resident 44 with PROM exercises to both wrists and both hands. RNA 1 assisted Resident 44 with PROM exercises to Resident 44's both legs, applied splints to Resident 44's both legs after exercises were complete, stated she was finished with the RNA session, and exited Resident 44's room. RNA 1 did not apply hand roll splints to Resident 44's both hands. During a review of Resident 44's admission Record, the admission Record indicated Resident 44 was admitted to the facility on [DATE] with diagnoses including anoxic brain injury (injury to the brain caused by lack of oxygen), functional quadriplegia (complete inability to move due to severe physical disability or medical condition), and contractures of the right knee and unspecified joints (where two bones meet).During a review of Resident 44's Minimum Data Set (MDS, a resident assessment tool), dated 3/20/2026, the MDS indicated Resident 44 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 44 was dependent (helper does all the effort) in hygiene, toileting, bathing, dressing, rolling to both sides, and transfers (moving from one place to another). The MDS indicated Resident 44 had functional limitations in ROM (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in both arms and both legs.During a review of Resident 44's Order Summary Report, the Order Summary Report indicated a physician's order, dated 7/31/2025, for RNA to provide PROM exercises to Resident 44's both, five times a week.During a review of Resident 44's Order Summary Report, the Order Summary Report indicated a physician's order, dated 7/31/2025, for RNA to apply hand rolls to Resident 44's both hands for six hours, five times a week.During a concurrent observation, interview and record review on 4/21/2026 at 11:05 am with RNA 1, RNA 1 reviewed Resident 44's RNA physician's orders, dated 7/31/2025, and confirmed Resident 44 had RNA orders for RNA to provide PROM exercises to Resident 44's both arms and apply hand roll splints to Resident 44's both hands. RNA 1 stated PROM exercises to both arms meant physically assisting Resident 44 with PROM exercises to the entire arm, including the shoulders, elbows, wrists, and fingers of the hand. RNA 1 confirmed she did not assist with PROM exercises to Resident 44's both wrists and hands and did not apply hand roll splints to Resident 44's both hands because she forgot. RNA 1 stated Resident 44's both hands were the stiffest joints of the body and needed ROM and splinting to prevent contractures. RNA 1 returned to Resident 44's room to assist with ROM exercises to Resident 44's both hands and wrists. After assisting with ROM exercises, RNA 1 placed a yellow ball into each of Resident 44's hands. RNA 1 stated she was supposed to put hand rolls in Resident 44's both hands according to the RNA order but could not find the treatment nurse and thought rolled up towels and balls were more appropriate because it helped manage Resident 44's hand hygiene and odor. RNA 1 stated a hand roll splint was rolled up gauze (thin, breathable cloth material often used to bandage wounds) obtained from the treatment nurse, not actual splints. RNA 1 stated she often placed rolled up towels, soft stress balls, and/or gauze rolls into Resident 44's hands depending on what was available to her at the time despite RNA order being written specifically for hand roll splints. RNA 1 exited Resident 44 to look for the treatment nurse and returned with 2 packages of rolled up gauze. RNA 1 removed the yellow ball from each of Resident 44's hands, removed the gauze rolls from their packages, and applied the gauze rolls into each of Resident 44's hands. RNA 1 stated it was important to provide ROM and splints as ordered to prevent joint stiffness and contractures and prevent injury.During a concurrent interview and record review on 4/21/2026 at 2:09 pm with the Director of Rehabilitation (DOR), the DOR stated the Rehabilitation Department (Rehab) created the RNA programs based on a resident's needs. The DOR stated RNAs were to carry out RNA exercises and splint application as ordered. The DOR reviewed Resident 44's RNA physician's orders, dated 7/31/2026, and confirmed Resident 44 had RNA orders for PROM exercises to Resident 44's both arms and application of hand roll splints to Resident 44's both hands. The DOR stated if an RNA order was written for PROM exercises to both arms, it was expected the RNA provide PROM exercises to the entire arm, which included the shoulder, elbow, wrist, and fingers of the hand. The DOR stated hand rolls were cylindrical splints placed in the palm of a resident's hand and secured to the hand with an elastic strap. The DOR stated hand roll splints were used to help prevent contractures by keeping the hand in a proper position. The DOR stated if an order was written for RNA to apply hand roll splints to a resident's hands, it was expected the RNA apply the hand roll splint, not a gauze roll, towel roll, or ball. The DOR stated gauze rolls, towel rolls, and balls were not appropriate items to be placed in Resident 44's both hands as they were not assessed and recommended by Rehab and could potentially cause harm if placed into Resident 44's hands without a formal assessment. The DOR stated if RNA did not provide PROM exercises to Resident 44's both wrists and hands and apply hand roll splints to Resident 44's both hands as ordered, it could result in a decline ROM and activities of daily living (ADL, basic activities such as eating, dressing, toileting), worsening contractures, and skin breakdown (tissue damage caused by friction, shear, moisture, or pressure).During an interview on 4/23/2026 at 1:53 pm with the Director of Nursing (DON), the DON stated RNAs assisted residents in the facility with activities such as ROM exercises and splinting to ensure the residents maintained their current level of function and did not experience a functional decline after discharge from skilled therapy services (services that require specialized training and experience of a licensed therapist or therapy assistant). The DON stated it was important for RNA to provide exercises as ordered to prevent injury and potential declines in ROM and function.2. During an observation on 4/20/2026 at 12:30 pm in Resident 44's room, Resident 44 was lying in bed, sleeping. Resident 44's both elbows were bent and resting on the chest. Resident 44 was holding a yellow and red colored ball in each hand.During an observation on 4/21/2026 at 1:44 p.m. in Resident 44's room, Resident 44 was sitting in a gerichair by the window with both elbows bent and resting on the chest, both wrists bent, and both hands positioned in fists.During a review of Resident 44's OT Evaluation and Plan of Treatment (OT Eval), dated 5/15/2025, the OT Eval indicated Resident 44's ROM of both hands were impaired.During a concurrent interview and record review on 4/22/2026 at 1:42 pm with the DOR, the DOR stated the facility monitored for changes in joint ROM by Joint Mobility Assessments (JMA, a brief assessment of a resident's ROM in both arms and both legs) conducted by Rehab upon admission and quarterly and by staff report. The DOR stated PTs and OTs used goniometers (instrument used for the precise measurement of angles) to measure joint mobility to objectively (unbiased, based on facts) determine a resident's baseline ROM and detect changes in joint ROM. The DOR stated any limitations in joint ROM observed in an OT or PT evaluation should be measured with a goniometer and documented in the evaluation because it was an objective way of establishing a resident's ROM baseline and monitoring for changes in ROM. The DOR reviewed Resident 44's OT Eval, 5/15/2025, and confirmed Resident 44's ROM of both hands were documented as impaired. The DOR stated Resident 44's ROM impairments of both hands should have been measured with a goniometer since they were limited but were not. The DOR stated Resident 44's baseline ROM of both hands were not determined due to lack of objective measurements in the OT evaluation which in turn affected staff's ability to monitor and detect any changes in ROM.During an interview on 4/23/2026 at 1:53 pm with the DON, the DON stated the facility monitored changes in ROM by staff report, observations during daily care, and JMAs done quarterly and annually by Rehab. The DON stated it was important for staff to objectively measure ROM during ROM evaluations to ensure the facility had an accurate assessment of a resident's joints since it affected their ability to effectively monitor changes and provide the appropriate services to address any declines. 3. During an observation on 4/21/2026 at 1:44 p.m. of Resident 44's RNA session, in Resident 44's room, Resident 44 was sitting in a gerichair by the window with both elbows bent and resting on the chest, both wrists bent, and both hands positioned in fists. RNA 1 stated all of Resident 44's joints in both legs and both arms were tight and required increased time with exercises to help Resident 44 relax during ROM exercises. RNA 1 stated Resident 44 was unable to move by himself and required total assistance for mobility and re-positioning. During a review of Resident 44's Order Summary Report, the Order Summary Report indicated a physician's order, dated 7/16/2025, for Rehab Therapies (PT, OT) to evaluate and treat Resident 44.During a review of Resident 44's PT Evaluation and Plan of Treatment (PT Eval), dated 7/22/2025, the PT Eval indicated the reason for the PT Eval was due to a new onset of ROM decline and the need for re-establishing a maintenance program with the focus on RNA training for safe handling (techniques used to move, lift, and reposition patients without causing strain or injury to the patient or person assisting with mobility). The PT Evaluation did not include an assessment of Resident 44's mobility.During a concurrent interview and record review on 4/22/2026 at 1:42 pm with the DOR, the DOR stated a PT evaluation was a comprehensive (inclusive, including everything necessary) assessment of a resident's level of function, ROM, and mobility which included rolling to both sides, changing positions, transfers (moving from one place to another), walking, and gait (manner of walking). The DOR reviewed Resident 44's PT Eval, dated 7/22/2025, and confirmed PT did not assess Resident 44's mobility. The DON stated the mobility assessment was an essential part of a PT Eval and should have been evaluated to determine Resident 44's baseline level of function which enabled staff to appropriately monitor for any changes, improvements, and/or declines. The DOR stated one of the reasons for the PT Eval referral was to re-establish the RNA program and educate the RNAs in safe handling techniques which included bed mobility, positioning, and transfers. The DOR stated that PTs cannot effectively teach RNAs how to safely move and handle residents unless the residents' mobility was first assessed by the PT. The DOR stated the lack of a mobility assessment in a PT evaluation could lead to ineffective instruction of safe handling techniques and inability to determine changes, improvements, or declines in mobility.During an interview on 4/23/2026 at 1:53 pm with the DON, the DON stated Rehab and nursing assessed a resident's mobility. The DON stated if mobility was not formally assessed as indicated, it could result in a decline in a resident's function due staff's inability to effectively monitor and detect changes in mobility. During a review of the facility's undated Job Description titled, Restorative Nursing Aide (RNA), the Job Description indicated RNAs assisted the therapists in administering treatment plans to residents under the general supervision of the DON or assigned RNA lead. The Job Description indicated essential responsibilities and job functions of the RNA included ensuring equipment was used correctly and safely in performing resident care, providing therapists with observations, feedback, resident problems, risks to resident safety and resident feedback related to care and treatment responses, recognizing limits of training to avoid evaluation treatment and giving instructions and directions to resident/family in care and management of care.During a review of the facility's undated P/P titled, Splint Application, the P/P indicated a splint was a device that was placed on a resident's limb to help improve or correct performance or prevent further deformity. The P/P indicated therapy assessed the resident for the appropriate splint and set up a program for application. The P/P indicated the residents with splints would be monitored by RNAs or Certified Nursing Assistants under the supervision of a licensed nurse to ensure correct usage and optimal splint condition. During a review of the facility's Policy and Procedure (P/P) titled, Resident Mobility and Range of Motion, revised 7/2017, the P&P indicated residents would not experience an avoidable reduction in ROM and residents with limited ROM would receive the treatment and services to increase and/or prevent a further decrease in ROM. The P/P indicated the care plan would be developed by the interdisciplinary team based on comprehensive assessment and include specific interventions, exercises, and therapies to maintain, prevent avoidable decline in, and/or improve mobility and ROM. The P/P indicated the interventions may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards of practice and be consistent with state laws an practice acts. The P/P indicated the documentation of the resident's progress toward the goals and objective would be include attempts to address any changes or decline in the resident's condition or needs. Cross reference to F726

Based on observation, interview, and record review, the facility failed to maintain resident confidentiality when Respiratory Therapist (RT) 1 left the computer with the electronic health record (EHR) open and a clipboard with notes containing a list of resident names fully exposed and unattended in the facility hallway.This deficient practice violated the residents' right to privacy and confidentiality.Findings:During an observation on 4/20/2026 at 10:55 am in the facility hallway, there was an unattended computer screen and a clipboard displaying the names and personal health information of several residents sitting on a bedside table, unattended, in the hallway.During a concurrent observation and interview on 4/20/2026 at 11:00 am with RT 1, RT 1 exited a resident's room and sat down at the table containing the computer and clipboard. RT 1 stated he left to visit a resident and accidentally left both his computer screen and clipboard open and unattended in the hallway. RT 1 stated he should have closed the computer screen and turned the clipboard over, since both contained personal health information about several residents, which must remain private and confidential. During an interview on 4/23/2026 at 1:53 pm with the Director of Nursing (DON), the DON stated facility resident's information should always be kept private and confidential. The DON stated the computer screen and clip board with residents' information should not have been left open to public view. The DON stated that all residents' information must be kept confidential and secure to protect and respect residents' rights. During a review of the facility's Policies and Procedures (P/P) titled Protected Health Information (PHI), Management and Protection of, revised 2021, the P/P indicated it was the responsibility of all personnel who have access to resident and facility information to ensure that such information is managed and protected to prevent unauthorized release or disclosure.

Based on interview and record review, the facility failed to ensure the General Acute Care Hospital (GACH) Discharge Summary for one of six sampled residents (Resident 3) was in the medical record and readily accessible.This deficient practice had the potential to delay and negatively affect the delivery of necessary care and services.Findings:During a review of Resident 3's admission Record, the admission Record indicated the facility initially admitted Resident 3 on 12/26/2022 and re-admitted Resident 3 on 2/13/2025 with diagnoses including a left ulna (longer of the two bones in the forearm which stretches from the elbow to the wrist) fracture (broken bone), anoxic brain damage (injury to the brain caused by lack of oxygen), and osteoporosis (condition in which the bones become brittle) with pathological fracture (broken bone caused by an underlying disease or condition that weakens the bone structure). During a review of Resident 3's Minimum Data Set (MDS, resident assessment tool), dated 2/17/2026, the MDS indicated Resident 3 had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 3 was dependent (helper does all the effort) in oral hygiene, toileting, bathing, dressing, personal hygiene, rolling to both sides, and transfers. The MDS indicated Resident 3 had functional limitations in ROM (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in both arms and both legs. During a review of Resident 3's GACH Emergency Department (ED) Note (GACH ED Note), dated 2/8/2025, the GACH ED Note indicated Resident 3 was transferred to the hospital from the facility for an evaluation of Resident 3's left forearm fracture sustained on 2/8/2025 while staff tried to move Resident 3 in bed. The GACH ED Note indicated Resident 3 could return to the facility after a splint was placed on Resident 3's left arm. The GACH ED Note indicated for Resident 3 to follow up with her primary care physician/Orthopedics in the next seven to 10 days after discharge where Resident 3 would be given aftercare instructions for her left arm fracture.During a concurrent interview and record review on 4/23/2026 at 12:22 pm with Registered Nurse Supervisor 3 (RNS 3), RNS 3 stated a licensed nurse was responsible for accepting a resident's paperwork, implementing new physician orders and scheduling follow up appointments as needed when a resident was re-admitted to the facility after discharge from the hospital. RNS 3 reviewed Resident 3's clinical record and confirmed Resident 3 sustained a left ulna fracture on 2/8/2025, went to the hospital for evaluation and treatment of the fracture, and returned to the facility on 2/10/2026. RNS 3 reviewed Resident 3's GACH ED Note, dated 2/8/2025, and confirmed Resident 3 was placed in a left arm splint and discharged back to the facility with the recommendation to follow up with orthopedics in seven to 10 days. RNS 3 reviewed Resident 3's clinical record and stated Resident 3's GACH Discharge Summary for 2/10/2025 when Resident 3 was re-admitted back to the facility from the hospital for evaluation of the left ulna fracture was missing. RNS 3 stated the licensed nurse needed a resident's Discharge Summary from the hospital to know what type of care to provide to the resident, including medications and follow up care or appointments. RNS 3 stated if the Discharge Summary was missing from the medical record, the facility would not know how to provide the appropriate care for the resident. RNS 3 stated Resident 3's GACH Discharge Summary was supposed to be in the resident's electronic medical record (EMR) but was not. RNS 3 stated it was important that GACH Discharge Summaries were readily accessible and scanned into the EMR to ensure staff were aware of any recommendations, instructions, follow-up appointments, and changes to the plan of care. During a concurrent interview and record review on 4/23/2026 at 12:35 pm with the Medical Record Director (MR), the MR confirmed Resident 3's GACH Discharge Summary for 2/10/2025 was missing and not in Resident 3's clinical record. The MR stated the GACH Discharge Summary should be uploaded into Resident 3's EHR but was not and had to contact the GACH to obtain the GACH Discharge Summary. During an interview on 4/23/2026 at 1:23 pm with the Director of Nursing (DON), the DON stated a licensed nurse was responsible for accepting a resident's paperwork, implementing new physician orders and scheduling follow up appointments as needed when a resident was re-admitted to the facility after discharge from the hospital. The DON stated the licensed nurse needed the resident's GACH Discharge Summary to know what type of care to provide the resident upon re-admission to the facility. The DON stated it was a common occurrence for residents to return from the hospital without a Discharge Summary. The DON stated if a resident's GACH Discharge Summary was missing and inaccessible to staff, it could negatively impact a resident's care and result in missed appointments and a lack of or delay in necessary care and services. During a review of the facility's Policy and Procedure (P/P) titled Location and Storage of Medical Records, 12/2006, the P/P indicated all current medical records were filed in the medical records department and were maintained by the medical records clerk. The P/P indicated archived medical records would be clearly identified as archived records and stored appropriately. During a review of the facility's P/P titled, Charting and Documentation, 7/2017, the P/P indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The P/P indicated the medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The P/P indicated documented in the medical record would be objective, complete, and accurate.

Based on interview and record review, the facility failed to ensure one of two hospice (compassionate care for people who are near the end of life) residents (Resident 13) home health aide ([HHA] trained professional who provides in-home personal care, basic health monitoring, and companionship to elderly, disabled, or chronically ill individuals) visits were made twice a week.The deficient practice had the potential to result in negative health outcomes. Findings:During a review of Resident 13's admission Record, the admission Record indicated Resident 13 was recently re-admitted to the facility on [DATE] with diagnoses including Severe Protein Calorie Malnutrition (life-threatening condition resulting from inadequate intake of protein and calories, causing significant muscle wasting, fat loss, and organ dysfunction.), dementia (a progressive state of decline in mental abilities), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements)During a review of Resident 13's Minimum Data Set ([MDS] a resident assessment tool), dated 3/3/2026, the MDS indicated Resident 13's cognition (ability to think) was severely impaired. The MDS indicated Resident 13 was dependent on staff for all Activities of Daily Living ([ADLs]activities such as bathing, dressing and toileting a person performs daily)During a review of Resident 13's hospice admission Agreement, 2/18/2026, the agreement indicated hospice aide will make visit twice a week. During a review of Resident 10's Order Summary Report, active orders as of 4/22/2026, the report indicated Resident 13 was admitted under hospice care.During a concurrent interview and record review on 4/22/2026 at 10:28 a.m. with Registered Nurse Supervisor (RNS) 3, Resident 13s hospice records were reviewed. RNS 3 stated the HHA was supposed to visit twice a week and documented evidence indicated the HHA did not visit twice a week. During an interview on 4/23/2026 at 8:44 a.m. with the Director of Nursing (DON), the DON stated that hospice care was essential to ensuring residents' comfort goals were met.During a review of the facility's policy and procedure (P&P) titled, Hospice Program, revised 7/2017, the P&P indicated hospice providers who contract with facility are held responsible for meeting professional standards.

Based on observation, interview, and record review, the facility failed to ensure reasonable accommodation of resident needs when staff did not respond in a timely manner to gastrostomy tube (GT-a tube surgically inserted into the stomach to allow access for nutrition, fluids, and medications) alarms for 2 of 8 sampled residents (Residents 56 and 74).This deficient practice resulted in the potential for the GT pump to become dislodged or for the tube to slip out of proper position, causing incorrect or delayed delivery of the required volume (Resident 74). Findings: During a review of Resident 74's admission Record on 4/20/26, the admission Record indicated, Resident 74 was admitted on [DATE] with diagnoses including chronic respiratory failure with hypoxia (dangerous condition where body tissues do not receive enough oxygen), gastrointestinal hemorrhage (uncontrollable escape of blood from damaged blood vessels of the stomach and intestines, dysphasia (language disorder caused by brain damage) following cerebral infarction (or ischemic stroke, occurs when blood flow to part of the brain is blocked by a clot/thrombus, causing tissue death), hypertension , anemia (blood disorder where low red blood cell or hemoglobin levels reduce oxygen delivery), diabetes mellitus, and BPH. During a review of Resident 74's Minimum Data Set (MDS-a resident assessment tool) dated 4/7/26, Resident has no speech, rarely/never understood, sometimes understands, highly impaired vision, cognitive skills for daily decision making severely impaired, impaired ROM on both sides, dependent with ADLs, always bladder/bowel incontinent, on oxygen therapy (treatment providing extra concentrated oxygen), tracheostomy care (routine cleaning and maintenance of a surgically created hole and tube in the neck), and suctioning. During a review of Resident 74's Physician Orders dated 4/3/26, Physician Orders indicated, Resident 74 enteral feed order every shift enteral feed order every shift tube feeding - Glucerna 1.5 (high-calorie, nutrient-dense beverage designed for people with diabetes or high blood sugar) via GT @65 ml/hr x 18 hours via pump to provide 1170ml/1755kcal per day, to start from 2pm till 8am and or until dose is completed dx: dysphagia (swallowing difficulty). Physician Orders indicated, enteral feed order every shift enteral: monitor GT patency every shift, start date 4/3/26. During an observation on 4/20/26 at 9:16 a.m., Resident 74's GT feeding pump was audibly alarming, and the pump screen displayed the message, found tube slip detected, remove and reload cassette. During an observation on 4/20/26 at 9:30 a.m., Licensed Vocational Nurse (LVN) and Registered Nurse (RN) walked past Resident 74's room without entering to check on or respond to the beeping GT pump. During a follow-up observation on 4/20/26 at 9:38 a.m., more than 20 minutes after the GT pump was first noted to be alarming, no staff had entered the room to address the beeping. During a concurrent observation and interview on 4/20/26 at 9:40 a.m. with LVN 1, LVN 1 entered the room and stated, I can't tell you if it is loose. LVN 1 stated, it doesn't say whether the tubing is dislodged or if clogging is detected. If the feeding is complete, the screen will show a check mark, but this machine didn't indicate anything. During a review of Resident 74's Care Plan dated 4/21/26, the CP indicated Resident 74 is at risk for alteration in nutritional status due to use of: GT feeding related to dysphagia. The CP indicated, administer feeding and flush as ordered at proper rate and volume.During an interview on 4/23/26 at 12:13 p.m. with the DON, DON stated, Resident 74's GT pump needs to be attended right away. DON stated, if GT pump keeps beeping and no one attends to it, Resident doesn't receive the correct order of feeding; there is delayed total volume delivery. DON stated, if there is a machine beeping, we shouldn't ignore it. We cannot just keep educating the staff, if not following, it's the behavior of staff that should be dealt with.

Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 67) was assessed and monitored properly for the use of hand mittens (padded, mitt-shaped devices designed to prevent patients from pulling at tubes or self-injury). This deficient practice had the potential to place Resident 67 in unnecessary restraints.Findings:During an observation on 4/20/2026 at 10:12 a.m., Resident 67 was observed in bed with a hand mitten (soft, padded gloves worn over a patient's hands to prevent them from pulling out tubes or causing self-harm). on his left hand.During a review of Resident 67's admission Record, the admission Record indicated Resident 67 was admitted to the facility on [DATE] with diagnoses including gastrostomy tube (G-tube, a tube placed directly into the stomach for long-term feeding), hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) affecting right dominant hand, and anxiety disorder.During a review of Resident 67's history and physical (H&P) dated 2/17/2026, the H&P indicated Resident 67 does not have the capacity to understand and make decisions.During a review of Resident 67's Minimum Data Set (MDS, a resident assessment tool), dated 4/10/2026, the MDS indicated Resident 67 had severe cognitive impairment. The MDS indicated Resident 67 was dependent on all aspects of activities of daily living (ADL, basic activities such as eating, dressing, toileting). The MDS indicated Resident 67 had impairments on both sides of the upper (arms/shoulders) and lower (hips/legs) extremities.During a review of Resident 67's Restraint-Physical Initial Evaluation on 1/19/2026 at 10:34 a.m., the Restraint-Physical Initial Evaluation indicated hand mittens were implemented for Resident 67 as they are least restrictive and would be used as a trial period instead of Ativan (medication used for anxiety or agitation)During a review of Resident 67's Quarterly Restraint-Physical Assessment on 4/9/2026 at 6:05 p.m., the Quarterly Restraint-Physical Assessment indicated Resident 67 had cognitive impairment and continued to try to pull out the g-tube. There were no attempts documented to reduce the hand mitten restraint over the past quarter and Resident 67 continued the use of hand mitten restraints.During a concurrent interview and record review on 4/22/2026 at 9:48 a.m. with Licensed Vocational Nurse 8 (LVN) 8, LVN 8 stated hand mittens were considered restraints as it did not allow Resident 67 to move. LVN 8 stated Resident 67 had not had any episodes of pulling out his g-tube or dislodgements and indicated there is no documentation of monitoring episodes of him pulling out his g-tube. LVN 8 stated they have not tried other methods to see if Resident 67 needs to continue wearing the hand mittens. LVN 8 stated if Resident 67 did not need hand mittens and have them, that it is considered abuse as it could restrain Resident 67 and jeopardize the residents' skin integrity and mobility.During a concurrent interview and record review on 4/22/2026 at 12:12 p.m. with the Minimum Data Set Nurse (MDSN), the MDSN stated she, the admissions nurse, or the Quality Assurance (QA) nurse does the restraint assessment. The MDSN stated a restraint reassessment for Resident 67 occurred on 4/9/2026 and only visual monitoring was being done with no documentation. The MDSN stated if Resident 67 had restraints when it is not indicated it would affect them.During an interview on 4/23/2026 at 3:04 p.m. with the Director of Nursing (DON), the DON stated restraints restrict the mobility of residents and hand mittens are utilized because Resident 67 pulled on the g-tube. The DON stated prior to applying restraints, the licensed staff would try the least restrictive interventions before moving to a more invasive approach. The DON stated the licensed nurses did visual checks and based on the assessment, the continuation of hand mittens was determined. The DON stated there was no documentation and tally marks of Resident 67 trying to pull out his g-tube. The DON stated having documentation would allow licensed nurses to assess if the intervention is effective and not monitoring the residents would unnecessarily have them continue an intervention that is not needed. The DON stated leaving restraints on when not indicated could restrict Resident 67 movement and cause skin issues.During a review of the facility's policy and procedures (P&P) titled, Use of Restraints, revised 4/2017, the P&P indicated restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. When the use of restraints is indicated, the lease restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need for restraints will be documented. Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptoms and to determine if there are less restrictive interventions (programs, devices, referrals, etc.) that may improve the symptoms. The following safety guidelines shall be implemented and documented while a resident is in restraints: a resident placed in a restraint will be observed at least every thirty (30) minutes by nursing personnel and an account of the resident's condition shall be recorded in the resident's medical record. Documentation regarding the use of restraints shall include full documentation of the episode leading to the use of the physical restraint. This includes not only the resident symptoms but also the conditions, circumstances, and environment associated with the episode, the length of effectiveness of the restraint time, and observation, range of motion and repositioning flow sheets.

Based on interview and record review the facility failed to ensure one of five sampled residents (Resident 8) received non pharmacological interventions (evidence-based, non-invasive, non-drug treatments aimed at improving, maintaining, or modifying health conditions) prior to the administration of PRN (given as needed or requested) Ativan (a medication used to treat anxiety-feelings of fear, dread, or uneasiness).This deficient practice had the potential to result in resident's unnecessary consumption of medications and cause untoward adverse reactions for taking psychotropic (drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) medications.Findings:During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was admitted to the facility on [DATE] with diagnoses including nontraumatic intracerebral (brain) hemorrhage (bleeding), acute and chronic respiratory failure (body can't get enough oxygen into the blood), dependent on ventilator (a medical device to help support or replace breathing), Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (mental health condition characterized by excessive persistent worry).During a review of Resident 8's Minimum Data Set ([MDS] resident assessment tool), dated 3/23/2026, the MDS indicated Resident 8's cognition was moderately impaired. The MDS indicated Resident 8 was dependent (helper does all the effort) on staff for activities of daily living (activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 8's Order Listing Report, from 1/1/2026 to 4/31/2026, the report indicated Ativan 0.5 mg via gastrostomy ([G-tube] a surgical opening fitted with a device to allow feedings to be administered directly to the stomach) was ordered every 6 hours PRN for anxiety manifested by restlessness leading to shortness of breath/hyperventilation (rapid deep breathing).During a review of Resident 8's Medication Administration Record (MAR) for the period of 4/1/2026 through 4/22/2026, the MAR showed that Resident 8 received Ativan 0.5 mg PRN for six days. The MAR also indicated that non pharmacological interventions were not attempted prior to administering Ativan.During a concurrent interview and record review on 4/23/2026 at 8:34 a.m., with Registered Nurse Supervisor (RN) 2, Resident 8's MAR was reviewed, and RN 2 stated nonpharmacological measures were not attempted prior to the administration of Ativan. RNS 2 stated nonpharmacological measures should be attempted before administering Ativan to prevent unnecessary use of Ativan.During an interview on 4/23/2026 at 8:44 a.m. with the Director of Nursing (DON), the DON stated non-pharmacological interventions for behavior prior to medication use were to prevent use of Ativan because the medication has undesirable side effects.During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Use, revised 7/2022, the P&P indicated: non-pharmacological interventions are used (unless contraindicated) to minimize the need for medications when possible.

Based on interview and record review, the facility failed to ensure one of one resident (Resident 88) received daily activities appropriate to the resident's needs. The deficient practice had the potential to negatively affect the residents' physical and mental well-being. Findings:During a review of Resident 88's admission Record, the admission Record indicated Resident 88 was admitted to the facility on [DATE] with diagnoses including cerebral palsy (a group of permanent movement and posture disorders caused by abnormal brain development or damage before, during, or shortly after birth), muscle weakness, and contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion) of the left and right knee.During a review of Resident 88's Minimum Data Set ([MDS] a resident assessment tool), dated 2/4/2026, the MDS indicated Resident 88's cognition (ability to think) was severely impaired. The MDS indicated Resident 10 was dependent on staff for all Activities of Daily Living (ADLs- activities such as bathing, dressing and toileting a person performs daily)During a concurrent interview and record review on 4/21/2026 at 3:24 p.m. with the Activities Director (AD), Resident 88's Activities Point of Care Report, for March and April 2026 was reviewed. The AD stated Resident 88 did not have daily activities. The AD acknowledged that residents should receive daily activities to support brain stimulation and promote quality of life.During an interview on 4/23/2026 at 8:44 a.m. with the Director of Nursing (DON), the DON stated activities are a part of residents' daily living that can stimulate cognition.During a review of the facility's policy and procedure (P&P) titled, Activity Program, revised 6/2018, the P&P indicated activities are provided to support the well-being of residents.

Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 41) who was assessed as being at very high risk for pressure ulcer (a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) development was provided a pressure relieving barrier to be placed between Resident 41's overlapping, contracted (loss of motion of a joint associated with stiffness and joint deformity) toes of the left foot as indicated per facility policy.This deficient practice had the potential to result in Resident 41 developing pressure ulcers on the left foot. Findings: During a review of Resident 41's admission Record, the admission Record indicated the facility initially admitted Resident 41 on 9/6/2024 with diagnoses including anoxic brain damage (injury to the brain caused by lack of oxygen), acute respiratory failure (condition that occurs when the lungs cannot get enough oxygen into the blood) with hypoxia (medical condition where the body's tissues and organs do not receive adequate oxygen to maintain normal function), and a persistent vegetative state (chronic condition of wakefulness without awareness following severe brain damage). During a review of Resident 41's Minimum Data Set (MDS, resident assessment tool), dated 3/5/2026, the MDS indicated Resident 41 was dependent (helper does all the effort) in oral hygiene, toileting, bathing, dressing, personal hygiene, rolling to both sides, and transfers. The MDS indicated Resident 41 had functional limitations in ROM (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in both arms and both legs. The MDS indicated Resident 41 was at risk for pressure ulcer development. During a review of Resident 41's Braden Scale (pressure ulcer risk assessment tool), dated 3/5/2026, the Braden Scale indicated Resident 41 was at very high risk for pressure ulcer development due to completely limited sensory perception (unresponsive to painful stimuli due to diminished level of consciousness or sedation or limited ability to feel pain over most of the body), very moist skin, complete immobility (inability to move), and concerns for friction (force that resists or slows down movement when two surfaces rub against each other) and shearing (tissue damage that occurs when skin stays in one place while the underlying bone or tissues shift causing tissues to stretch, tear or slide in opposite directions). During a concurrent observation and interview on 4/20/2026 at 11:34 am with Registered Nurse 1 (RN 1), in Resident 41's room, Resident 41 was lying in bed. Resident 41's both legs were fully straight with both legs curved inwards and hyperextended (the extension of a body part beyond its normal limits) at the knees and both feet pointing downwards. Resident 41's second toe was positioned on top of the big toe on the left foot, causing an overlap. RN 1 assessed Resident 41's left foot and confirmed Resident 41's second toe overlapped the big toe. RN 1 physically separated both toes and confirmed there was a visible indentation of Resident 41's second toe on Resident 41's big toe caused by direct pressure from the overlapping toes. RN 1 stated Resident 41's toes on the left foot were overlapping and required staff to physically separate and consistently reposition the toes to prevent areas of pressure. RN 1 stated Resident 41 should have a barrier or ointment in between Resident 41's overlapping toes to prevent pressure ulcers but did not. During a concurrent observation and interview on 4/20/2026 at 11:57 am with Licensed Vocational Nurse 2 (LVN 2), LVN 2 assessed Resident 41's left foot and confirmed Resident 41 had contractures of the left foot causing the second toe and big toe to overlap. LVN 2 physically separated Resident 41's second toe and big toe on the left foot and confirmed there was a visible indentation of Resident 41's second toe on the top, left side of Resident 41's big toe caused by areas of pressure from the overlap. LVN 2 stated the area of pressure caused by the overlapping of Resident 41's second toe and big toe of the left foot should be off loaded with a barrier device in between both toes to prevent pressure ulcers and skin breakdown. LVN 2 stated Resident 41 was at high risk for skin breakdown (tissue damage caused by friction, shear, moisture, or pressure) and pressure ulcers due to immobility, contractures, and overlapping toes causing prolonged area of pressure. During an interview on 4/23/2026 at 1:53 pm with the Director of Nursing (DON), the DON stated the lack of repositioning, prolonged areas of pressure, poor nutrition, and immobility put residents at risk for skin breakdown and pressure ulcers. The DON stated Resident 41 was at high risk for developing skin breakdown and pressure ulcers due to immobility, contractures, and multiple co-morbidities (presence of two of more distinct medical or mental health conditions occurring simultaneously in the same individual). The DON stated contracted, overlapping toes placed residents at high risk for pressure ulcer development due to areas of prolonged pressure and should be assessed by the Rehabilitation Department (Rehab), nursing, and/or the physician to ensure the pressure between the toes was off-loaded, monitored, and treated appropriately to prevent skin breakdown and pressure ulcers. During a review of the facility's Policy and Procedure (P/P) titled, Prevention of Pressure Injuries, revised 4/2020, the P/P indicated staff were to review the care plan and identify the risk factors as well as the interventions designed to reduce or eliminate pressure injuries. The P/P indicated staff inspected skin daily when performing or assisting with personal care or activities of daily living (ADLs) which included the inspection of pressure points, repositioning the resident, and providing support devices and assistance as needed. The P/P indicated skin care and prevention of pressure injuries included the use of facility-approved protective dressings for at risk individuals. The P/P indicated staff were to review and select medical devices with consideration to the ability to minimize tissue damage, including size, shape, its application and ability to secure the device, monitor regularly for comfort and signs of pressure-related injury, and to consult with current clinical practice guidelines for prevention measures associated with specific devices.

Based on observation, interview and record review, the facility failed to ensure a resident with a physician order for a foley catheter (also called indwelling catheter, a thin, flexible tube that drains urine from the bladder into a bag outside the body) and had monitoring and care provided to prevent recurrent urinary tract infection ([UTI], a bacterial infection that affects the urinary tract, which includes the bladder, ureters, and kidneys) for one of two sampled residents (Resident 94).This deficient practice had the potential to result in Resident 94 acquiring recurrent UTIs when foley catheter was not monitored and care was not provided according to the physician's order.Findings:During a review of Resident 94's admission Records, the admission Records indicated Resident 94 was originally admitted to the facility on [DATE] with a readmission date on 12/30/2025 with diagnoses of chronic obstructive pulmonary disease ([COPD], lung disease that causes obstruction of airflow and can limit normal breathing), diabetes mellitus ([DM], a chronic disease that affects how the body processes sugar), and vesicoureteral reflux ([VUR], the backward flow of urine from the bladder up the ureters into the kidneys).During a review of Resident 94's history and physical (H&P), dated 12/31/2025, the H&P indicated Resident 94 had the capacity to understand and make decisions.During a record review of Resident 94's Minimum Data Set ([MDS], a resident assessment tool) dated 2/26/2026, the MDS indicated Resident 94 had intact cognitive (ability to think, understand, learn, and remember) status. The MDS indicated Resident 94 required moderate assistance (helper does less than half the effort) for self-care abilities such as eating, hygiene and dressing. The MDS indicated Resident 94 was maximal assistance (helper does more than half the effort) for mobility such as sit to stand and transfers. The MDS indicated Resident 94 had a neurogenic bladder (a dysfunction of the bladder caused by nerve damage leading to an inability to empty the bladder) and an indwelling catheter was in place.During a record review of Resident 94's Order Summary Report dated 7/6/2025, the Order Summary Report indicated cleanse indwelling catheter site with water and soap, rinse then dry pat every shift. The Order Summary Report indicated to monitor catheter urinary drainage bag and document the following every shift for color, consistency, odor, hematuria, bladder distention, burning, sensation, document (+) if there is presence of signs and symptoms of UTI, document (0) if there is absence of signs and symptoms of UTI.During a review of Resident 94's Treatment Administration Record (TAR) dated 2/1/2026 to 2/28/2026, the TAR indicated to cleanse the indwelling catheter site with water and soap, rinse then pat dry every shift, it was not done the night shift on 2/19/2026. The TAR indicated the treatment of monitoring catheter urinary drainage bag and document the following every shift for color, consistency, odor, hematuria, bladder distention, burning, sensation, document (+) if there is presence of signs and symptoms of UTI, document (0) if there is absence of signs and symptoms of UTI was done every shift except 11:00 p.m. shift on 2/19/2026.During a review of Resident 94's TAR dated 3/1/2026 to 3/31/2026, the treatment of cleansing indwelling catheter site with water and soap, rinse then pat dry every shift was done every shift except evening shift on 3/8/2026, night shift on 3/8/2026, and night shift on 3/26/2026. The TAR indicated the treatment of monitoring catheter urinary drainage bag and document the following every shift for color, consistency, odor, hematuria, bladder distention, burning, sensation, document (+) if there is presence of signs and symptoms of UTI, document (0) if there is absence of signs and symptoms of UTI was done every shift except 3:00 p.m. shift on 3/8/2026, 11:00 p.m. shift on 3/8/2026, and 3:00 p.m. shift on 3/26/2026.During a review of Resident 94's TAR dated 4/1/2026 to 4/30/2026, the treatment of cleansing indwelling catheter site with water and soap, rinse then pat dry every shift was done every shift except night shift on 4/5/2026. The TAR indicated the treatment of monitoring catheter urinary drainage bag and document the following every shift for color, consistency, odor, hematuria, bladder distention, burning, sensation, document (+) if there is presence of signs and symptoms of UTI, document (0) if there is absence of signs and symptoms of UTI was done every shift 11:00 p.m. shift on 4/5/2026.During a concurrent observation and interview on 4/20/2026 at 11:37 a.m. in Resident 94's room, Resident 94 was laying in bed watching television. Resident 94 stated she was hospitalized in December, and had a catheter placed. Resident 94 stated she could not walk to the restroom, and the catheter was placed to help her empty her bladder. During a concurrent interview and record review on 4/9/2026 at 10:14 a.m. with Registered Nurse Supervisor (RNS) 3, the TAR for dated 2/1/2026 to 2/28/2026, TAR dated 3/1/2026 to 3/31/2026 and TAR dated 4/1/2026 to 4/30/2026 was reviewed. RNS 3 stated there was missing documentation for cleansing and monitoring the urinary catheter drainage bag on some dates for February, March and April 2026. RNS 3 stated he cannot say the nurses are doing the monitoring and following the physician's order for cleansing, but if it was not documented in the TAR, it was not done. RNS 3 stated if staff are not following physicians' orders, it increases the risk of infections. RNS 3 stated Resident 94 had her share of UTI and was getting antibiotics (medications that treat bacterial infections by killing bacteria or stopping their growth) for UTI in the past. RNS 3 stated if the nurses are not following the physician's order to monitor and cleansing the indwelling catheter as ordered, the resident may get recurrent infections. During an interview on 4/9/2026 at 1:03 p.m. with the Director of Nursing (DON), the DON stated the importance of monitoring and providing indwelling catheter care was to prevent infection. The DON stated Resident 94 had recurrent UTI in the past and staff should be following physician's orders to monitor and provide catheter care to prevent UTI.During a review of the facility's policy and procedures (P&P) titled Catheter Care, Urinary, revised September 2014, indicated, purpose of this procedure is to prevent catheter-associated urinary tract infections.maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag.do not clean the periurethral area with antiseptics to prevent catheter-associated UTI's while the catheter is in place. Routine hygiene (e.g., cleansing of the meatal surface during daily bathing or showering) is appropriate.be sure the catheter tubing and drainage bag are kept off the floor.empty the drainage bag regularly using a separate, clean collection container for each resident and avoid splashing and prevent contact of the drainage spigot with the nonsterile container.the following information should be recorded in the resident's medical record such as the date and time that catheter care was given, the name and title of the individual(s) giving the catheter care, character of urine such as color (straw-colored, dark, or red), clarity (cloudy, solid particles, or blood), and odor, any problems noted at the catheter-urethral junction during perinea] care such as drainage, redness, bleeding, irritation, crusting, or pain, any problems or complaints made by the resident related to the procedure.

Based on interview and record review, the facility failed to ensure one of one hemodialysis ([HD]a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) residents (Resident 10) received HD on 1/27/2026.This deficient practice had the potential to result in fluid overload (a condition where excessive water and sodium accumulate in the body) weight gain, edema (swelling in legs/arms), and shortness of breath.Findings:During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was recently re-admitted to the facility on [DATE] with diagnoses including chronic kidney disease (a serious, long-term condition where kidneys are damaged and cannot effectively filter blood, often leading to waste buildup) and dependence on renal dialysis.During a review of Resident 10's Minimum Data Set (MDS - a resident assessment tool), dated 2/5/2026, the MDS indicated Resident 10's cognition (ability to think) was severely impaired. The MDS indicated Resident 10 was dependent on staff for all Activities of Daily Living (ADLs- activities such as bathing, dressing and toileting a person performs daily)During a review of Resident 10's Order's, dated 1/13/2026, the order indicated to start hemodialysis to an outpatient dialysis center on Tuesday, Thursday, and Saturday. During a concurrent interview and record review on 4/22/2026 at 2:24 p.m. with Registered Nurse Supervisor (RNS) 1, Resident 10's SBAR & Initial COC/Alert Charting & Skilled Documentation, dated 1/27/2026, was reviewed. RNS 1 stated Resident 10 missed dialysis on 1/27/2026 because there was an issue with transportation. RNS 1 stated the HD residents should not miss dialysis because it could cause fluid overload. During an interview on 4/23/2026 at 8:44 a.m. with the Director of Nursing (DON), the DON stated missing dialysis could cause fluid overload.During a review of the facility's policy and procedure (P&P) titled, End Stage Renal Disease, ([ESRD]irreversible kidney failure) Care of Resident with revised 9/2010, the P&P indicated residents with ESRD will be cared for according to currently recognized standards of care.

Based on observation and interview, the facility failed to ensure a thermometer was placed in the dry storage food area. This deficient practice had the potential to result in food-borne illnesses (food poisoning) of the residents with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea and fever and can lead to other serious medical complications and hospitalization.During a concurrent observation and interview on 4/20/2025 at 9:08 a.m. with the Dietary Manager (DM), the DM verbalized the current storage room temperature is 72 degrees Fahrenheit ( F, temperature scale). The DM stated the facility did not need to have a thermometer in the dry storage room and indicated that when the room gets too hot, they will put the thermometer in the dry storage room and take the temperature. The DM stated nothing in the storage room would be affected by not having a thermometer since there is no produce. During an interview on 4/23/2025 at 3:03 p.m. with the Director of Nursing (DON), the DON stated a thermometer should be in the dry storage room so they can monitor the temperature as certain foods have temperature requirements and would not want the items to spoil. The DON stated if there were no thermometers in the dry storage room, they would not be able to monitor the temperature, and they may hand out spoiled goods to the residents since they did not maintain the room temperature. During a review of the facility's policy and procedures (P&P) titled, Storage of Food and Supplies, dated 2023, the P&P indicated thermometers should be placed in all storage areas and checked frequently. Recommended temperature is 50 degrees Fahrenheit ( F, temperature scale) - 85 F- if dry food storage goes over 85 F take corrective action.

Based on observation, interview, and record review, the facility failed to ensure exterior waste disposal containers were fully closed and trash collection area was cleaned and free of black sticky residue.This failure had the potential to result in the attraction of pests and spread of pathogens due to unsanitary environment.Findings:During an observation on 4/20/2026 at 8:34 a.m. of the designated trash collection area located on the left side of the facility, two of three gray waste disposal containers and one blue waste container were not fully closed. The floor of the designated trash collection area had used pair of gloves and black sticky residue.During a concurrent observation and interview on 4/20/2026 at 9:10 a.m. with the Dietary Supervisor (DS), the DS stated the waste disposal containers were full and were not fully closed, a used pair of gloves was on the floor, and the floor had black sticky residue. The DS stated the importance of keeping the waste disposal containers fully closed and the designated waste disposal area clean was to ensure trash was contained and to prevent rodents or pests from digging through the trash. The DS stated if the designated waste disposal area was not clean, there would be potential for flies, rodents, or any pests to dig through the trash and potential find a way to enter the facility.During a review of the facility's policy and procedure (P&P) titled. Garbage and Trash dated, 2023, the P&P indicated, The trash collection area is a potential feeding ground for vermin and rodents and must be kept clean. 1. The area must be swept and washed down by maintenance with a detergent on a regular basis. If a commercial rubbish service is used, arrangements must be made for periodic exchange of trash bins.

Based on observation, interview, and record review, the facility failed to ensure a resident, who required two-person assistance (two staff members assisting the resident with care) for turning and repositioning in bed, was not turned and repositioned by one person and sustained an injury for one of ten sampled residents (Resident 1). The facility failed to: 1. Ensure a certified nursing assistant (CNA 1) did not turn and reposition Resident 1 by himself on 2/8/2025. 2. Ensure CNA 1 followed Resident 1's untitled Care Plan dated 10/2/2023, which indicated Resident 1 required two-person assistance with turning and repositioning and did not turn the resident without a second person assistance. As a result of these deficient practices Resident 1 sustained an acute (sudden onset) fracture (broken bone) of the distal (situated away from the center of the body or from the point of attachment) shaft (part of arm) of the left forearm (lower part of the arm) and was transferred to a general acute care hospital (GACH) on 2/28/2025 and was admitted to the GACH for observation. At the GACH Resident 1 was applied splint (soft, padded material that is used to secure the injury) to a left arm. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including anoxic (lack of oxygen causing tissue death) brain damage, age-related osteoporosis (bones become brittle and fragile), and contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints ) of muscles. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 12/6/2024, the MDS indicated Resident 1 was rarely or never understood. The MDS indicated Resident 1 had functional limitations in range of motion ([ROM], the extent or limit to which a part of the body can be moved around a joint or a fixed point) and had impairments on bilateral (both) upper extremities (arms) and lower extremities (legs) that interfered with functions of daily living or placed Resident 1 at risk for injury. The MDS indicated Resident 1 was totally dependent on staff in rolling from left to right (the ability to roll from laying on back to left side and right side and return to lying on back on the bed). During a review of Resident 1's untitled Care Plan initiated on 10/2/2023, the Care Plan indicated Resident 1 required two-person assistance with turning and repositioning, due to impaired mobility, and total dependence with bed mobility (the ability to move around in bed, including rolling, sitting up, and scooting). During a review of Resident 1's Alert Charting (Succeeding Documents for Change of Condition [COC] and Skilled Documentation about an event that has occurred with a resident ) dated 2/8/2025, the Alert Charting document indicated a restorative nursing assistant ([RNA] a certified nursing assistants that have additional training in specific therapeutic techniques) 1 alerted licensed vocational nurse (LVN) 1 of a potential incident with Resident 1 and certified nursing assistant 1 (CNA 1). The Alert Charting document indicated CNA 1 informed LVN 1 he was working with Resident 1 to change her bed sheets and in the process of turning the resident to her left side, he heard a discomforting, unnatural sound (indicating something was wrong) from what sounded like the left wrist or arm, so he asked RNA 1 to get LVN 1. The Alert Charting document indicated Resident 1's physician (MD 1) was notified and ordered a STAT (urgent) Xray (a photographic or digital image of the internal composition of something, especially a part of the body) of the left hand and left forearm. Resident 1 left the facility with emergency services (911) on 2/8/2025 at 3:54 p.m. to the GACH. During a review of Resident 1's Order Summary Report (the physician's orders), the Order Summary Report indicated a physician's order dated 2/8/2025 for a STAT Xray of the resident's left hand and left forearm and transfer the resident to GACH via 911 for further evaluation and treatment due to acute fracture of the distal forearm. During a review of Resident 1's Radiology (the medical specialty that uses medical imaging to diagnose diseases and guide treatment within the body) Results Report dated 2/8/2025, the Radiology Results Report indicated an Xray taken on 2/8/2025 of the left forearm indicated the resident had an acute fracture of the distal shaft of the left forearm, normal bony mineralization (the degree of bone density), and no osteoblastic (the cells that form new bones and grow and heal existing bones) or osteolytic lesion (a softened bone area) were noted. During a review of Resident 1's GACH's Emergency Department (ED) Note dated 2/8/2025, the ED Note indicated Resident 1 was brought to the ED via 911 for evaluation of a left forearm fracture. The ED Note indicated Resident 1 sustained a left forearm fracture while the resident was being moved in bed at the facility. The ED Note indicated Resident 1 had contractures (a stiffening/shortening at any joint that reduces the joint's range of motion) on all four limbs, left arm deformity and was positive for trauma on the left forearm. The ED Note indicated a left arm splint was applied, and Resident 1 was admitted to the GACH for observation. The ED Note indicated Resident 1 had a flat mood and affect (absence of an appropriate emotional response) and was bedridden with limbs contractures. During a review of Resident 1's untitled Care Plan initiated 2/14/2025, the Care Plan indicated Resident 1 had a fracture of the left forearm with a soft splint. The Care Plan indicated Resident 1 was at risk for pain and skin breakdown. The Care Plan goals for Resident 1 included monitoring (frequency not defined) Resident 1 for pain and ensure the resident would not have any adverse effects (an undesired effect) from the left forearm fracture. The Care Plan Interventions for Resident 1 included two-person assistance for all activities of daily living ([ADL] the everyday tasks that people perform to care for themselves) care, cradling (to support protectively) Resident 1's left arm while providing ADL care and repositioning to keep the left arm in alignment (how the head, shoulders, spine, hips, knees and ankles relate and line up with each other) with the left side of the body, turning Resident 1 to the right side and back only, and gentle handling of Resident 1 during ADL care. During a review of the Order Summary Report dated 2/17/2025, the Order Summary Report indicated an order dated 2/17/2025 for Norco (pain management) tablet 5-325 (strength) milligrams (mg, a unit of measurement), give one tablet via gastrostomy tube (GT, a tube inserted through the belly that brings nutrition directly to the stomach) every eight hours for pain management for 14 days. During an interview on 2/21/2025 at 12:13 p.m., CNA 1 stated on 2/8/2025 he (CNA 1) was going to change Resident 1's soiled adult incontinence (no voluntary control of urination and bowel movements) briefs (disposable, absorbent underwear that helps with urinary or bowel incontinence). CNA 1 stated it was around 9 a.m. and all the other CNAs were busy with other residents' morning care. CNA 1 stated RNA 1 was putting splints on other residents (unknown), and LVN 1 was busy passing medication. CNA 1 stated there was no one available to help him to turn Resident 1. CNA 1 stated Resident 1 required a two-person assistance, but he could not get anyone to help him to turn Resident 1, so he felt confident he could turn the resident alone, and he did it. CNA 1 stated Resident 1 resided in the subacute unit (a level of care needed by a patient who does not require hospital acute care but who requires more intensive licensed skilled nursing care than is provided to the majority of patients in a skilled nursing facility) and needed two-person assistance when turning due to the resident being stiff, Resident 1's inability to help with turning, presence of medical devices including gastrostomy tube ([GT] and tracheostomy [surgically created opening in the trachea [windpipe]), and having contractures. CNA 1 stated that the subacute unit was very busy with residents' care due to the complexity of the residents, and he was instructed to call a licensed nurse for help if a CNA could not assist him, but the LVNs were busy as well. CNA 1 stated this was not the first time he was unable to obtain help to turn Resident 1. CNA 1 stated on /2/28/2025 when he was changing Resident 1, he was standing on the right side of Resident 1's bed and he put one of his hands behind resident 1's right shoulder and one hand behind Resident 1's right knee and began to turn her to the left side when he heard a loud cracking sound. CNA 1 stated he did not know where the cracking sound came from, so he pulled her onto her back carefully. CNA 1 stated Resident 1 had a deformity (contracture) in her left wrist that caused her left land to point outward away from her body and after the loud cracking noise. CNA 1 stated he noticed the resident's left hand and wrist appeared more open and looser than normal, meaning the arm was able to move a little more towards the body when it usually could not. CNA 1 stated RNA 1 just happened to enter the room at that time and he asked her to call LVN 1 for help. CNA 1 stated when repositioning Resident 1 with a two-person assistance you were able to see where the resident's limbs were including the contracted left hand and wrist from both sides of the bed to ensure you knew where the arm was always. CNA 1 stated they were able to turn and reposition Resident 1 more carefully using a two-person assistance. During an interview on 2/21/2025 at 1:07 p.m., RNA 1 stated on 2/8/2025 CNA 1 asked her to call LVN 1 for help, so she did, CNA 1 told her (RNA 1) he heard a pop. RNA 1 stated Resident 1 was very stiff, and staff had to take extra precautions when working with the resident because the stiffness made it hard to move and reposition Resident 1. RNA 1 stated it was kind of scary to move the resident's limbs around due to the severity of stiffness Resident 1 had and staff had to be extra gentle and take precautions when moving her around. RNA 1 stated Resident 1 was supposed to be a two-person assistance because she was very fragile, so they needed two-people to turn her safely. RNA 1 stated CNA 1 was a big guy, and he may have assumed he could turn the resident by himself without an assistance because the resident was a small lady. RNA 1 stated it gets kind of hard because there was usually three CNAs on the subacute unit during the day shift (7 a.m. to 3 p.m.) and if two were helping each other, she does not know who was helping the third CNA. During an interview on 2/21/2025 at 1:45 p.m., MD 1 stated facility staff had to take precautions with this resident population and be careful with the residents because they do not respond appropriately to pain due to anoxic brain damage so staff could not tell if the resident was in pain. MD 1 stated there was an increased risk for fracture in residents with brittle (break or shatter easily) bones, so facility staff had to handle these residents gently, turn the residents carefully, and not rush care. During an observation and concurrent interview in Resident 1's room on 2/21/2025 at 2:16 p.m., with LVN 2, LVN 2 was observed to uncover Resident 1's left arm while Resident 1 was in bed. Resident 1 was observed to have a splint on her left forearm. LVN 2 stated the facility staff could not tell if Resident 1 was in pain, so they were giving her around the clock (regularly scheduled) Norco at this time for pain from the fracture. LVN 2 stated Resident 1's left hand and wrist were contracted causing the left hand to point outwards. During an interview on 2/21/2025 at 2:18 p.m., CNA 2 stated they usually need two-person assistance for the residents on the subacute unit due to their health status but sometimes everyone was busy, so you must keep going to get your work done and do the work alone. During an interview on 2/21/2025 at 2:26 p.m., the director of rehabilitation ([DOR] a medical specialty that helps people regain abilities lost due to injury, disease, or surgery) stated she reviewed Resident 1's rehabilitative services Discharge (DC) Summary from June 2023 and the DC Summary indicated Resident 1 was totally dependent on staff for bed mobility. The DOR stated a total dependence meant the resident could not help with the activity at all and often the resident would be two-person assist. The DOR stated due to Resident 1's stiffness and posturing (involuntary and abnormal positioning of the body due to preserved motor reflexes) it can be harder to turn her. The DOR stated Resident 1 had a left wrist contracture which abnormally pointed away from her body and when you turned Resident 1, you had to ensure all her limbs were out of the way. The DOR stated Resident 1's left arm at the shoulder was internally rotated (causes the associated limb to rotate internally or toward the body) which caused the left hand and wrist to point out away from the body, so you had to adjust the arm and help it become midline prior to turning. During an interview on 2/21/2025 at 2:52 p.m., the director of staff development (DSD) stated if the resident was assessed as a two-person assistance on the care plan, they should be a two-person assistance for resident safety. The DSD stated most subacute residents should be a two-person assistance they do not want medical devices getting dislodged, or they have contractures, so they do not want any injuries. During an interview on 2/21/2025 at 3:26 p.m., the director of nursing (DON) stated Resident 1 had a flat affect but after she was readmitted back from the hospital with the fracture, they noticed some facial grimacing (a facial expression of pain) and an order from MD 1 for Norco 5-325 mg for 14 days was received. The DON stated the plan was to reevaluate her in two weeks to see if she still required the Norco. The DON stated residents with osteoporosis needed to be handled gently. The DON reviewed Resident 1's care plans and stated Resident 1 had a Care Plan to prevent skin issues that indicated Resident 1 was a two-person assist. The DON stated if the care plan indicated Resident 1 was a two-person assistance for turning and repositioning, she should have had two people assisting her to turn and reposition. During a review of the facility's policy and procedure (P/P) titled Turning a Resident on His/ Her Side Away from You, dated 10/2020, the P/P indicated the purpose of this procedure was to provide comfort to the resident and to promote good body alignment. The P/P indicated to review the resident's care plan to assess for any special needs of the resident.

49573 Based on observation, interview, and record review, the facility failed to provide services to five of 13 sampled residents (Resident 76, 48, 61, 68, and 54) with limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) by failing to: 1.Provide Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) services after identifying ROM impairments (unspecified) in both arms and indicating Resident 76 could benefit from skilled services (therapy services performed by licensed therapists and necessary to treat illness and injury) for contracture (a stiffening/shortening at any joint that reduces the joint's range of motion) prevention management during the OT Evaluation, dated 8/7/2024. 2.Provide Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) services after identifying a ROM decline in both ankles and indicating Resident 76 could benefit from skilled services to address limitations in both ankles during the PT Evaluation, dated 8/7/2024. 3.Provide PT services after identifying further ROM decline in the right knee and both ankles and indicating Resident 76 could benefit from skilled services to address limitations in both ankles during the PT Evaluation, dated 9/9/2024. 4.Perform an accurate quarterly Joint Mobility Screen ([JMS] brief assessment of a resident's range of motion in both arms and both legs) of Resident 76's ROM in both arms and legs on 10/31/2024 and 1/27/2025. 5.Perform a quarterly JMS of Resident 48's ROM in both arms and legs between 11/21/2023 and 5/20/2024. 6.Provide an OT Evaluation after identifying a decline in both of Resident 48's elbows during the quarterly JMS, dated 5/20/2024, and prior to the application of both elbow extension (straightening) splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) for four to six hours (4-6 hours) in accordance with professional standards. 7.Provide an OT Evaluation prior to applying Resident 61's right elbow extension splint (a device that immobilizes a joint in an extended position) for 4-6 hours in accordance with professional standards on 6/20/2024. 8.Identify Resident 61's ROM decline in the left hand and left ankle since JMS on 12/23/2024. 9.Provide PROM to Resident 68's arms and legs since admission to hospice (specialized care designed to give supportive care to people in the final phase of a terminal illness with a focus on comfort, quality of life rather than cure, and free of pain to live each day as fully as possible) on 1/9/2025. 10.Ensure Resident 54 received RNA services as ordered for the resident. Findings: a. During a review of Resident 76's General Acute Care Hospital (GACH) Documents Review Report, the GACH Documents Review Report indicted Resident 76 was admitted to the GACH on 3/27/2024 and found to have a meningioma (brain tumor). The GACH Documents Review Report indicated Resident 76 underwent surgical removal of the meningioma on 4/2/2024, partial removal of the skull on 4/3/2024, and placement of a tracheostomy tube (hole made through the front of the neck and into the windpipe [trachea] to enable the resident to breath) on 4/13/2024. During a review of Resident 76's GACH Discharge Medication Orders, dated 4/25/2024, the GACH Discharge Medication Orders indicated to discharge Resident 76 to a sub-acute (level of care that does not require hospitalization but requires more intensive skilled nursing care including medical equipment, supplies, and treatments such as ventilators [medical device to help support or replace breathing) with gastrostomy tube feeding [G-tube feeding, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems]). The GACH Discharge Medication Orders indicated Resident 76 had a helmet and both ankle foot orthosis ([AFO] brace to position the foot and ankle) boots. During a review of Resident 76's Admission Record, the Admission Record indicated the facility admitted Resident 76 on 4/25/2024 with diagnoses including severe hypoxic ischemic encephalopathy (brain injury that occurs when the brain does not receive enough oxygen [hypoxia] and blood flow [ischemia]), cerebral infarction (brain damage due to loss of oxygen to the area) of the right posterior cerebral artery ([PCA] blood vessel that supplies blood and oxygen to a portion of the brain), cerebral edema (swelling of brain tissue due to excessive fluid), and attention to the G-tube. During a review of Resident 76's History and Physical (H&P), dated 4/26/2024, the H&P indicated Resident 76's diagnoses included a meningioma, surgical removal of the meningioma, and cerebral infarct with left sided weakness. The H&P indicated Resident 76 did not have the capacity to understand and make decisions. During a review of Resident 76's JMS, dated 4/26/2024, the JMS indicated Resident 76 had full/functional ROM in all joints of both arms and legs, including both shoulders, elbows, wrists, hands, hips, knees, and ankles. Resident 76's JMS indicated skilled rehabilitation services (therapy given to restore an individual back to their highest possible level of physical, mental, and psychosocial well-being) were not indicated (reason not indicated) and Resident 76 would benefit from the Restorative Nursing Aide ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) program. During a review of Resident 76's physician orders, dated 4/26/2024, the physician orders indicated for the RNA to assist Resident 76 with passive range of motion ([PROM] movement of joint through the ROM from an external force with no effort from the person) exercises to both arms and legs, five times per week for three months or as tolerated. During a review of Resident 76's Rehab Progress Notes, dated 5/8/2024 written by the Director of Rehabilitation (DOR), the Rehab Progress Notes indicated Resident 76's family requested both AFOs for Resident 76 (date of family's request not documented). The Rehab Progress Notes indicated the DOR assessed Resident 76's ROM and muscle tone (amount of tension or resistance in muscles) to determine if Resident 76 could benefit from the AFOs. The Rehab Progress Notes indicated Resident 76 had normal tone and did not have any signs of foot drop (difficulty lifting the front part of the foot). The Rehab Progress Notes indicated the DOR did not recommend both AFOs since Resident 76's ankle ROM was within normal limits ([WNL] normal joint movement) and application of both AFOs might affect Resident 76's skin integrity. During a review of Resident 76's SBAR ([Situation, Background, Assessment, and Recommendation] communication tool used by healthcare workers when there is a change of condition among residents) and Initial COC (Change of Condition) Alert Charting and Skilled Documentation, dated 5/20/2024, the SBAR indicated Resident 76's family was at bedside with concerns of redness and discoloration above the resident's right eye. The SBAR indicated Resident 76's physician was contacted, and the physician recommended Resident 76 be transferred to the GACH for further evaluation. During a review of Resident 76's Nurses Notes, dated 5/20/2024, the Nurses Notes indicated Resident 76 was transferred to the GACH in stable condition with helmet placed. The Nurses Notes indicated Resident 76 did not have any signs or symptoms of bleeding, discomfort, or distress. During a review of Resident 76's Census (record of hospitalization s, room changes, and payor source changes), the Census indicated the facility readmitted Resident 76 on 5/25/2024. During a review of Resident 76's JMS, dated 5/29/2024, the JMS indicated Resident 76 had full/functional ROM in all joints in both arms and legs, including both shoulders, elbows, wrists, hands, hips, knees, and ankles. The JMS indicated Resident 76's skilled rehabilitation services were not indicated (reason not indicated) and would benefit from the RNA program. During a review of Resident 76's physician orders, dated 5/29/2024, the physician orders indicated for the RNA to assist Resident 76 with PROM exercises to both arms and legs, five times per week for three months or as tolerated. During a review of Resident 76's Personal Inventory Update, dated 7/10/2024, the Personal Inventory Update included three foam baseballs. During a review of Resident 76's JMS, dated 8/2/2024, the JMS indicated Resident 76 had full/functional ROM in all joints in both arms and legs, including both shoulders, elbows, wrists, hands, hips, knees, and ankles. The JMS indicated Resident 76 had an RNA ROM program. During a review of Resident 76's OT Evaluation and Plan of Treatment, dated 8/7/2024 (five days after the JMS on 8/2/2024) written by Occupational Therapist 1 (OT 1), the OT Evaluation indicated Resident 76's prior level of function (ability prior to admission to the facility) was independent. The OT Evaluation indicated Resident 76 had impaired ROM (unspecified) in both shoulders, elbows/forearms, wrists, and hands. The OT Evaluation indicated Resident 76 had rigidity (muscle stiffness), hypertonicity (muscle with abnormally increased muscle tone, resulting in stiffness and difficulty moving), and swelling in both arms. The OT Evaluation indicated Resident 76's skin was intact without any observable issues. The OT Evaluation indicated Resident 76 could benefit from continued skilled services for neuromuscular retraining (technique used to restore movement patterns through repetitive motion to retrain the brain), cognitive (relating to the ability to think, understand, learn, and remember) and visual retraining, and contracture prevention management. The OT Evaluation indicated Resident 76 was at risk for further decline in function, immobility, and muscle atrophy (loss of muscle mass) without skilled therapy intervention. During a review of Resident 76's PT Evaluation and Plan of Treatment, dated 8/7/2024 (five days after the JMS on 8/2/2024) written by Physical Therapist 2 (PT 2), the PT Evaluation indicated Resident 76's prior level of function was independent with all functional mobility and walked without an assistive device. The PT Evaluation indicated Resident 76 was referred to PT for assessment of mobility and function. The PT Evaluation indicated Resident 76's ROM in both hips and knees were within functional limits ([WFL] sufficient movement without significant limitation). The PT Evaluation indicated both of Resident 76's ankles had impaired ROM with the right ankle measuring negative 20 degrees (-20 degrees) of dorsiflexion (bending the ankle toward the body, normal 0 to 20 degrees) and the left ankle measuring -15 degrees of dorsiflexion. The PT Evaluation indicated Resident 76 was alert, non-verbal, had left-sided neglect (condition after a brain injury where a person is not aware of the left side), had left-sided hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and had left leg hypertonicity. The PT Evaluation indicated Resident 76 had been bed bound since 3/2024, had limitations in both ankles into dorsiflexion, and both ankles exhibited foot drop while lying in bed. The PT Evaluation indicated Resident 76 would benefit from continued skilled PT services to address limitations in ankle dorsiflexion, improve muscle strength, and provide education on positioning and bed mobility. The PT Evaluation indicated Resident 76 was at risk for immobility, further decline in function, pressure injuries, decreased skin integrity, muscle atrophy, and increased muscle tone without skilled therapy intervention. During a review of Resident 76's Census, the Census indicated Resident 76 moved from the facility's sub-acute area (Nursing Station 2) to Nursing Station 1 on 8/17/2024. During a review of Resident 76's PT Evaluation and Plan of Treatment, dated 9/9/20204 written by PT 2, the PT Evaluation indicated Resident 76 was referred to PT for assessment of mobility and function. The PT Evaluation indicated Resident 76's ROM in both hips and left knee were WFL. The PT Evaluation indicated Resident 76's right knee and both ankles had impaired ROM with right knee extension measuring -30 degrees of extension (normal 0 degrees), right ankle measuring -30 degrees of dorsiflexion, and left ankle measuring -35 degrees of dorsiflexion. The PT Evaluation indicated Resident 76 had been bed bound since 3/2024, had limitations in the right knee and both ankle joints, and exhibited foot drop with right knee flexion (bent) while lying in bed. The PT Evaluation indicated Resident 76 was at risk for immobility, further decline in function, pressure injuries, decreased skin integrity, muscle atrophy, and increased muscle tone without skilled therapy intervention. During a review of Resident 76's JMS, dated 10/31/2024 (after ROM limitations were identified on 8/7/2024 and 9/9/2024) and 1/27/2025, the JMS indicated Resident 76 had full/functional ROM in all joints in both arms and legs, including both shoulders, elbows, wrists, hands, hips, knees, and ankles. The JMS indicated Resident 76 had an RNA ROM program. During a review of Resident 76's Minimum Data Set ([MDS] a resident assessment tool), dated 1/27/2025, the MDS indicated Resident 76 did not have any speech, rarely/never expressed ideas and wants, rarely/never understood verbal content, and was severely impaired for daily decision making. The MDS indicated Resident 76 did not have any ROM limitations in both arms and legs. The MDS indicated Resident 76 was dependent (helper does all of the effort or the assistance of two or more helpers is required for the resident to complete the activity) for oral hygiene, toileting, bathing, dressing, rolling to either side in bed, and chair/bed-to-chair transfers. During an interview on 2/4/2025 at 8:53 a.m., with the DOR, the DOR stated the residents (in general) received a JMS upon admission to the facility and on a quarterly basis. The DOR stated the purpose of the JMS was to identify any changes in ROM to prevent ROM limitations and the development of contractures. The DOR described contractures as limitations in motion caused by muscle tone and/or shortening of soft tissues. The DOR stated contractures could be managed with early detection with the use of splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion). The DOR stated the purpose of splints included placing the joints in the most optimal position to prevent the development of a contracture or to prevent contractures from worsening if already present. The DOR stated ROM limitations and contractures could affect a resident's skin integrity including the development of wounds, cause fractures due to increased muscle tone, and cause pain. During a concurrent observation and interview on 2/4/2025 at 4:29 p.m., with Resident 76's Family (Family1), in Resident 76's room, Resident 76 was lying in bed, without any splints on both arms and legs. Family 1 stated Resident 76's health insurance did not cover services (unspecified) Resident 76 was supposed to receive. Family 1 stated Resident 76 received ROM exercises; Family 1 stated did not know if the exercises were completed daily. Family 1 stated Resident 76 was admitted to the facility with boots on both feet and the facility staff (unidentified) informed Family 1 that Resident 76 did not need the boots since Resident 76's ankle joints were not locked up. During an observation of Resident 76's RNA session on 2/5/2025 at 8:01 a.m., in Resident 76's room, RNA 1 stood on the right side of the bed to perform ROM exercises to the right shoulder, elbow, forearm, wrist, and hand. RNA 1 performed ROM exercises to the right leg, including hip abduction (moving the leg at the hip joint away from the body), hip flexion (bending the leg at the hip joint toward the body) with the knee extended (straightened), knee flexion, ankle rotation clockwise and counterclockwise, and ankle dorsiflexion. RNA 1 was observed unable to fully bend Resident 76's right knee, which was limited to less than 90 degrees. RNA 1 was observed unable to fully bend Resident 76's right ankle into dorsiflexion and the resident's right ankle remained in plantarflexion. RNA 1 walked to the left side of Resident 76's bed to perform ROM exercises to the left shoulder, elbow, forearm, wrist, and hand. RNA 1 performed ROM exercises on the left leg, including hip abduction, hip flexion with knee flexion, ankle rotation clockwise and counterclockwise, and ankle dorsiflexion. RNA 1 was observed unable to fully bend Resident 76's left ankle into dorsiflexion and the left ankle remained in plantarflexion. RNA 1 placed small pillows underneath both of Resident 76's arms and placed a soft doll inside Resident 76's right hand. During an interview on 2/5/2025 at 8:27 a.m., with RNA 1, RNA 1 stated Resident 76 received PROM exercises to both arms and legs. RNA 1 stated Resident 76's right knee required gentler ROM, and the left arm and leg were tighter than the right side. RNA 1 stated Resident 76 did not wear any splints. During a concurrent interview and record review on 2/5/2025 at 3:26 p.m., with the DOR, Resident 76's JMS, dated 4/26/2024, Rehab Notes, dated 5/8/2024, Census, and OT Evaluation, dated 8/7/2024, were reviewed. The DOR stated Resident 76 was admitted to the facility on [DATE], received a JMS on 4/26/2024, and was referred to the RNA program for PROM to both arms and legs. The DOR stated Resident 76 was not a therapy candidate due to Resident 76's inability to follow directions and inability to move without assistance. The DOR reviewed Resident 76's Rehab Notes, dated 5/8/2024, and stated the DOR performed a screen of both legs after Resident 76's family requested AFOs. The DOR stated AFOs were not recommend for Resident 76 since Resident 76 did not have any signs of foot drop. The DOR reviewed Resident 76's Census and stated Resident 76 was discharged to the hospital on 5/20/2024, readmitted to the facility on [DATE], and remained at the facility since readmission. The DOR reviewed the OT Evaluation, dated 8/7/2024, which indicated Resident 76 had unspecified ROM limitations in both arms and would benefit from skilled rehabilitation services. The DOR stated the OT Evaluation was submitted to Resident 76's health insurance and Resident 76 did not receive OT treatment due to the health insurance's denial for services. The DOR stated Resident 76 continued to receive RNA services for PROM exercises. During a concurrent interview and record review on 2/5/2025 at 3:45 p.m., with the DOR, Resident 76's PT Evaluations, dated 8/7/2024 and 9/9/2024, and the JMS, dated 10/31/2024 and 1/27/2025, were reviewed. The DOR stated the PT Evaluation, dated 8/7/2024, indicated Resident 76 had ROM limitations in both ankles which were positioned in plantarflexion. The DOR stated there should have been a recommendation for ankle splints or ROM only depending on Resident 76's skin integrity. The DOR reviewed the PT Evaluation, dated 9/9/2024, and stated Resident 76 had increased tone in the right leg and was positioned in more plantarflexion at both ankles. The DOR stated the PT Evaluation indicated Resident 76 would benefit from further PT services but did not receive services since Resident 76's health insurance denied further services. The DOR stated the JMS on 10/31/2024 and 1/27/2025 (after ROM limitations were already identified) indicated Resident 76 had Full/Functional ROM in all joints of both arms and legs. During a concurrent observation and interview on 2/5/2025 at 3:59 p.m., with the DOR outside Resident 76's bedroom, Resident 76's ankles were visible from the doorway. The DOR stated Resident 76's ankles were positioned in plantarflexion. The DOR stated the facility did not provide any additional PT intervention to prevent Resident 76's plantarflexion after the family's request for AFOs on 5/8/2024 and after identifying the ROM limitation twice during the PT Evaluations, dated 8/7/2024 and 9/9/2024. The DOR stated the facility did not provide additional intervention and did not have any documentation AFO boots were trialed to determine Resident 76's wear tolerance (amount of time a person could wear a splint before experiencing discomfort or skin irritation). The DOR stated Resident 76 developed plantarflexion ROM limitations while in the facility and stated they were preventable. During an interview on 2/6/2025 at 8:25 a.m., with PT 2, PT 2 stated the types of splints the PTs usually recommended at the facility included hip abduction wedges (placed in-between legs to prevent legs from rubbing together), knee extension splints, AFOs for walking, and PRAFOs ([Passive Range Ankle Foot Orthoses] device worn on the calf and foot to suspend the heel and hold the ankle in a neutral [90-degree] position). PT 1 stated PRAFOs were recommended (in general) for residents who can potentially have skin integrity issues and develop contractures. PT 1 stated the professional standard to provide a splint to a resident (in general) included performing a ROM assessment, assessing skin integrity and muscle tone, and determining a resident's response to the splint, which included applying the splint initially for 30 minutes after performing skin checks and then gradually applying the splint for more time to determine the resident's splint wearing tolerance. PT 1 stated the purpose of splints included contracture prevention, especially for immobilized patients who have been bed bound and do not have the ability to reposition themselves. During a concurrent observation and interview on 2/6/2025 at 8:49 a.m., with PT 2 in Resident 76's room, PT 2 assessed Resident 76's hands and both legs. Resident 76 was observed lying in bed with both ankles positioned in plantarflexion. PT 2 stood on the right side of Resident 76's bed to move the right leg at the hip, knee, and ankle joints. PT 2 bent Resident 76's right knee and measured the knee ROM using a goniometer (device that measures joint ROM). PT 2 stated Resident 76 had 42 degrees of knee flexion (normal 135 degrees) and had increased muscle tone. PT 2 stated Resident 76 used to have more ROM in the right knee. PT 2 bent Resident 76's right ankle into dorsiflexion which measured 24 degrees of plantarflexion (or -24 degrees of dorsiflexion). PT 2 walked to the left side of Resident 76's bed to move the left leg at the hip, knee, and ankles joints. PT 2 bent Resident 76's left ankle into dorsiflexion which measured 29 degrees of plantarflexion (or -29 degrees of dorsiflexion). PT 2 described both of Resident 76's hands as closed into a fist with some swelling. PT 2 extended Resident 76's left-hand fingers and stated Resident 76's fingernails were digging into the skin of the left palm. Resident 76's left palm was observed with redness and a small scab (dry, rough protective crust that forms over a wound). PT 2 described Resident 76's left-hand scab as a previous wound that was healing. PT 2 stated Resident 76's left hand was resistive to movement as PT 2 attempted to place a rolled towel inside the left hand. PT 2 extended Resident 76's right-hand fingers and stated the middle finger was unable to completely extend at the fingertip joint. During a concurrent interview and record review on 2/6/2025 at 9:43 a.m., with PT 2, Resident 76's PT Evaluations, dated 8/7/2024 and 9/9/2024, and JMS, dated 1/27/2025, were reviewed. PT 2 reviewed the PT Evaluation, dated 8/7/2024, and stated Resident 76 had ROM impairments in both ankles. PT 2 stated Resident 76 was receiving RNA ROM exercises to prevent worsening ROM of both ankles. PT 2 stated Resident 76 would have benefitted from PT services, including splints since the RNAs were not qualified in determining wear tolerance. PT 2 stated Resident 76 did not receive additional PT because the health insurance did not authorize therapy services. PT 2 reviewed the PT Evaluation, dated 9/9/2024, and stated Resident 76's right knee was unable to fully extend and had full flexion. PT 2 stated feeling surprised today (during the assessment) that Resident 76's right knee extended fully and had limitations in knee flexion. PT 2 stated Resident 76's PT Evaluation, dated 9/9/2024, indicated Resident 76 continued to have ROM limitations in both ankles, including the inability to bend both ankles to neutral (90-degree position) and were positioned in plantarflexion. PT 2 stated Resident 76 did not receive PT services after the PT Evaluation, dated 9/9/2024, because the health insurance did not authorize therapy services. PT 2 stated Resident 76 would have benefited from therapy services to delay further progression of the contractures after both PT Evaluations. PT 2 reviewed Resident 76's JMS, dated 1/27/2025 (10 days prior to interview), and stated Resident 76's ROM has declined. PT 2 stated Resident 76 had ROM limitations in both hands with the left hand worse than the right hand. PT 2 stated Resident 76 was developing a right knee extension contracture due to limitations into knee flexion and had plantarflexion contractures of both ankles. During a review of the Physiatrist (medical doctor who specializes in physical medicine and rehabilitation) Consultation, dated 2/6/2025 written by Medical Doctor 1 (MD 1), the Physiatrist Consultation indicated Resident 76 was at-risk for joint contractures of both hands due to positioning and recommended hand rolls (soft roll positioned in the palm of the hand and fastened with a strap) and to continue the RNA program for ROM to prevent contractures. The Physiatrist Consultation indicated Resident 76 had plantarflexion contractures in both ankles and recommended to use heel protectors to offload pressure and prevent skin breakdown (tissue damage caused by friction [surfaces rubbing against each other], shear [straight produced by pressure], moisture, or pressure) and to continue the RNA program for PROM to both legs to prevent worsening contractures. The Physiatrist Consultation indicated splinting the plantarflexion contractures would not likely provide functional progress since Resident 76 was not likely to ambulate. During an interview on 2/6/2025 at 1:54 p.m., with MD 1, MD 1 stated Resident 76 was assessed today (date of interview) due to the facility's concerns of contractures. MD 1 stated Resident 76's hands were positioned in a flexion and the fingertip joints of the left hand were bent and digging into the palm, causing redness in the palm. MD 1 stated the facility needed to monitor the resident's the hands closely, protect the left palm, and provide ROM exercises. MD 1 stated Resident 76 had plantarflexion contractures in both ankles which could have been prevented with PROM and splinting. During a concurrent interview and record review on 2/6/2025 at 2:52 p.m., with OT 1, Resident 76's OT Evaluation, dated 8/7/2024, was reviewed. OT 1 stated the OT Evaluation indicated Resident 76's ROM in both arms were impaired because of increased muscle tone and stiffness and did not have actual ROM limitations. OT 1 did not know the reason Resident 76 did not receive skilled services at the facility in accordance with OT 1's recommendations. During an interview on 2/7/2025 at 11:07 a.m., with the DOR, the DOR stated Resident 76 did not receive therapy at the facility because they did not receive authorization from Resident 76's health insurance to provide services. During a telephone interview on 2/7/2025 at 12:14 p.m., with Family 1, Family 1 stated Resident 76's hands have been in closed fists since admission to the facility. Family 1 stated he brought balls and dolls to the facility so the staff could place them and open both of Resident 76's hands. Family 1 stated the GACH discharged Resident 76 to the facility with splints that kept both ankles at 90-degree angles but Resident 76 did not wear them. Family 1 stated the facility found the splints but the therapist (unidentified) informed Family 1 that the splints would hinder the ankles more than help. Family 1 stated the facility did not provide therapy services due to Resident 76's health insurance. Family 1 stated feeling frustrated Resident 76 did not receive any therapy services and should have received therapy to work with the muscles early. During an interview on 2/7/2025 at 3:17 p.m., with the Director of Nursing (DON), the DON stated the purpose of therapy services (in general) was to assist residents in regaining strength, to prevent any decline in ROM to prevent contractures, prevent decline in mobility, activities of daily living ([ADLs] tasks related to personal care including bathing, dressing, hygiene, eating, and mobility), and speech. During a concurrent interview and record review on 2/7/2025 at 3:52 p.m., with the DON, Resident 76's PT and OT Evaluations, dated 8/7/2024, and the facility's policies and procedures (P&P) tilted, Rehabilitation Policy and Procedures, revised 12/30/2019, and Resident Mobility and Range of Motion, revised 7/2017, were reviewed. The DON reviewed Resident 76's PT and OT Evaluations, dated 8/7/2024, and stated the facility did not have any documentation therapy services were provided after the evaluations. The DON stated splints could prevent plantarflexion contractures in addition to ROM. The DON stated Resident 76 did not receive any therapy services to determine whether splints were appropriate. The DON reviewed the facility's P&Ps and stated the P&Ps did not indicate health insurance authorization was necessary prior to providing further intervention to prevent ROM loss. The DON stated the purpose of preventing contractures (in general) was to prevent pain, further impairment in mobility, and fractures. During a concurrent interview and record review on 2/7/2025 at 4:57 p.m. with the DON, Resident 76's JMS dated 1/27/2025 and Physiatrist Consult, dated 2/6/2025, were reviewed. The DON stated the JMS, dated 1/27/2025, indicated both of Resident 76's ankles had full/functional ROM and the Physiatrist Consult, dated 2/6/2025 (10 days after the JMS) indicated Resident 76 had plantarflexion contractures of both ankles. The DON stated Resident 76's JMS was inaccurate. The DON stated an inaccurate JMS would not identify ROM loss and would prevent treatment of ROM loss. During a review of the facility's P&P titled, Rehabilitation Policy and Procedures: Evaluation and Plan of Care, revised 12/30/2019, the P&P indicated the evaluating clinician was responsible to complete the written treatment plan. During a review of the facility's P&P titled, Resident Mobility and Range of Motion, revised 7/2017, the P&P indicated residents will not experience an avoidable reduction in ROM and residents with limited ROM will receive treatment and services to increase and/or prevent a further decrease in ROM. The P&P also indicated intervention may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards of practice. b. During a review of Resident 48's Admission Record, the Admission Record indicated the facility originally admitted Resident 48 on 8/7/2020 and readmitted on [DATE]. The Admission Record indicated Resident 48's diagnoses included respiratory failure (serious condition that develops when the lungs cannot get oxygen into the blood), encephalopathy (disease that affects the brain, causing changes in its function), cerebral infarction (brain damage due to a loss of oxygen to the area), dysphagia (difficulty swallowing), attention to tracheostomy (hole made through the front of the neck an into the windpipe [trachea] to allow air into the lungs), and attention to gastrostomy ([G-tube] surgical opening fitted with a device to allow feedings to be administered directly t [TRUNCATED]

Based on interview and record review, the facility failed to ensure residents, with a change in condition (COC- a sudden, clinically important deviation from a patient's baseline [a minimum or starting point used for comparisons] in physical, cognitive (ability to think, understand, learn, and remember) behavioral, or functional status which without immediate intervention, may result in complications or death) manifested by temperature of 103.8 degrees Fahrenheit ( F-unit of measurement [normal body temperature can range from 97 F to 99 F ]), heart rate of 130 beats per minute ( bpm normal resting heart rate is between 60 and 100 beats per minute), hematuria ( blood in the urine) was transferred to a general acute care hospital (GACH) without a delay for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure Licensed Vocational Nurse (LVN 1) assessed and monitored Resident 1's condition, including vital signs, when the resident had a change in condition as follows: a. On [DATE] at 10:12 p.m. Resident 1 had body temperature of 99.8 F b. On [DATE] 10:57 a.m., Resident 1 had hematuria (blood in urine). c. On [DATE] at 11:43 p.m. Resident 1 had an elevated body temperature of 103.8 F and heart rate of 130 bpm. 2. Develop a care plan for Resident 1's diagnosis of neuromuscular dysfunction of the bladder (neurogenic bladder-impaired bladder control and difficulty emptying the bladder) with interventions to prevent the resident from developing a urinary tract infection (UTI- an infection in the bladder/ urinary tract) and sepsis (a life-threatening condition in which the body's reaction to an infection). 3. Ensure licensed nurses, transferred Resident 1 to GACH on [DATE] at 11:53 p.m., without a delay of up to 6 hours, when Resident 1 had an elevated temperature of 103.8 F and heart rate of 130 bpm. These failures resulted in a six-hour delay transferring Resident 1 to the GACH from the time Resident 1 had a change in condition, where he was diagnosed with septic shock (life threatening condition when an infection spreads throughout the body and causes a dangerously low blood pressure) and he expired on [DATE], (13 hours after he was admitted to the GACH. On [DATE], at 2:34 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation had cause, or is likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of the Administrator (ADM) and Director of Nursing (DON) due to the facility's failure to transfer Resident 1 to GACH) timely, when he had a COC on [DATE]. On [DATE], at 2:30 p.m., the facility submitted an acceptable IJ removal plan ([IJRP]- an intervention to immediately correct the deficient practices). After verification the IJRP was implemented through observation, interview, and record review, the IJ was removed while onsite on [DATE] at 2:30 p.m., in the presence of the ADM, DON, and the Regional Director of Operations (RDO). The IJRP included the following: 1.License Nurse 1 was educated by the DON regarding Change of Condition policy and procedure focusing on immediate notification of the physician as it relates to quality of care. 2. In-service education was commenced by the DON and Quality Staff Registered Nurse (QS RN) to all licensed nurses on [DATE] regarding physician notification of the change of condition (COC) including but not limited to vital signs that are out of range for the sepsis prevention (that is [i.e.] temperature< 96.8 F or >99 F or, HR <60 bpm or >90 bpm, respiratory rate <12 or > 20, systolic blood pressure (SBP- pressure exerted when the heart beats and blood is ejected into the arteries) < 100 mmHg. If base line SBP is < 100 mmHg, + 5 mmHg than the baseline, Oxygen saturation (O2 Sat a measure of how much oxygen the blood is carrying as a percentage) of < 90% and any change of condition. 3. In-service education was commenced by the DON and/or designee on [DATE] regarding initiation, review, and revision of resident-centered care plan of residents with a diagnosis of neuromuscular dysfunction of the bladder with interventions to prevent the resident from developing UTI/sepsis and other areas that accurately reflects resident's conditions and care. 4.Competency Skills Check for licensed nurses was commenced on [DATE] by DON and QS RN regarding (1) assessing residents' change in conditions (2) identifying symptoms of infection/sepsis and of change of condition, (3) assess, monitor and implement needed interventions based on residents' change in condition (4) recognizing symptoms of urinary tract infection and including elevated temperature, hematuria, abdominal pain, and low back pain, and (5) compliance with recognizing, evaluating and monitoring. 5.The facility checked Situation, Background, Assessment, Recommendation (SBAR a technique that can be used to facilitate prompt and appropriate communication) /COC from [DATE] to [DATE]. All 161 SBAR/COC showed that medical doctor (MD) was notified on a timely manner. 6.In-service education was commenced by the DON and/or designee on [DATE] regarding initiation, review, and revision of resident-centered care plan of residents with a diagnosis of neuromuscular dysfunction of the bladder with interventions to prevent the resident from developing UTI/sepsis and other areas that accurately reflects resident's conditions and care. 7.In-service education was commenced on [DATE] regarding Physician Notification of the COC including but not limited to vital signs that are out of range for the sepsis prevention. As of [DATE] at 10 a.m., 50 out of 50 Registered Nurses (RNs)/Licensed Vocational Nurses (LVN) staff (100%) received the in-service on Physician Notification of the COC including but not limited to vital signs that are out of range for the sepsis prevention. 8.Competency Skills Check regarding COC was commenced on [DATE] by DON and QS RN. As of [DATE] at 10 a.m., Competency Skills Check regarding COC was conducted to 50 out of 50 RNs/LVNs staff (100%). What measures will be put into place or what systemic changes will make to ensure that the deficient practice does not recur? 1.The facility nursing staff will notify the DON or designee at the time of a change of condition. The DON or designee (i.e. Assistant Director of Nursing (ADON) and RN Supervisor) will ensure that MD/Nurse Practitioner (NP- a nurse who has advanced clinical education and training) and Physician Assistant (PA-a licensed medical professional who works with physicians to provide patient care) notification has been completed ( i.e. MD notified of the COC, MD responded, and carry out physician order, if with physician order) or the DON or designee will call the MD/NP/PA on call personally. In the event the resident's MD/NP/PA on record may not be reached at the time of the residents COC, the RN Supervisor will obtain orders from a doctor on the medical panel (i.e. other medical doctors) obtain the order to send the resident to the acute care hospital if needed in real time as to prevent any delay in resident care. 2.COC of the previous day will be reviewed by the clinical team (such as but not limited to DON, ADON, Director of Staff Development (DSD), Infection Preventionist (IP) on the following day in the Clinical Meeting to ensure that all change of conditions have been checked for compliance such as but not limited to (1) assessing any residents' change in condition (1) symptoms of infection/sepsis and of change of condition were identified, (2) appropriate assessment, monitoring and needed interventions were implemented (3) symptoms of UTI including elevated temperature, hematuria, abdominal pain, and low back pain were identified and (4) compliance with recognizing, evaluating, monitoring. 3.The License Nurse will follow the process of MD notification: a. The attending physician will be notified promptly (i.e. within 30 minutes) for any change of conditions including but not limited to out-of-range vital signs, cardiovascular (heart) changes, neurological changes (brain/mental), genitourinary (bladder), etc. b. If no response from the attending physician within 30 minutes, the Medical Director will be notified of any change of conditions including but not limited to out-of-range vital signs, cardiovascular changes, neurological changes, genitourinary, etc. c. If no response from the Medical Director and the resident is manifesting a significant change of condition (such as decrease level of consciousness, unresponsiveness, critical labs level, out of range vital sign, etc. [used at the end of a list to indicate that further, similar items are included.]) registered nurse will refer Physician Orders for Life-Sustaining Treatment (POLST form is a written medical order that specifies a patient's end-of-life care preferences) if to be sent out to emergency room (ER) for further evaluation. Then, attending physician will be notified thereafter. 4. In-service education was commenced to Licensed Nurses by the DON and/or designee on [DATE] regarding timely Physician Notification of the COC including but not limited to vital signs that are out of range for the sepsis prevention and any change of change of condition. 5.In-service education was commenced by the DSD to CNAs on [DATE] regarding identification and reporting to License Nurse in-charge and/or the RN Supervisor in a timely manner of any change of condition. 6.The DSD or designee (i.e. QS RN, RN Supervisor) will do random verbal quiz to CNAs on different shifts re identification and reporting to License Nurse in-charge and/or the RN Supervisor in a timely manner of any change of condition. CNAs will be immediately re-in serviced by the DSD for those CNAs needing further education. DSD will present the findings and progress status to the Monthly Quality Assessment Assurance (QAA- responsible for identifying and responding to quality deficiencies that are identified in the facility) meeting for recommendations/suggestions. a. Four CNAs weekly for four weeks then; b.Three CNAs weekly for two weeks then; c.Two CNAs a month for two months. 7.In-service education was commenced by the DON and/or designee on [DATE] regarding initiation, review, and revision of care plan of residents with a diagnosis of neuromuscular dysfunction of the bladder with interventions to prevent the resident from developing urinary tract infection (UTI) and sepsis and other care plan that accurately reflects the residents' conditions and care. 8.Competency Skills Check for Licensed Nurses (Registered Nurses and Licensed Nurses [LN]) on COC by DON, QS RN and was commenced on [DATE]. 9.The DON, or designee will do random verbal quiz to licensed nurses (LN) on different shifts re regarding (1) Verbalize/name change of condition such as symptoms of infections/sepsis, (2) name the process of timely Physician Notification of the Change of Condition (COC) including but not limited to out-of-range vital signs which is an early sign of infection and change of condition, (3) name symptoms of UTI and including elevated temperature, hematuria, abdominal pain, and low back pain, and (4) able to name/recognize, evaluate, monitor, and assess any residents' change of condition: a. Four LNs weekly for four weeks then; b. Three LNs weekly for two weeks then; c. Two LNs a month for two months. 10.The DON or designee (i.e. ADON, QS RN) will conduct random chart audits on SBAR/Change of Conditions. The DON or designee (i.e. ADON, QS RN) will further investigate for findings (such as but not limited to MD was not notified on a timely manner, or other missing information in the SBAR). An in-service education will immediately be provided to the RN/LN involved. Findings and progress status will be presented in the Monthly QAA Meeting for suggestions/recommendations. d.Three residents weekly for four weeks then; e.Two residents weekly for two weeks then; f.Two residents a month for two months. 11.Licensed Nurse staff who are not present during the In-service education (such as those who are on leave, per-diem, or part-time status), in-service education will be provided on day-1 return to work prior to start of shift. 12.New hires (licensed nurses) and Registries (provides nursing personnel to facility in need of temporary staff) will be educated on change of condition and physician notification regulations, as well as facility policy and procedure, accordingly in orientation by the DON and/or DSD 13.The DON implemented a Quality Assurance Performance Improvement (QAPI data-driven approach to improving the quality of care and services in nursing homes) Performance Improvement Project (PIP) with a focus on physician notification of significant changes. 14.The PIP resulted in implementation of daily ADON/designee audits of the Clinical Alerts Listing audit to monitor timely notification of MD for residents with vital signs that are out-of-range and other change of conditions. 15.The QS RN/consultant nurse will visit the facility at least once a week to provide general oversight and monitoring of the PIP. How the facility plans to monitor performance to make sure that solutions are sustained. 1.Under the supervision of the Administrator, DON or Designee will be responsible and accountable to submit audit findings utilized the Quality Assurance (QA) monitoring/audit tool to QAA committee member monthly for 3 months until 100% compliance. 2.The Administrator and DON shall be responsible for the implementation, monitoring, and evaluation of this Plan of Correction. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure (a serious condition that occurs when your lungs can't get enough oxygen into your blood or remove carbon dioxide), bronchopneumonia (an inflammation of the lungs that affects the small airways and the surrounding lung tissue, seizures (a sudden uncontrolled change in behavior or body movement caused by abnormal electrical activity in the brain, hemiplegia (paralysis on the same side of the body) and hemiparesis (total paralysis of the arm, leg, and trunk on the same side of the body), encounter for tracheostomy (a surgical procedure that creates an opening in the neck into the windpipe, and neuromuscular dysfunction of the bladder. During a review of Resident 1's History and Physical (H&P), dated [DATE], the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Physician Order Summary report dated [DATE], the Physician Order Summary indicated to notify Medical Doctor (MD) if Resident 1 had any of the following symptoms: 1. Temperature less than (<) 96.8 F or greater than 99 F. 2. Heart rate greater than (>) 90 beats per minute 3. Respiratory (breathing) rate greater than 20 4. Acute change in mental status 5. Oxygen saturation (O2 sat- a measure of how much oxygen the blood is carrying as a percentage) less than 90 percent (%) 6. Systolic blood pressure (SBP- pressure exerted when the heart beats and blood is ejected into the arteries [blood vessels that distribute oxygen-rich blood to your entire body]), if baseline less than 100 millimeters of mercury (mmHg a unit of measurement for pressure), more than 5 mmHg lower than the baseline, every shift for sepsis prevention. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated [DATE], the MDS indicated, Resident 1 had severe impairment in cognitive (ability to think, understand, learn, and remember), skills for daily decision making. The MDS indicated Resident 1 was dependent on staff with bed mobility, chair/ bed to chair transfer, and tub/ shower transfer. During a record review of Resident 1's COC dated [DATE] timed at 6:19 a.m., the COC indicated Resident 1 had a moderate amount of hematuria in his incontinent pad (diaper). The COC indicated on [DATE] at 6:30 a.m. Resident 1's Primary Care Physician (PCP) 1 was notified., but there was no documentation of recommendations or physician orders. During a record review of Resident 1's COC dated [DATE] timed at 7:10 a.m., the COC indicated Resident 1 was unresponsive to verbal, tactile (any form of touch or physical contact perceived by the skin such as a sternal rub [a painful stimulus to the chest that is used to assess a patient's responsiveness ]), and deep stimuli (when a person does not respond to pain, touch, and voice). The COC indicated PCP 1 was notified and facility staff called 911. During a review of Resident 1's Paramedics Run Sheet (a detailed written record that paramedics fill out during each emergency medical call) dated [DATE] timed at 6:33 a.m., the Paramedics Run Sheet indicated Resident 1 was observed with eyes open and unresponsive. The Paramedics Run Sheet indicated Resident 1 had fever for three days and became hypotensive (low blood pressure) with an altered mental status. The Paramedics Run Sheet indicated on [DATE] at 6:46 a.m., Resident 1's blood pressure was ,d+[DATE] mmHg, HR 110 bpm, and respiratory rate of 20. During a review of Resident 1's GACH emergency room (ER) Notes dated [DATE], the GACH ER Notes indicated, Resident 1 was admitted on [DATE] at 7:31 a.m., with diagnoses of UTI, acute kidney injury (a sudden loss of kidney function, that can range from minor to complete kidney failure) and septic shock (a life-threatening condition that occurs when the body's response to an infection causes dangerously low blood pressure). The GACH ER notes indicated on [DATE] was 8:11 a.m., Resident 1 was noted to have severe sepsis. GACH ER notes indicated Resident 1's temperature was 98.7 F, HR 111 bpm, and blood pressure ,d+[DATE] mmHg. The GACH ER notes indicated on [DATE] at 6:12 p.m., the first code blue (a hospital emergency code that indicates a patient needs immediate medical attention, usually due to cardiac (heart) or respiratory arrest) was called, and at 7:50 p.m., the second code blue was called. The GACH ER notes indicated on [DATE], at 8:11 p.m., Resident 1 expired. During an interview on [DATE] at 3:14 p.m. with LVN 2, LVN 2 stated she did not assess or monitor Resident 1's vital signs when the resident had a change of condition (temperature of 103.8 F and HR 130 bpm) on [DATE] at 11:43 p.m. LVN 2 stated there was no documentation of Resident 1's temperature and HR after it was last taken on [DATE] at 11:43 p.m. During a concurrent interview and record review on [DATE], at 4:24 p.m., with Registered Nurse Supervisor (RNS 1), Resident 1's Weight and Vital Sign Summary and Situation, Background, Assessment, Recommendation (SBAR a communication tool used by healthcare workers when there is change of condition among the residents) / Change of Condition (COC) were reviewed. The Weight and Vital Sign Summary indicated, Resident 1 had the following temperatures and heart rates: a. On [DATE] 10:12 pm for Resident 1's temperature 99.8 F b. On [DATE] 11:25 am for Resident 1's HR 96 bpm c. On [DATE] 11:31 pm for Resident 1's HR 91 bpm d. On [DATE] 2:31 pm Resident 1's temperature 99.1 F e. On [DATE] 10:32 pm Resident 1's temperature 99.8 F f. On [DATE] 11:43 pm Resident 1's temperature 103.8 F g. On [DATE] 2:31 p.m., for Resident 1's HR 98 bpm h. On [DATE] 11:43 p.m., for Resident 1's HR 130 bpm RNS 1 stated Resident 1's physician order dated [DATE] indicated to notify MD if Resident 1 had any of the following symptoms: Temperature less than 96.8 F or greater than 99 F, Heart rate greater than 99 bpm Respiratory rate greater than 20, Acute change in mental status, O2 saturation less than 90 %, systolic blood pressure, if baseline less than 100 mmHg, more than 5 mmHg lower than the baseline, every shift for sepsis prevention. RNS 1 stated the orders should have been followed for Resident 1's physician to address COC. RNS 1 stated there was no care plan for neuromuscular dysfunction of the bladder to ensure licensed nurses will have specific intervention related to the diagnosis. RNS 1 further stated that there was no re-assessment done by licensed nurses after Resident 1 was noticed to have change of condition (temperature of 103.8 F and HR 130 bpm) on [DATE] at 11:43 p.m. During an interview on [DATE], at 4:40 p.m., with Licensed Vocational Nurse (LVN 1), LVN 1 stated Resident 1 physician was not notified of Resident 1's temperature of 103.8 F and HR 130 bpm on [DATE] at 11:43 p.m. LVN 1 stated nonpharmacological (healthcare strategies that do not involve the use of medications) interventions including cooling measures such as removing blankets, put a fan on, and placing cold towels on Resident 1's forehead and under the arms were initiated. LVN 1 stated Resident 1's physician was not called because Resident 1 had a COC on [DATE] when Resident 1 had temperature of 99.8 F and hematuria. LVN 1 stated she failed to inform Resident 1's physician when he spiked a temperature of 103.8 F. LVN 1 stated she did not think it was an infection as Resident 1's temperature went down to 99 F. LVN 1 stated she does not recall the exact time Resident 1's temperature was taken and was not documented. LVN 1 stated she did not notify the doctor of Resident 1's HR of 130 bpm, as Resident 1's heart rate came down but failed to document. LVN 1 stated Resident 1's physician should be notified as interventions (cooling measures) were not working. LVN 1 stated no other temperatures or heart rates were documented after it was taken on [DATE] at 11:43 p.m. LVN 1 stated the next vital signs was taken on [DATE] at 6 a.m., (6 hours after). LVN 1 stated Resident 1 was sent to the GACH on [DATE] at 6 a.m. During an interview on [DATE], at 5:10 p.m., with RNS 3, RNS 3 stated Resident 1's physician was not notified of the resident's temperature of 103.8 F, as Resident 1 was already on monitoring for elevated temperatures and hematuria. RNS 3 stated primary care physicians get upset when called so nonpharmacological interventions were initiated for Resident 1. RNS 3 stated looking back Resident 1's physician should have been notified of Resident 1's temperature of 103.8 F as Resident 1 had previous elevated temperature of 99.8 F on [DATE]. RNS 3 stated Resident 1 could have had a UTI, pneumonia (an infection/ inflammation in the lungs), or sepsis (a life-threatening blood infection). RNS 3 stated on [DATE] when Resident 1 had altered level of consciousness (a change in a person's state of awareness and alertness, where they are not fully conscious or responsive to their surroundings) and low blood pressure of ,d+[DATE] mmHg, it could have been sepsis. RNS 3 stated Resident 1 was transferred to GACH via 911 on [DATE] at 6 a.m. During an interview on [DATE], at 9:35 a.m., with Resident 1's Primary Care Physician (PCP)1, PCP 1 stated on [DATE] he was not informed of Resident 1's temperature of 103.8 F and HR of 130 bpm. PCP 1 stated he could have ordered for Resident 1 to be transferred to a GACH especially when Resident 1 was exhibiting signs of infection. PCP 1 stated on [DATE] at 11:43 p.m., Resident 1 could have had a septic shock (a life-threatening condition that occurs when an infection spreads throughout the body and causes a dangerously low blood pressure) when his temperature increased to 103.8 F and HR 130 bpm. PCP 1 stated Resident 1 should have been transferred to the GACH. During an interview on [DATE], at 1:57 p.m., with RN 3, RN 3 stated, on [DATE] Resident 1 had altered level of consciousness ( ALOC-a change in a person's state of awareness and alertness, where they are not fully conscious or responsive to their surroundings) as Resident 1's eyes were closed, the resident was not responding to tactile stimuli (any form of touch or physical contact perceived by the skin such as a sternal rub [a painful stimulus to the chest that is used to assess a patient's responsiveness ]), and when called by his name. RN 3 stated Resident 1's temperature was checked every 30 minutes to one hour but was not documented. RN 3 stated if it was not documented it was not done. RNS 3 stated he should have called Resident 1's PCP 1 or called 911 when Resident 1 had a COC. During a concurrent interview and record review on [DATE] at 11:13 a.m., with the Director of Nursing (DON), Resident 1's COC, Physician's Orders, Nurse Notes, Medication Administration Record (MAR) for the month of ,d+[DATE] were reviewed. The DON stated the Physician Order dated [DATE] for sepsis prevention indicated to notify MD if any vital signs were abnormal such as temperature less than 96.8 F or greater than 99 F and HR greater than 90 bpm. The DON stated there was no documentation indicating on [DATE] Resident 1's physician was notified when Resident 1 had a temperature of 99.8 F. The DON stated, on [DATE] at 11:43 p.m., when Resident 1 had a temperature of 103.8 F and HR of 130 bpm, licensed staff should have transfer Resident 1 to a GACH for evaluation and treatment and not wait until the next day [DATE] at 6 a.m., (6 hours later). The DON stated there was no care plan to address Resident 1's diagnosis of neuromuscular dysfunction of the bladder. The DON stated it was important to have a plan of care with interventions needed for Resident 1's diagnosis. The DON stated when there was a change of condition for any resident licensed nurses were expected to complete an assessment, notify the physician and resident representative. The DON stated sepsis was a complication of an infection that could be fatal. During a review of Job Description LVN, ([undated]), the Job Description LVN indicated, the LVN is responsible for demonstrating the ability to assign meaning to a resident symptoms and initiating appropriate action and consistently monitoring resident condition, initiating appropriate nursing action, consistently documenting resident care and reports pertinent clinical observations and reactions to the appropriate individual, and documenting nursing interventions and resident responses including physical and psychological response. During a review of the Job description Registered Nurse (RN), ([undated]), the Job Description RN indicated, The RN is responsible for making supervisory decisions, demonstrating the ability to assign meaning to resident symptoms and initiating appropriate action, consistently monitoring resident condition and initiates appropriate nursing intervention, consistently documenting resident care and reports pertinent clinical observations and reactions to the appropriate individual, and documenting nursing interventions, consistently and accurately performs reassessments during each shift and when the resident condition changes, and documenting nursing interventions and resident responses including physical and psychological response. During a review of the facility's policy and procedure (P&P) titled, Guidelines for Notifying Physicians of Clinical Problems, dated ,d+[DATE], the P&P indicated, These guidelines are to help ensure that 1) medical care problems are communicated to the medical staff in a timely, efficient, and effective manner and 2) all significant changes in resident status are assessed and documented in the medical record. During a review of the facility's P&P titled, Change in a Resident's Condition or Status, dated ,d+[DATE], the P&P indicated, The nurse will notify the resident's Attending Physician or physician on call when there has been a(an) specific instruction to notify the Physician of changes in the resident's condition. Cross Reference F580

Based on interview and record review, the facility failed to notify the physician when a resident experienced a change of condition ([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive [ability to think, understand, learn, and remember], behavioral, or functional status) for one of three sampled residents (Resident 1) when Resident 1 had a temperature of 103.8 degrees Fahrenheit ( F-unit of measurement [normal body temperature can range from 97 F to 99 F ]), heart rate (HR) of 130 beats per minute ( bpm normal resting heart rate is between 60 and 100 beats per minute) on [DATE] at 11:43 p.m., and hematuria ( blood in the urine) that started on [DATE]. The facility failed to: 1. Ensure licensed nurses notified Resident 1's physician when Resident 1 had a temperature greater than (>) 99 F, heart rate > 90 beats per minute (bpm), and systolic blood pressure (SBP- pressure exerted when the heart beats and blood is ejected into the arteries [blood vessels that distribute oxygen-rich blood to your entire body] ) less than (<) 100 Millimeters of mercury (mmHg a unit of measurement for pressure) as ordered by Resident 1's physician for sepsis ( a life threatening condition in which the body's reaction to an infection) prevention dated [DATE] The licensed nurses did not notify Resident 1's physician as follows: a. On [DATE] 10:12 pm for Resident 1's temperature 99.8 F b. On [DATE] 11:25 am for Resident 1's HR 96 bpm c. On [DATE] 11:31 pm for Resident 1's HR 91 bpm d. On [DATE] 2:31 pm Resident 1's temperature 99.1 F e. On [DATE] 10:32 pm Resident 1's temperature 99.8 F f. On [DATE] 11:43 pm Resident 1's temperature 103.8 F g. On [DATE] 2:31 p.m., for Resident 1's HR 98 bpm h. On [DATE] 11:43 p.m., for Resident 1's HR 130 bpm This failure resulted in Resident 1 had a blood pressure of ,d+[DATE] mmHg with HR of 112 and had an altered level of consciousness (ALOC a change in a person's state of awareness and alertness, where they are not fully conscious or responsive to their surroundings) on [DATE] at 6 a.m. Resident 1 was transferred to general acute care hospital (GACH) on [DATE] via 911. Resident 1 was admitted to GACH where he was diagnosed with septic shock (life threatening condition when an infection spreads throughout the body and causes a dangerously low blood pressure) and he expired on [DATE], (13 hours after he was admitted to the GACH. On [DATE], at 2:34 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation had cause, or is likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of the Administrator (ADM) and Director of Nursing (DON) due to the facility's failure to follow Resident 1's physician order to notify physician of temperature > 99 F, heart rate > 90 bpm, and SBP <100 mmHg as ordered by Resident 1's physician for sepsis prevention. On [DATE], at 2:30 p.m., the facility submitted an acceptable IJ removal plan ([IJRP]- an intervention to immediately correct the deficient practices). After verification the IJRP was implemented through observation, interview, and record review, the IJ was removed while onsite on [DATE] at 2:30 p.m., in the presence of the ADM, DON, and the Regional Director of Operations (RDO). The IJRP included the following: 1.License Nurse 1 was educated by the DON regarding Change of Condition policy and procedure focusing on immediate notification of the physician as it relates to quality of care. 2. In-service education was commenced by the DON and Quality Staff Registered Nurse (QS RN) to all licensed nurses on [DATE] regarding physician notification of the change of condition (COC) including but not limited to vital signs (measure the basic functions of the body which include temperature, blood pressure, pulse and respiratory [breathing] rate) that are out of range for the sepsis prevention (that is [i.e.] temperature< 96.8 F or >99 F or, HR <60 bpm or >90 bpm, respiratory rate <12 or > 20, systolic blood pressure (SBP- pressure exerted when the heart beats and blood is ejected into the arteries) < 100 mmHg. If base line SBP is < 100 mmHg, plus (+) 5 mmHg than the baseline, Oxygen saturation (O2 Sat a measure of how much oxygen the blood is carrying as a percentage) of < 90% and any change of change of condition. 3. In-service education was commenced by the DON and/or designee on [DATE] regarding initiation, review, and revision of resident-centered care plan of residents with a diagnosis of neuromuscular dysfunction of the bladder (neurogenic bladder-impaired bladder control and difficulty emptying the bladder) with interventions to prevent the resident from developing urinary tract infection (UTI- an infection in the bladder/ urinary tract), /sepsis and other areas that accurately reflects resident's conditions and care. 4.Competency Skills Check for licensed nurses was commenced on [DATE] by DON and QS RN regarding (1) assessing residents' change in conditions (2) identifying symptoms of infection/sepsis and of change of condition, (3) assess, monitor and implement needed interventions based on residents' change in condition (4) recognizing symptoms of urinary tract infection and including elevated temperature, hematuria, abdominal pain, and low back pain, and (5) compliance with recognizing, evaluating and monitoring. 5.The facility checked Situation, Background, Assessment, Recommendation (SBAR a technique that can be used to facilitate prompt and appropriate communication) /COC from [DATE] to [DATE]. All 161 SBAR/COC showed that medical doctor (MD) was notified on a timely manner. 6.In-service education was commenced by the DON and/or designee on [DATE] regarding initiation, review, and revision of resident-centered care plan of residents with a diagnosis of neuromuscular dysfunction of the bladder with interventions to prevent the resident from developing UTI/sepsis and other areas that accurately reflects resident's conditions and care. 7.In-service education was commenced on [DATE] regarding Physician Notification of the COC including but not limited to vital signs that are out of range for the sepsis prevention. As of [DATE] at 10 a.m., 50 out of 50 Registered Nurses (RNs)/Licensed Vocational Nurses (LVN) staff (100%) received the in-service on Physician Notification of the COC including but not limited to vital signs that are out of range for the sepsis prevention. 8.Competency Skills Check regarding COC was commenced on [DATE] by DON and QS RN. As of [DATE] at 10 a.m., Competency Skills Check regarding COC was conducted to 50 out of 50 RNs/LVNs staff (100%). What measures will be put into place or what systemic changes will make to ensure that the deficient practice does not recur? 1.The facility nursing staff will notify the DON or designee at the time of a change of condition. The DON or designee (i.e. Assistant Director of Nursing (ADON) and RN Supervisor) will ensure that MD/Nurse Practitioner (NP- a nurse who has advanced clinical education and training) and Physician Assistant (PA- a licensed medical professional who works with physicians to provide patient care) notification has been completed ( i.e. MD notified of the COC, MD responded, and carry out physician order, if with physician order) or the DON or designee will call the MD/NP/PA on call personally. In the event the resident's MD/NP/PA on record may not be reached at the time of the residents COC, the RN Supervisor will obtain orders from a doctor on the medical panel (i.e. other medical doctors) obtain the order to send the resident to the acute care hospital if needed in real time as to prevent any delay in resident care. 2.COC of the previous day will be reviewed by the clinical team (such as but not limited to DON, ADON, Director of Staff Development (DSD), Infection Preventionist (IP) on the following day in the Clinical Meeting to ensure that all change of conditions have been checked for compliance such as but not limited to (1) assessing any residents' change in condition (1) symptoms of infection/sepsis and of change of condition were identified, (2) appropriate assessment, monitoring and needed interventions were implemented (3) symptoms of UTI including elevated temperature, hematuria, abdominal pain, and low back pain were identified and (4) compliance with recognizing, evaluating, monitoring. 3.The License Nurse will follow the process of MD notification: a. The attending physician will be notified promptly (i.e. within 30 minutes) for any change of conditions including but not limited to out-of-range vital signs, cardiovascular (heart) changes, neurological changes (brain/mental), genitourinary (bladder), etc. b. If no response from the attending physician within 30 minutes, the Medical Director will be notified of any change of conditions including but not limited to out-of-range vital signs, cardiovascular changes, neurological changes, genitourinary, etc. c. If no response from the Medical Director and the resident is manifesting a significant change of condition (such as decrease level of consciousness, unresponsiveness, critical labs level, out of range vital sign, etc. [used at the end of a list to indicate that further, similar items are included.]) registered nurse will refer Physician Orders for Life-Sustaining Treatment (POLST form is a written medical order that specifies a patient's end-of-life care preferences) if to be sent out to emergency room (ER) for further evaluation. Then, attending physician will be notified thereafter. 4. In-service education was commenced to Licensed Nurses by the DON and/or designee on [DATE] regarding timely Physician Notification of the COC including but not limited to vital signs that are out of range for the sepsis prevention and any change of change of condition. 5.In-service education was commenced by the DSD to CNAs on [DATE] regarding identification and reporting to License Nurse in-charge and/or the RN Supervisor in a timely manner of any change of condition. 6.The DSD or designee (i.e. QS RN, RN Supervisor) will do random verbal quiz to CNAs on different shifts regarding identification and reporting to License Nurse in-charge and/or the RN Supervisor in a timely manner of any change of condition. CNAs will be immediately re-in serviced by the DSD for those CNAs needing further education. DSD will present the findings and progress status to the Monthly Quality Assessment Assurance (QAA- responsible for identifying and responding to quality deficiencies that are identified in the facility) meeting for recommendations/suggestions. a. Four CNAs weekly for four weeks then; b.Three CNAs weekly for two weeks then; c.Two CNAs a month for two months. 7.In-service education was commenced by the DON and/or designee on [DATE] regarding initiation, review, and revision of care plan of residents with a diagnosis of neuromuscular dysfunction of the bladder with interventions to prevent the resident from developing urinary tract infection (UTI) and sepsis and other care plan that accurately reflects the residents' conditions and care. 8.Competency Skills Check for Licensed Nurses (Registered Nurses and Licensed Nurses [LN]) on COC by DON, QS RN and was commenced on [DATE]. 9.The DON, or designee will do random verbal quiz to licensed nurses (LN) on different shifts re regarding (1) Verbalize/name change of condition such as symptoms of infections/sepsis, (2) name the process of timely Physician Notification of the Change of Condition (COC) including but not limited to out-of-range vital signs which is an early sign of infection and change of condition, (3) name symptoms of UTI and including elevated temperature, hematuria, abdominal pain, and low back pain, and (4) able to name/recognize, evaluate, monitor, and assess any residents' change of condition: a. Four LNs weekly for four weeks then; b. Three LNs weekly for two weeks then; c. Two LNs a month for two months. 10.The DON or designee (i.e. ADON, QS RN) will conduct random chart audits on SBAR/Change of Conditions. The DON or designee (i.e. ADON, QS RN) will further investigate for findings (such as but not limited to MD was not notified on a timely manner, or other missing information in the SBAR). An in-service education will immediately be provided to the RN/LN involved. Findings and progress status will be presented in the Monthly QAA Meeting for suggestions/recommendations. d. Three residents weekly for four weeks then; e. Two residents weekly for two weeks then; f. Two residents a month for two months. 11.Licensed Nurse staff who are not present during the In-service education (such as those who are on leave, per-diem, or part-time status), in-service education will be provided on day-1 return to work prior to start of shift. 12.New hires (licensed nurses) and Registries (provides nursing personnel to facility in need of temporary staff) will be educated on change of condition and physician notification regulations, as well as facility policy and procedure, accordingly in orientation by the DON and/or DSD 13.The DON implemented a Quality Assurance Performance Improvement (QAPI data-driven approach to improving the quality of care and services in nursing homes) Performance Improvement Project (PIP) with a focus on physician notification of significant changes. 14.The PIP resulted in implementation of daily ADON/designee audits of the Clinical Alerts Listing audit to monitor timely notification of MD for residents with vital signs that are out-of-range and other change of conditions. 15.The QS RN/consultant nurse will visit the facility at least once a week to provide general oversight and monitoring of the PIP. How the facility plans to monitor performance to make sure that solutions are sustained. 1.Under the supervision of the Administrator, DON or Designee will be responsible and accountable to submit audit findings utilized the Quality Assurance (QA) monitoring/audit tool to QAA committee member monthly for 3 months until 100% compliance. 2.The Administrator and DON shall be responsible for the implementation, monitoring, and evaluation of this Plan of Correction. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure (a serious condition that occurs when your lungs cannot get enough oxygen into your blood or remove carbon dioxide), bronchopneumonia (an inflammation of the lungs that affects the small airways and the surrounding lung tissue, seizures (a sudden uncontrolled change in behavior or body movement caused by abnormal electrical activity in the brain), hemiplegia (paralysis on the same side of the body) and hemiparesis (total paralysis of the arm, leg, and trunk on the same side of the body), encounter for tracheostomy (a surgical procedure that creates an opening in the neck into the windpipe, and neuromuscular dysfunction of bladder. During a review of Resident 1's History and Physical (H&P), dated [DATE], indicated Resident 1 does not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated [DATE], indicated, Resident 1 had severe impairment in cognitive skills for daily decision making. Resident 1 was dependent with bed mobility, chair/ bed to chair transfer, and tub/ shower transfer. During a review of Resident 1's Physician Order Summary report dated [DATE], the Physician Order Summary indicated to notify Medical Doctor (MD) if Resident 1 have any of the following symptoms: 1. Temperature less than 96.8 F or greater than 99 F. 2. Heart rate greater than 90 beats per minute 3. Respiratory (breathing) rate greater than 20 4. Acute change in mental status 5. O2 sat. less than 90 percent (%) 6. Systolic blood pressure (SBP- pressure exerted when the heart beats and blood is ejected into the arteries [blood vessels that distribute oxygen-rich blood to your entire body]), if baseline less than 100 millimeters of mercury (mmHg a unit of measurement for pressure), more than 5 mmHg lower than the baseline, every shift for sepsis prevention. During a review of Resident 1's SBAR and Initial Change of Condition/ Alert Charting and Skilled Documentation, dated [DATE] timed at 6:19 a.m., the SBAR/ initial COC indicated, Resident 1 had moderate amount of hematuria (blood in the urine) in Resident 1's incontinent pad (diaper) and elevated temperature (temperature not indicated). During a concurrent interview and record review on [DATE], at 4:24 p.m., with Registered Nurse Supervisor (RNS 1), Resident 1's Weight and Vital Sign Summary and Situation, Background, Assessment, Recommendation (SBAR a communication tool used by healthcare workers when there is change of condition among the residents) / Change of Condition (COC) dated [DATE] and [DATE] were reviewed. The Weight and Vital Sign Summary indicated, Resident 1 had the following temperature and heart rate readings: a. On [DATE] 10:12 pm for Resident 1's temperature 99.8 F b. On [DATE] 11:25 am for Resident 1's HR 96 bpm c. On [DATE] 11:31 pm for Resident 1's HR 91 bpm d. On [DATE] 2:31 pm Resident 1's temperature 99.1 F e. On [DATE] 10:32 pm Resident 1's temperature 99.8 F f. On [DATE] 11:43 pm Resident 1's temperature 103.8 F g. On [DATE] 2:31 p.m., for Resident 1's HR 98 bpm h. On [DATE] 11:43 p.m., for Resident 1's HR 130 bpm RNS 1 stated Resident 1's physician should be notified of Resident 1's vital signs as ordered for sepsis prevention. RNS 1 stated the physician orders should have been followed so Resident 1's physician could have given physician orders to address Resident 1's COC. RNS 1 stated physician notification should be documented to Resident 1's medical record to ensure licensed nurses would know what treatment was ordered for Resident 1. During an interview on [DATE], at 4:40 p.m., with Licensed Vocational Nurse (LVN 1), LVN 1 stated Resident 1 physician was not notified of Resident 1's temperature of 103.8 F and HR 130 bpm on [DATE] at 11:43 p.m. LVN 1 stated nonpharmacological (healthcare strategies that do not involve the use of medications) interventions including cooling measures such as removing blankets, put a fan on, and placing cold towels on Resident 1's forehead and under the arms were initiated. LVN 1 stated Resident 1's physician was not called because Resident 1 had a COC on [DATE] at 10:12 p.m. when Resident 1 had temperature of 99.8 F. LVN 1 stated she failed to inform Resident 1's physician when the resident had a temperature of 103.8 F. LVN 1 stated she did not think it was an infection as Resident 1's temperature went down to 99 F. LVN 1 stated she did not recall the exact time Resident 1's temperature was taken and she did not document it. LVN 1 stated she did not notify Resident 1's Physician of Resident 1's HR of 130 bpm on [DATE] at 11:43 p.m., as Resident 1's heart rate came down. LVN 1 stated Resident 1's physician should have been notified as interventions (cooling measures) were not working. LVN 1 stated no other temperatures or heart rates were documented after it was taken and documented on [DATE] at 11:43 p.m. LVN 1 stated the next vital signs was taken on [DATE] at 6 a.m., (after 6 hours). LVN 1 stated Resident 1 was sent to the GACH on [DATE]. During an interview on [DATE], at 5:10 p.m., with RNS 3, RNS 3 stated on [DATE] at 11:43 p.m., Resident 1 had a temperature of 103.8 F, but Resident 1's physician was not notified. RNS 3 stated looking back Resident 1's physician should have been notified as Resident 1 had previous elevated temperature of 99.8 F on [DATE]. RNS 3 stated Resident 1 could have had a urinary tract infection (UTI- an infection in the bladder/ urinary tract), pneumonia (an infection/ inflammation in the lungs), or sepsis (a life-threatening blood infection). RNS 3 stated on [DATE] when Resident 1 had an altered level of consciousness (a change in a person's state of awareness and alertness, where they are not fully conscious or responsive to their surroundings) and low blood pressure of ,d+[DATE] mmHg, it could have been sepsis. RNS 3 stated Resident 1 was transferred to GACH via 911 on [DATE] at 6 a.m. During an interview on [DATE], at 9:35 a.m., with Resident 1's Primary Care Physician (PCP)1, PCP 1 stated on [DATE] he was not informed of Resident 1's temperature of 103.8 F and HR of 130 bpm. PCP 1 stated he could have ordered for Resident 1 to be transferred to a GACH especially when Resident 1 was exhibiting signs of infection. PCP 1 stated on [DATE] at 11:43 p.m., Resident 1 could have had a septic shock (a life-threatening condition that occurs when an infection spreads throughout the body and causes a dangerously low blood pressure) when his temperature increased to 103.8 F and HR 130 bpm. PCP 1 stated Resident 1 should have been transferred to the GACH. During an interview on [DATE], at 1:57 p.m., with RN 3, RN 3 stated, on [DATE] Resident 1 had altered level of consciousness as Resident 1's eyes were closed, the resident was not responding to tactile stimuli (any form of touch or physical contact perceived by the skin such as a sternal rub [a painful stimulus to the chest that is used to assess a patient's responsiveness ]), and when called by his name. RN 3 stated Resident 1's temperature was checked every 30 minutes to one hour but was not documented. RN 3 stated if it was not documented it was not done. RNS 3 stated he should have called Resident 1's PCP 1 or called 911 when Resident 1 had a COC. During a concurrent interview and record review on [DATE] at 11:13 a.m., with the Director of Nursing (DON), Resident 1's COC, Physician's Orders, Nurse Notes, Medication Administration Record (MAR) for the month of ,d+[DATE] were reviewed. The DON stated the Physician Order dated [DATE] for sepsis prevention indicated to notify MD if any vital signs were abnormal such as temperature < 96.8 F or > 99 F and HR > 90 bpm. The DON stated there was no documentation indicating on [DATE], Resident 1's physician was notified when Resident 1 had a temperature of 99.8 F. The DON stated, on [DATE] at 11:43 p.m., when Resident 1 had a temperature of 103.8 F and HR of 130 bpm, licensed staff should have called PCP 1. The DON stated when there was a change of condition for any resident, licensed nurses were expected to complete an assessment, notify the physician and resident representative. The DON stated sepsis was a complication of an infection that could be fatal. During a review of Job Description LVN, ([undated]), the Job Description LVN indicated, LVN is responsible for demonstrating the ability to assign meaning to a resident symptoms and initiating appropriate action and consistently monitoring resident condition, initiating appropriate nursing action, consistently documenting resident care and reports pertinent clinical observations and reactions to the appropriate individual, and documenting nursing interventions and resident responses including physical and psychological response. During a review of the Job description Registered Nurse (RN), ([undated]), the Job Description RN indicated, The RN is responsible for making supervisory decisions, demonstrating the ability to assign meaning to resident symptoms and initiating appropriate action, consistently monitoring resident condition and initiates appropriate nursing intervention, consistently documenting resident care and reports pertinent clinical observations and reactions to the appropriate individual, and documenting nursing interventions, consistently and accurately performs reassessments during each shift and when the resident condition changes, and documenting nursing interventions and resident responses including physical and psychological response. During a review of the facility's policy and procedure (P&P) titled, Guidelines for Notifying Physicians of Clinical Problems, dated ,d+[DATE], the P&P indicated, These guidelines are to help ensure that 1) medical care problems are communicated to the medical staff in a timely, efficient, and effective manner and 2) all significant changes in resident status are assessed and documented in the medical record. During a review of the facility's P&P titled, Change in a Resident's Condition or Status, dated ,d+[DATE], the P&P indicated, The nurse will notify the resident's Attending Physician or physician on call when there has been a(an) specific instruction to notify the Physician of changes in the resident's condition. Cross Reference F684

Based on observation, interview, and record review, the facility failed to ensure the resident was free of physical and verbal abuse for one of seven sampled residents (Resident 1). The facility failed to: 1. Ensure Resident 1 was not verbally and physically abused by Resident 7. 2. Adhere to its policy and procedure titled, Abuse Prevention Program, which indicated the residents have the right to be free from abuse including verbal and physical abuse. Resident 7 verbally and physically abused Resident 1 by telling Resident 1 to shut up and placing a pillow over Resident 1 ' s face. This deficient practice resulted in Resident 1 being verbally and physically abused, feeling violated and fearful for her life. Findings: During a review of Resident 1 ' s Admission Record (face sheet), the face sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis including chronic obstructive pulmonary disease (a disease that block the airflow and make it difficult to breathe) and a history of cerebral infarction (lack of adequate blood supply to the brain cells, depriving the oxygen supply and nutrients, which can cause parts of the brain to die). During a review of Resident 1 ' s Minimum Data Set (MDS), a standardized assessment and care-screening tool (an assessment of a resident's functional capabilities and helps the nursing staff to identify health problems), dated 9/16/2022, the MDS indicated Resident 1 ' s cognition (thought process) was intact, and she was able to make independent decisions that were reasonable. The MDS indicated Resident 1 was totally dependent on staff with a one-person physical assistance to complete activities of daily living (ADLs) tasks such as repositioning, mobility, transfer, bathing, and hygiene, and is incontinent (inability to control) of both bowel and bladder functions. During a telephone interview on 12/20/2022 at 7:06 a.m., the Resident 1 ' s responsible party (RP 1), RP 1 stated she came to visit Resident 1 at the facility on 12/19/2022 after 11:30 a.m. RP 1 stated she observed Resident 1 ' s room door was closed, and she could hear Resident 1 calling the nurse from outside the door. RP 1 stated when she opened the door, she saw Resident 1 upset and her pillow was on the floor. RP 1 stated Resident 1 told her there was a guy who shoved the pillow on her face pressing her nose as if to choke (suffocating) her and told her to shut up and then left the room. RP 1 stated Resident 1 was in distress and trembling in fear as she could see how much this affected her. RP 1 stated, I was upset as to how someone can disrespect and lay his hands on an elderly without mercy. RP 1 stated she reported the incident to the nursing staff (charge nurses) immediately on 12/19/2022. During an interview on 12/20/2022 at 12:20 p.m. with Resident 1, Resident 1 stated, I was calling a nurse in a loud voice when a guy with white hair, long beard, and wearing a green dress (gown) came inside my room, told me to shut up, and picked up my pillow and pressed the pillow hard on my face. Resident 1 stated she was scared for her life and felt violated of what the guy did to her. Resident 1 stated she saw the same man standing outside her door the day before (12/19/2022) and remembered he closed the door to her room. During a review of Resident 7 ' s Admission Record (face sheet), the face sheet indicated Resident 7 was admitted to the facility on [DATE] with a diagnosis including aftercare of ileostomy (a surgical procedure creating an opening through the stomach to empty intestinal wastes to an external pouch [bag; for drainage] placed over the opening) and diabetes mellitus (elevated sugar levels in the blood and urine). During a review of Resident 7 ' s MDS dated [DATE], the MDS indicated Resident 7 was able to make independent decisions that were consistent and reasonable. According to the MDS, Resident 7 required extensive assistance of a one-person physical assist to complete ADLs tasks such as locomotion (movement) on unit and off unit, bathing, and toilet use. During a review of Resident 7 ' s Physical Therapy Evaluation and Notes, dated 12/13/2022, the Physical Therapy Treatment Notes indicated Resident 7 was able to ambulate at 175 feet with no assistive device. On 12/22/2022 at 11:07 a.m., during a review of the facility ' s video camera surveillance (a system of monitoring activity in an area or building using a television system in real time), with the administrator (ADM), the video surveillance showed on 12/19/2022 between the hours of 7:50 a.m. to 9:05 a.m., Resident 7, who has white hair and a long beard, was wearing a green gown walking steadily, with no assistive device, out of his room. Resident 7 was standing by the nursing station and later sat down by the reception sitting area. At 11:02 a.m. on the same day, the video surveillance showed Resident 7 walking in the hallway, without any assistive device, towards Resident 1 ' s door and appeared to speak to someone inside the room of Resident 1. Resident 7 then walked back into his room. At 11:07 a.m., of the same day, the surveillance video showed Resident 7 walking out of his room while wearing a pair of gloves, went towards Resident 1 ' s room and closed the door and then went back to his room. At 11:17 a.m., on the same day, the video surveillance showed Resident 7 walking out of his room with gloves on both hands, holding a small bag, and disposed the gloves and bag, inside the housekeeper ' s bin which was across the hall, and then Resident 7 walked back into his room. According to the video surveillance camera, the door of Resident 1 remained closed on the same day (12/19/2022), from 11:07 a.m. to 11:27 a.m., until a woman (RP 1) appeared walking towards the room of Resident 1, knocked on the door and subsequently opened the resident ' s door. During a telephone interview on 12/22/2022 at 1:43 p.m. with Resident 7, Resident 7 stated he stayed at the facility for a month, and he recovered well after surgery (ileostomy). Resident 7 stated he was discharged home on 12/20/2022. Resident 7 stated during his stay at the facility, he had no problems with his activities of daily living and was able to move in and out of bed, walk at the facility and use the bathroom without help or any assistive device. Resident 7 stated during his stay, he would always hear Resident 1 in the next room, hollering for a nurse anytime of the day or night and it always annoyed him. Resident 7 stated when he used the bathroom, since he shared a bathroom with both Residents 1 and 2 (females) he would shout out Shut up! at Resident 1 from inside of the bathroom. Resident 7 stated the bathroom has locks from inside of both doors (his room and the room of Residents 1 and 2). Resident 7 denied closing the door of Resident 1 on 12/19/2022 at 11:07 a.m. (which Resident 7 was observed closing Resident 1 ' s door on the surveillance camera on 12/19/2022 at 11:07 a.m.). During an interview on 12/23/2022 at 10:06 a.m. with Certified Nursing Assistant 4 (CNA 4), CNA 4 stated she has seen Resident 7 leave his room and stand by Resident 1 ' s door and shout at Resident 1 to shut up. CNA 4 stated she had also seen Resident 7 opened the bathroom door and shouted at Resident 1, telling her, Shut up! CNA 4 could not remember the exact dates these incidents occurred, but she stated when it happened, she informed the licensed nurses immediately. CNA 4 stated she was concerned because Resident 7 was disrespectful to not only Resident 1 but also her roommate (Resident 2), by opening the bathroom door shouting at Resident 1. CNA 4 stated, Anything could happen to Residents 1 and 2, such as other form of abuse, even death, because Residents 1 and 2 cannot defend themselves. During a concurrent observation and interview while looking at the shared bathroom on 12/23/2022 at 10:38 a.m. with the Licensed Vocational Nurse (LVN 1) confirmed the shared bathroom doors of Resident 1 and 2 both females and Resident 7 a male, are easily accessible through both rooms. LVN 1 confirmed Resident 7 was ambulatory, used the bathroom frequently which gave Resident 7 access to both Residents 1 and 2 ' s room through the shared bathroom. LVN 1 stated, This was a safety issue, and it was the facility ' s duty to protect the residents. During an interview on 12/23/2022 at 10:53 a.m. with the Registered Nurse Supervisor (RNS), the RNS confirmed the accessibility of the shared bathroom doors of Resident 1, Resident 2, and Resident 7. The RNS stated no one knows of Resident 7 ' s intentions nor his mindset and Resident 1 and Resident 2 could have been really harmed. The RNS stated it was the duty of the facility and its staff to protect the residents because most of them are vulnerable. During an interview on 1/3/2023 at 10:33 a.m. with the ADM, the ADM confirmed the bathroom was shared with the residents being male and female. The ADM remained silent when asked how vulnerable residents such as Residents 1 and 2 could protect themselves from a male resident who can access their room at any time. The ADM stated Resident 7 was in the facility for a month and the Social Services Director (SSD) had done an investigation and interviewed Residents 1 and Resident 7 when the incident was reported by RP 1. The ADM stated Resident 7 was moved to a different room after it was reported, because we agree now Resident 1 description matched Resident 7 ' s description of the perpetrator. During a review of the facility ' s policy and procedure (P/P), revised in 1/2022 and titled, Abuse Prevention Program, the P/P indicated the facility ' s residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation and this includes, but not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse and physical or chemical restraint not required to treat the resident ' s symptoms.

Based on interview and record review, the facility failed to ensure a resident received the necessary care and treatment, which included ongoing assessment and follow a physician's orders [REDACTED]. Resident 1 experienced shortness of breath, cough, and an elevated temperature of 100.4 degrees Fahrenheit ((F) normal reference range (NRR) 98.7 F to 99 F), and an oxygen saturation (SAT) ((O2 sat) measure of how much oxygen the blood is carrying (NRR 94-100 percent (%) on room air)) that dropped to 93 % from 96 % that morning. This deficient practice resulted in a delay in diagnosis, care, and treatment for [REDACTED]. Once transferred to the GACH, Resident 1 required an admission into the intensive care unit ((ICU) higher level of care) and placed on ventilator (breathing machine) after being diagnosed with [REDACTED]. Findings: A review of Resident 1's Face Sheet (Admission Record) indicated Resident 1 was admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a standardized care screening and assessment tool, dated 1/3/2020 indicated Resident 1 was usually able to make himself understood and understand others. The MDS indicated Resident 1 was totally dependent in care with a one-person physical assist for bed mobility, eating, and personal hygiene. A review of Resident 1's physician's orders [REDACTED]. A review of Resident 1's COC form, dated 3/25/20 and timed at 12:15 p.m., indicated Resident 1 was observed self-gagging with towel, in an attempt to get phlegm (thick [MEDICATION NAME] substance secreted by the mucous membranes of the respiratory passages) out of his mouth. A review of Resident 1's Nurse's Progress Note, dated 3/25/20 and timed at 12:25 p.m. indicated Licensed Vocational Nurse 1 (LVN 1) noted Resident 1 was gagging with a towel. The note indicated LVN 1 asked Resident 1 what he was doing, and Resident 1 stated, I am getting the phlegm out of my throat. LVN 1 explained the risks to using a towel to get the phlegm out his throat and Resident 1 responded he understood. Resident 1's physician (Physician 1) was notified and ordered for Resident 1 to receive a breathing treatment ([MEDICATION NAME] (used to treat air flow blockage)) three times a day and whenever necessary (PRN). The note indicated Resident 1's responsible party was notified. A review of Resident 1's COC form, dated 3/30/2020 and timed at 9:18 a.m. indicated on 3/30/2020 at 8:30 a.m., Resident 1's respiration rate was 18 breaths per minute ((bpm) NRR 12-20) and had a 96% O2 saturation (SAT) level. The COC indicated Resident 1's physician (Physician 1) was notified on 3/30/20 at 8:40 a.m. with no new orders given. A review of Resident 1's Nurse's Progress Note, dated 3/30/2020 and timed at 8:40 a.m., indicated Resident 1 was awake and alert, and vital signs were assessed as follow: temperature of 100.4 degrees F, blood pressure 129/74 (NRR 120/80), pulse 71 (NRR 60-100 beats per minute), respirations 18, and a O2 SAT of 96%. The note indicated Physician 1 was notified and the resident would continually to be monitored, follow-up with Physician 1, and notify the resident 's Responsible Party. A review of Physician 1's follow-up text message to the facility's staff, dated 3/30/2020 and timed at 11:12 a.m. indicated Physician 1 responded and indicated Send the resident to (name of GACH) ER, please. A review of Resident 1's nurse's progress notes indicated there was no documented evidence any fever reducing measures, such as medication or cooling measures (ice packs, cool towel) were provided to Resident 1. A review of Resident 1's physician's orders [REDACTED]. differentials (measure of the red blood cells, white blood cells, and platelets in the blood), Covid test (the resident refused) and an urinalysis with culture and sensitivity ((C/S) test to determine if bacteria was present in the urine and which antibiotic medication the bacteria will responds to ) and a STAT chest x-ray to rule out pneumonia. A review of Resident 1's physician's orders [REDACTED]. A review of Resident 1's x-ray results, dated 3/30/2020 indicated Resident 1 had patchy infiltrates (an abnormal substance that accumulates gradually within the cells, body tissues, or within the lung) on the right mid lung consistent with pneumonia (lung infection). A review of Resident 1's late entry (L/E) Progress Note, dated 3/30/2020 and timed at 10:20 p.m. indicated Resident 1 was in bed, alert and verbally responsive. The note indicated Resident 1 had an elevated temperature of 100.4 F with congestion (abnormal or excessive accumulation of a body fluid making it difficult to breathe), cough, and shortness of breath. The note indicated Physician 1 was made aware and an order was received to transfer Resident 1 to a GACH for further evaluation. Resident 1 was picked up by ambulance via gurney. Resident 1 was picked up by ambulance via gurney. Resident 1 remain alert and verbally responsive, condition stable. A further review of Resident 1's Progress notes, for 3/30/2020 indicated there was no documented evidence any fever reducing measures were provided to Resident 1 for the elevated temperature that was identified on 3/30/20 at 8:40 a.m. (over 13 hours prior to the resident transferring to the GACH and an ongoing assessment of Resident 1's lung sounds and oxygenation status by LVN 1. A review of Resident 1's vital signs recording for 3/30/2020 indicated Resident 1's oxygen SAT dropped to 93% at 7:15 p.m. and the last oxygen SAT was last assessed that morning at 8:42 a.m., measuring at 96 %. A review of Resident 1's physician's orders [REDACTED]. A review of Resident 1's GACH emergency department (ED) note, dated 3/30/2020 and timed at 9:35 p.m. indicated Resident 1 arrived to the ED at 9:16 p.m. with complaints of fever, shortness of breath with congestion and coughing. Resident 1's temperature was taken and was 100.1 degrees F. The ED note indicated Resident 1 complained of shortness of breath for three days, had a cough with white sputum (thick mucus coughed up from the lung), a runny nose, and a mild sore throat. A review of Resident 1's GACH's history of present illness, dated 3/30/2020 without a time indicated Resident 1 was admitted to the GACH with a present illness of shortness of breath for three (3) days with a fever developing that day of an onset of 12 hours prior to admission to the GACH, a productive cough, sore throat and congestion (an abnormal or excessive accumulation of a body fluid) for three days. The GACH Plan was to rule-out [MEDICAL CONDITION]. A review of Resident 1's GACH discharge summary, dated 4/10/2020 indicated Resident 1 initially presented to the GACH with symptoms of fever and cough with an infection and his condition slowly worsened even though the resident was provided with a full course of treatment. The discharge summary indicated Resident 1 was intubated (medical procedure involving the insertion of a tube into the airway for breathing) due to an acute [MEDICAL CONDITION]. Resident 1 was admitted into ICU and continued to worsen and was placed on a ventilator (machine that helps a person to breathe who is physically unable to breathe on their own). The GACH discharge summary indicated Resident 1 was placed on a DNR status (do not resuscitate (provide life-saving measures)) taken off the ventilator and passed away. On 6/16/2020 at 1:24 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 had an elevated temperature of 100.4 degrees F on 3/30/2020 at 8:30 a.m. LVN 1 stated she notified Physician 1 via text message LVN 1 stated she received an order to transfer Resident 1 to a GACH on 3/30/20 at 11:12 a.m. LVN 1 stated she did not document any cooling measures or administer any medications to lower Resident 1's temperature or recheck the resident's temperature. On 6/16/2020 at 3 p.m., during a telephone interview, LVN 2 stated she did not document any cooling measures or offered Resident 1 medication for pain or to lower Resident 1's temperature. LVN 2 stated she received an order to transfer Resident 1 on 3/30/2020 at 9 p.m. On 6/17/2020 at 11 a.m., during a telephone interview, Registered Nurse 1 (RN 1) stated, after reviewing Resident 1's clinical record, there was no documentation Resident 1 was provided cooling measures for the elevated temperature. RN 1 stated he was not aware of the delay with the transfer of Resident 1 to the GACH. On 6/18/2020 at 1:04 p.m., during an interview, the Director of Nursing (DON) stated she was in contact with Physician 1 via text message. The DON stated the reason she delayed Resident 1's transfer to the GACH was because Resident 1's temperature had gone down without the use of medications. The DON stated LVN 1 should have implemented cooling measures and documented what was done for Resident 1. A review of the facility's policy and procedure, revised 2/2014 and titled, Telephone orders indicated verbal orders may be accepted from each resident's Attending Physician and transcribed.

Based on interview and record review, the facility failed to ensure residents were free of unnecessary drugs due to inadequate monitoring of a resident's laboratory levels as prescribed by the physician for one of three sampled residents (Resident 1). Resident 1, who had a left toe osteo[DIAGNOSES REDACTED] (bone infection), was discharged from a general acute care hospital (GACH) on 4/1/19 with an order to receive an intravenous ((IV) into the vein) antibiotic ((ABX) used to treat infections) for two weeks and check the antibiotics lab levels every other day was not implemented. This deficient practices resulted in Resident 1 being transfer to the GACH for low blood pressure and had the potential for Resident 1 to not receive the therapeutic dose (initial dose of 15 milligrams (mg)/kilograms (kg) of body weight) prescribed to treat an infection and placed Resident 1 in a nephrotoxicity (body exposure to an antibiotic or toxin causing damage to the kidneys (two bean-shaped organs that help the body pass waste as urine)) for not checking the antibiotic lab levels. Findings: A review of Resident 1's GACH discharge order, dated 4/1/19 and timed at 1:49 p.m. indicated to discharge Resident 1 to the skilled nursing facility (SNF) and administer 1-gram ((gm) units of measurement) IV [MEDICATION NAME] (antibiotic) with [MEDICAL TREATMENT] (process of removing excess water, solutes, and toxins from the blood) and to check [MEDICATION NAME] levels every other day for two weeks. A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1 was admitted to the SNF on 4/1/19. Resident 1's [DIAGNOSES REDACTED].(cutting off a limb) of right great toe. A review of Resident 1's Minimum Data Set (MDS), an assessment and care screening tool, dated 4/8/19 indicated Resident 1 had no cognitive impairment (thought process) for daily decision making, was able to understand and make herself understood by others. The MDS indicated Resident 1 required extensive assistance of a one-person physical assist for toilet use, personal hygiene, grooming, feeding, bathing, and transferring. The MDS indicated Resident 1 was always incontinent (lack of voluntary control over urination or defecation) of bowel/bladder, was at risk for pressure ulcer to develop. The MDS indicated pressure reducing device for bed was provided as treatment. A review of the physician order [REDACTED]. A review of Resident 1's laboratory record did not indicate lab levels for [MEDICATION NAME] were done as prescribed by the physician. A review of the revised 9/12/19 DailyMed National Library of Medicine indicated systemic [MEDICATION NAME] exposure may result in acute kidney injury (AKI). Monitor renal function in all patients, especially patients with underlying renal impairment, patients with co-morbidities that predispose to renal impairment, and patients receiving concomitant therapy with a drug known to be nephrotoxic. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=f604d399-fded-4f4f-8efe-af558ed07b9d A review of Resident 1's [MEDICAL TREATMENT] record titled, [MEDICATION NAME] Utilization April 2019, indicated Resident 1 received six doses of [MEDICATION NAME] on the following days: 4/2/19, 4/4/19, 4/6/19, 4/9/19, 4/11/19 and 4/13/19 at the [MEDICAL TREATMENT] center. A review of Resident 1 GACH Emergency Department (ED) admission notes, dated 4/17/19 indicated Resident 1 was admitted with low blood pressure. The report indicated Resident 1's range of systolic (top number) blood pressure (SBP) during the first 24 hours of hospitalization were 63-95 and diastolic (bottom number) blood pressure (DBP) of 37-64 (Normal Reference Range (NRR) SBP 139-110 and DBP 80-70). The notes indicated Resident 1 was schedule to have a paracentesis (perforation of a cavity of the body with a hollow needle to remove fluid or gas) on 4/17/19 but was not done due to the resident's low blood pressure. On 2/28/2020 at 3 p.m., during an interview and review of Resident 1's complete clinical record with the Assistant Director of Nurses (ADON) and the Director of Medical Records (DMR), the ADON stated Resident 1's [MEDICATION NAME] lab levels where drawn at the [MEDICAL TREATMENT] center. The DMR stated there was no [MEDICATION NAME] levels found in Resident 1's clinical record. The ADON stated all new admission orders [REDACTED]. On 2/28/2020 at 6:47 p.m., during an interview and review of Resident 1's care plans, laboratory results, IDT's and physician orders, in the presence of the Administrator (ADM), Director of Staff Development (DSD), the ADON stated the [MEDICAL TREATMENT] center was not notified Resident 1 had orders for [MEDICATION NAME] levels to be drawn. The ADM stated the facility's staff was responsible to ensure all admission orders [REDACTED]. The ADM stated she (ADM) felt bad Resident 1 did not receive the care she needed to prevent ulcer from worsening and not having [MEDICATION NAME] levels check. On 3/3/2020 at 11:43 a.m., during an interview, the [MEDICAL TREATMENT] facility's administrator (DFA) stated the facility did not inform the [MEDICAL TREATMENT] Center of the physician's laboratory orders for [MEDICATION NAME]. The DFA stated the center does not draw levels for [MEDICATION NAME] per its company's policy. The DFA stated Resident 1 did receive the six doses of [MEDICATION NAME] but no labs were drawn. A review of the facility's policy and procedures titled, Admission Assessment and Follow-up: Role of the Nurse, revised 9/2012 indicated the purpose of the policy was to guide the facility staff in the gathering of the resident's information for managing the residents' care. The policy indicated the staff was to conduct an admission assessment, list all active diagnoses, reconcile the list of all medications from the medication history and admitting orders, contact the attending physician to obtain orders and contact outside services the resident will need.

Based on observation, interview and record review, the facility failed to develop and implement a baseline person-centered care plan for two of three sampled residents (Residents 1 and 2). Resident 1 was admitted to the facility with perianal (area around the anus) redness with maceration (softening and breaking down of skin from moisture exposure) on left heel ulcer 4 x 4 centimeters ((cm) unit of measurement), right big toe amputated (action of surgically removing a body part), right 2nd toe amputated with open wound 2 x 0.5 x 0.7 cm, right 4th digit toe amputated with open wound 4 x 2 x 1 cm. Resident 2 was admitted to the facility with diabetic ulcers (open sore or wound) on the left and right 5th toes, left anterior 2nd toe, left great toe, left heel, left lower abdomen, and right 5th toe and no groin area redness or ulcers. This deficient practice of not developing a baseline person-centered care plan that would identified the care Resident 1 needed, resulted in Resident 1 not receiving the care and services in a timely manner (within 48 hours following admission per policy and procedures) resulting in the worsening of the initial perianal redness and progressing to a right ischium (curved bone forming the base of the pelvis) Stage III (full thickness skin loss involving damage or necrosis (death skin) of subcutaneous tissue (innermost layer of the skin)) and resulted in Resident 2 to develop redness on her bilateral groin area and had potential for Resident 2's wound to worsen for not having a base-line care plan indicating the care Resident 2 would need to prevent decline of the wounds. Findings: a. A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. (cutting off a limb) of the right great toe. A review of GACH 1's document titled, Patient Transfer Summary, dated 4/1/19 and timed at 3:37 p.m., indicated Resident 1 had Incontinence Associated [MEDICAL CONDITION] ((IAD) irritation to the skin when exposed to urine/stool). A review of Resident 1's Minimum Data Set (MDS), an assessment and care screening tool, dated 4/8/19 indicated Resident 1 had no cognitive impairment (thought process for daily decision making), was able to understand and make herself understood by others. The MDS indicated Resident 1 required extensive assistance of a one-person physical assist for toilet use, personal hygiene, grooming, feeding, bathing, and transferring. The MDS indicated Resident 1 was always incontinent (lack of voluntary control with urination or defecation) of bowel/bladder, had an IAD and was at risk for development of pressure ulcer/injuries. The MDS indicated a pressure reducing device for Resident 1's bed was provided as treatment (sic). A review of Resident 1's admission care plans, there was no baseline center-person care plan found in Resident 1's care plans to identify goals and interventions for perianal redness and excoriation found during the initial assessment conducted on 4/2/19, right heel ulcer 4 x 4 cm, right big toe amputated, right 2nd toe amputated with open wound 2 x 0.5 x 0.7 cm, right 4th digit toe amputated with open wound 4 x 2 x 1 cm. A review of Resident 1's Physician order [REDACTED]. A review of Resident 1's Braden Scale (scale used to identify risk for pressure injury development) dated 4/2/19 and timed at 5:18 p.m. indicated Resident 1 was at mild risk for pressure injury development with a score of 15 (sic) (Severe risk: 9 or less. High risk: 10-12. Moderate risk: 13-14. Mild risk: 15-18). A review of Resident 1's Wound Nurse Body Observation, dated 4/2/19 and timed at 11:21 a.m., indicated Resident 1 had a perianal area redness/excoriated due to episodes of loose stools, left heel ulcer 4 x 4 cm, right big toe amputated, right 2nd toe amputated with open wound 2 x 0.5 x 0.7 cm, right 4th digit toe amputated with open wound 4 x 2 x 1 cm. A review of Resident 1's Change of Condition Assessment ((COC) an internal communication tool), dated 4/3/19 and timed at 7:18 p.m., indicated Resident 1 was noted putting her hand inside her diaper and smearing feces on herself. The COC indicated during an interview with Resident 1, she stated all she wanted was to be changed. A review of an Interdisciplinary Team ((IDT) group of healthcare professional working together toward the resident goals), dated 4/3/19 and timed at 4:11 p.m., indicated the IDT created a treatment plan for Resident 1 to have weekly body checks, physician notification of wound progress, supplemental (vitamins) medication administration and wound consult to promote healing. A review of Resident 1's physician orders, dated 4/8/19 and timed at 3:16 p.m., indicated to administer vitamin supplements to Resident 1 for wound healing. The order indicated Vitamin C (supplement) 500 milligrams (mg) by mouth (PO) every day (QD), Zinc Sulfate (supplement) 220 mg PO QD for 30 days and sugar free pro-stat (protein supplement) 30 milliliters (ML) PO. A review of Resident 1's nurses notes from 4/2019, did not indicate a pressure relieving device was provided on Resident 1's bed and no documented evidence Resident 1's physician was notified of the resident's wound progress and there was no wound consult done as prescribed by the physician. A review of Resident 1's COC Assessment, dated 4/10/19 and timed at 4:03 p.m., indicated Resident 1 complained of discomfort to the buttocks area on 4/10/19. The COC indicated upon assessment of Resident 1's buttocks there was [DIAGNOSES REDACTED] (superficial reddening of the skin because of injury or irritation) around the anal area, scant bleeding, and slight scattered maceration to the skin was noted. The COC Assessment indicated Resident 1's physician was notified on 4/10/19 at 1 p.m., with orders for monitoring, soap and water, pat dry and apply zinc oxide every shift for 21 days and re-evaluate on 5/1/19. A review of the Resident 1's Nurse's Progress Notes from 4/1/19 through 4/10/19, there was no note to indicate Resident 1's wounds were assessed, and/or a wound consult was done, per the IDT's recommendations. On 2/28/2020 at 3 p.m., during an interview and review of Resident 1's nurse's notes in the presence of the Director of Medical Records (DMR), the Assistant Director of Nurses (ADON) stated there was no physician notification of Resident 1's perianal wound maceration from 4/2/19 through 4/9/19 (7days). The ADON stated the initial registered dietitian ((RD) healthcare professionals licensed to assess, diagnose, and treat nutritional problems) recommendations were done on 4/9/19 seven (7) days after admission with orders for [MEDICATION NAME]-vite (combination of B vitamins used to treat or prevent vitamin deficiency) for [MEDICAL CONDITION] residents. The ADON stated there was no initial care plans completed for Resident 1's wounds identified during the resident's initial assessment on 4/2/19. The ADON stated initial care plans are created to identify residents' concerns with staffs' interventions. The ADON confirm there was no pressure reducing device ordered for Resident 1's bed, as per the MDS. On 2/28/2020 at 6:47 p.m., during an interview and review of Resident 1's clinical record and in the presence of the Administrator (ADM), Social Services Director (SSD), the ADON confirmed there was no RD recommendation done upon Resident 1's admission, no pressure reducing devices ordered for Resident 1, who was identified at risk for skin breakdown. The ADM stated RD consults are done within 48 hours of residents' initial admission and initial care plans created upon admission followed by a complete care plan within seven days of admission. On 3/3/2020 at 5:16 p.m., during a telephone interview, Resident 1's physician (Physician 1) stated not being aware of Resident 1's perianal wound. Physician 1 stated an initial wound assessment was conducted to implement a treatment and follow-up assessments of wound's progress. Physician 1 stated the facility should had follow its protocol and IDT interventions for wound treatments. Physician 1 stated it was the facility's responsibility to notify her of new and/or worsening wounds and ensure all staff was aware of care, such as RD and wound consults, pressure reliving devices and supplements were implemented for residents admitted with wounds or at risk for developing wounds. On 3/4/2020 at 1:20 p.m., during an interview and review, the GACH's Director of Compliance Officer indicated Resident 1 arrived to the GACH on 4/17/19 with a right 4th toe red in color and measurements of 3.5 x 3.5 cm with no drainage, left heel, dry flaky wound measuring 6 x 4 x 0.3 cm, and a right ischium Stage III red-yellowish in color and measuring 3 x 3 cm. The GACH's Director stated the wound pictures were taken on 4/17/19 at 4:40 p.m. On 3/4/2020 at 4 p.m., during a telephone interview, Licensed Vocational Nurse 3 (LVN 3) stated she did not remember Resident 1, but stated initial wound assessments were conducted by the treatment nurse which indicated a full description of the wound and proactive measures used to prevent the wound from worsening or developing new ones. b. A review of Resident 2's Admission Record (Face Sheet) indicated Resident 2 was admitted to the facility on [DATE]. A review of Resident 2's history and physical (H/P), dated 2/23/2020 indicated Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 2's care plans, there was no baseline care plan for wound treatment found in the clinical record. A review of Resident 2's physician orders, dated 2/22/2020 indicated to treat Resident 2's diabetic ulcers on the left and right 5th toes, left anterior 2nd toe, left great toe, left heel, and right 5th toe with normal saline (salt water), pat dry, apply [MEDICATION NAME] (topical antibiotic used in partial/full [MEDICAL CONDITION] prevent infection) and cover with gauze for 21 days and monitor left lower abdomen discoloration for skin breakdown and discomfort. On 2/28/2020 at 5:50 a.m., during an interview and in the presence of LVN 1, Resident 2 stated the cream on her night stand was given by CNA 2 who told her LVN 2 send her the cream to apply to her buttocks and it was the same cream she used for the wounds on the toes. Resident 2 stated she felt the staff did not care for her because they would not answer her call light at times and would leave her wet. Resident 2 stated she was not checked by the nurse prior to receiving the cream. On 2/28/2020 at 8:40 a.m., during an observation and interview, LVN 6 stated during Resident 2's body assessment, redness to the left and right groin and the buttocks area were noted and where not there before. On 2/28/2020 at 3:31 p.m., during an interview, LVN 2 stated on 2/27/20 she was informed Resident 2 was itching from her buttocks. LVN 2 stated she dispensed zinc oxide (sic) to the resident for her to apply. LVN 2 stated she did not conduct a skin assessment on the resident prior to dispensing the medication nor documented Resident 2 had complained. On 3/4/2020 at 4:11 p.m., during a telephone interview, LVN 4 stated a baseline care plan for Resident 2 was created upon identification of the wound after the initial assessment on 2/27/2020. LVN 4 stated if a resident had a high risk for developing wounds, measures such as a Low Air Loss ((LAL) mattress with tiny air holes that continually blow out air causing the resident to float and prevent ulcers), wound consults, supplements and diet consultations would be implemented. LVN 4 stated baseline care plans are used as guidance for implementations according to the residents needs and to measure the effectiveness of each measured implemented in the resident's care. On 3/5/2020 at 3:48 p.m., during a telephone interview and review with ADON and ADM, the ADON stated Resident 2's base-line care plans were created on 2/28/2020, six days after the initial admission on 2/22/2020. The ADON stated per the facility's Care Plan policy, an initial baseline care plans were done within 48 hours of resident's admission and was used as a guide to provide adequate care to each individual resident. The ADON stated the staff failed to follow the facility's policy. The ADM stated the facility was working on revising all residents' charts to identify those residents with no baseline care plans. A review of the facility's policy and procedure titled, Care Plans-Baseline, revised 12/2016 indicated the facility must develop and implement baseline plan of care to meet the resident's immediate needs within 48 hours of admission. The IDT Team will review the healthcare practitioner's orders (dietary needs, medications, routine treatments) and implement a baseline care plan and be use until the staff can conduct a comprehensive assessment and develop an IDT person-center care plan. The care plan should include initial goals, medications, dietary instructions, and treatments.

Based on observation, interview and record review, the facility failed to ensure residents received the necessary care to prevent pressure ulcers (prolonged pressure on the skin that results in injury to the skin and underlying tissue) from developing and worsening while promoting healing, which included conducting accurate assessments for two of three sampled residents (Residents 1 and 2). (Crossed Reference to F655). For Resident 1, staff failed to develop a person-centered care plan to treat perianal redness and excoriation. The pressure relieving device was not provided. The physician was not notified of Resident 1's wound progress. Resident 1 was not referred to registered dietician upon admission. Resident 1's had to wait 20 minutes and longer for staff to answer her call light. For Resident 2, staff failed to develop a person-centered care plan to prevent the development of skin ulcers. Resident 1 developed a scattered redness of moisture-associated skin damage ((MASD) skin inflammation caused by prolonged exposure to urine, stool, sweat, or saliva) to left/right groin (area between the abdomen and the thigh) and buttocks. These deficient practices resulted in worsening of Resident 1's redness and excoriation of the perianal area which developed into a right ischium (curved bone forming the base of the pelvis) Stage III (full thickness skin loss involving damage or necrosis (death tissue) of subcutaneous tissue). Resident 1 was admitted to the facility with perianal (area around the anus) redness and maceration (softening and breaking down of skin from moisture exposure); and for Resident 2 to develop redness on the groin area. Findings: a. A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. (cutting off a limb) of right great toe. A review Resident 1's GACH document titled, Patient Transfer Summary, dated 4/1/19 and timed at 3:37 p.m. indicated Resident 1 was transfer to the nursing skilled facility (SNF) with a [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), an assessment and care screening tool, dated 4/8/19 indicated Resident 1 had no cognitive impairment (thought process for daily decision making), and was able to understand and be understood by others. The MDS indicated Resident 1 required extensive assistance of a one-person physical assist for toilet use, personal hygiene, grooming, feeding, bathing, and transferring. The MDS indicated Resident 1 was always incontinent (lack of voluntary control of urination or defecation) of bowel/bladder, had an IAD and was at risk for pressure ulcer/injuries to develop. The MDS indicated a pressure reducing device for Resident 1's bed was provided as treatment (sic). A review of Resident 1's Braden Scale (scale used to identify risk for pressure injury development) dated 4/2/19 and timed at 5:18 p.m. indicated Resident 1 was at mild risk for pressure injury development with a score of 15 (sic). (Severe risk: 9 or less. High risk: 10-12. Moderate risk: 13-14. Mild risk: 15-18). A review of Resident 1's care plans indicated there was no documentation of a baseline center-person care plan for the residents to indicate the facility staffs' interventions to prevent worsening of Resident 1's perianal redness and excoriation. A review of Resident 1's initial assessment conducted on 4/2/19 by the Licensed Nurse indicated the following assessments, heel ulcer 4 x 4 centimeters (cm), right big toe amputated, right 2nd toe amputated with an opened wound 2 x 0.5 x 0.7 cm, right 4th digit toe amputated with open wound 4 x 2 x 1 cm. The initial assessment did not mention a redness to the perianal area and excoriation. A review of Resident 1's Physician Order Report, dated 4/1/19 through 4/17/19 indicated an order with a start date of 4/1/19 for Resident 1's perineal redness with maceration, to be cleansed with soap and water, pat dry and apply zinc oxide (medication to treat and prevent diaper rash) every day and leave open to air for 30 days. A review of Resident 1's Wound Nurse Body Observation, dated 4/2/19 and timed at 11:21 a.m., indicated Resident 1 had a perianal area redness/excoriated due to episodes of loose stools, left heel ulcer 4 x 4 centimeters (cm), right big toe amputated, right 2nd toe amputated with open wound 2 x 0.5 x 0.7 cm, right 4th digit toe amputated with open wound 4 x 2 x 1 cm. A review of Resident 1's Change of Condition Assessment (COC), dated 4/3/19 at 7:18 p.m. indicated Resident 1 was noted putting her hand inside her diaper and smearing feces on herself because she wanted to be changed. A review of an Interdisciplinary Team ((IDT) group of healthcare professionals from different fields who work together toward the same goal for residents), dated 4/3/19 and timed at 4:11 p.m. indicated the IDT treatment plan for weekly body checks, physician notification of wound progress, supplemental medication administration to promote healing, and wound consult for Resident 1. A review of Resident 1's nurses notes did not indicate a pressure relieving device was provided for Resident 1's bed, no physician notification of the resident's wound progress and no wound consult was done, the dietary supplements started on 4/8/19 (7 days after the dietary admission). A review of Resident 1's physician orders, dated 4/8/19 and timed at 3:16 p.m. indicated to administer to the resident the supplements for wound healing. The order indicated Vitamin C (supplement) 500 milligrams (mg) by mouth (PO) every day (QD), Zinc Sulfate (supplement) 220 mg PO QD for 30 days and sugar free pro-stat (protein supplement) 30 milliliters (ML) PO. A review of Resident 1's COC Assessment, dated 4/10/19 and timed at 4:03 p.m., indicated Resident 1 complained of discomfort to the buttocks area on 4/10/19. On assessment, [DIAGNOSES REDACTED] (redness of the skin) around the anal area, scant bleeding, and slight scattered maceration to the skin was noted. The COC indicated Resident 1's physician was notified on 4/10/19 at 1 p.m., with orders for monitoring, cleanse with soap and water, pat dry and apply zinc oxide every shift for 21 days and re-evaluate on 5/1/19. A review of Resident 1' nurses notes from 4/1/19 through 4/10/19, did not indicate a progress note was done for Resident 1's wounds and/or a wound consult was done. On 2/27/2020 at 1:35 p.m., during a telephone interview, Resident 1's Responsible Party 1 ((RP 1) a person designated to make decisions) stated Resident would call her at night telling her the nurses would leave her wet and soil (with urine and stool) all night. RP 1 stated Resident 1 would fall asleep waiting to be changed and wake-up wet and soil. RP 1 stated Resident 1 complained when the nurses did clean her, they would clean her with a rough cloth causing her buttocks area to bleed. On 2/28/2020 at 5:05 a.m., during an initial tour of the facility, call-lights from Rooms 3, 7, 25 and 31 were observed blinking and heard ringing at the nurses' station panel. The staff did not respond to the call light until 5:25 a.m. (20 minutes later). On 2/28/2020 at 3 p.m., during an interview and review of Resident 1's nurse's notes and in the presence of the Director of Medical Records (DMR), the Assistant Director of Nurses (ADON) stated there was no physician notification of Resident 1's perianal wound maceration from 4/2/19 through 4/9/19 (7days). The ADON stated the initial registered dietitian ((RD) healthcare professionals licensed to assess, diagnose, and treat nutritional problems) recommendations were done on 4/9/19 seven (7) days after admission with orders for [MEDICATION NAME]-vite (combination of B vitamins used to treat or prevent vitamin deficiency) for [MEDICAL CONDITION] residents. The ADON stated there was no initial baseline care plan completed for Resident 1's wounds identified during the resident's initial assessment on 4/2/19. The ADON stated initial care plans are created to identify residents' concerns with staffs' iterventions. The ADON confirm there was no pressure reducing device ordered for Resident 1's bed, as per the MDS. On 2/28/2020 at 6:47 p.m., during an interview and review of Resident 1's physician's orders, nurse's notes and RD assessment in the presence of the Administrator (ADM), Social Services Director (SSD), the ADON confirmed there was no RD recommendation done upon Resident 1's admission and no pressure reducing devices ordered for Resident 1, who was identified at risk for skin breakdown. The ADM stated the RD consults are done within 48 hours of resident's initial admission with an initial care plan created upon admission followed by a complete care plan within seven days of admission. On 3/3/2020 at 12:45 p.m., during an interview, the ADM stated there was no wound consult ordered for Resident 1 because of the resident's insurance. The ADM stated the facility's treatment nurse assessed the resident's wounds and documented on the resident's progress notes, but the ADM was not able to locate progress notes regarding Resident 1's wound progress. On 3/3/2020 at 5:16 p.m., during a telephone interview, Resident 1's physician (Physician 1) stated not being aware of the wounds to Resident 1's perianal area. Physician 1 stated an initial assessment was conducted to implement a treatment and to follow up with assessments of the wound progress. Physician 1 stated the facility should had followed their protocol for wound treatments and follow their IDT interventions. Physician 1 stated it was the facility's responsibility to notify her of new and/or worsening wounds to Resident 1 to ensure the staff was aware all care was provided, such as RD and wound consults, pressure relieving devices and supplements were implemented for all residents admitted with wounds or at risk for developing wounds. On 3/4/2020 at 1:20 p.m., during an interview, the GACH's Director indicated Resident 1 arrived to the GACH on 4/17/19 with a right 4th toe red in color and measurements of 3.5 x 3.5 cm with no drainage, left heel with dry flaky wound measuring 6 x 4 x 0.3 cm, and a right ischium Stage III red yellowish in color and measuring 3 x 3 cm. The GACH's Director stated the wound pictures were taken on 4/17/19 at 4:40 p.m. On 3/4/2020 at 4 p.m., during a telephone interview, Licensed Vocational Nurse 3 (LVN 3) stated not remembering Resident 1. LVN 3 stated initial wound assessments were conducted by the treatment nurse which indicated a full description of the wound and proactive measures taken to prevent the wound from worsening or developing. b. A review of Resident 2's Admission Record (Face Sheet) indicated Resident 2 was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 2's History and Physical (H/P), dated 2/23/2020 indicated Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 2's care plans there was no baseline care plan for wound treatment found in the clinical record. A review of Resident 2's physician orders, dated 2/22/2020 indicated to treat Resident 2's diabetic ulcers on the left and right 5th toes, left anterior 2nd toe, left great toe, left heel, and right 5th toe with normal saline (salt water), pat dry, apply [MEDICATION NAME] (topical antibiotic used in partial/full [MEDICAL CONDITION] prevent infection) and cover with gauze for 21 days once a day, and monitor left lower abdomen discoloration for skin breakdown and discomfort. The physician orders did not indicate Resident 2 had groin and buttocks MASD. On 2/28/2020 at 5:30 a.m., during an observation and interview, Resident 2 stated she was admitted to the facility on Friday 2/22/2020 with no wounds on her buttocks. Resident 2 stated the staff would put a diaper on her and tell her to go (urinate and defecate) in the diaper and left soil for 3-5 hours. Resident 2 stated on 2/22/2020 the night of her admission to the facility, she had a bowel movement (feces) in her diaper because nobody attended to her call. Resident 2 stated Certified Nurse Assistant 2 (CNA 2) told her she was bleeding from her buttocks. During the interview, Resident 2 had a medication cup containing a white/shiny topical ointment with a tongue depressor stick in on Resident 2's nightstand unattended. On 2/28/2020 at 5:45 a.m., during an interview, CNA 1 stated at times it takes up to an hour to answer call lights due to the facility being short-staffed. On 2/28/2020 at 5:49 a.m., during an interview and review of Resident 2's Treatment Administration Record (TAR), Licensed Vocational Nurse 1 (LVN 1) stated the white cream on Resident 2's bedside was [MEDICATION NAME] medication. On 2/28/2020 at 5:50 a.m., during an interview and in the presence of LVN 1, Resident 2 stated the cream on her night stand was placed by CNA 2, who told her LVN 2 gave her the cream to apply to her buttocks and it was the same cream she used for the wounds on the toes. Resident 2 stated she felt the staff did not care for her because they would not answer her call light at times and leave her wet. Resident 2 stated she was not checked by the nurse prior to receiving the cream. On 2/28/2020 at 8:40 a.m., during an observation and interview, LVN 6 stated during Resident 2's body assessment, redness to the left and right groin and the buttocks area that was not there before. LVN 6 stated not being aware or having to receive report of Resident 2's skin problems. On 2/28/2020 at 1:23 p.m., during an interview, CNA 2 stated on 2/27/2020 Resident 2 stated having redness and that was itchy on her buttocks area. CNA 2 stated she did not check the resident but did notify LVN 2. CNA 2 stated LVN 2 gave her the cream from the treatment cart to give to the resident to apply. CNA 2 stated not conducting a Stop and Watch (internal document identifying skin problems) form because she did not check the resident and gave the medication for the resident to apply. On 2/28/2020 at 3 p.m., during an interview and review of Resident 2's clinical chart with ADON and the DMR, ADON stated no previous documentation was found of Resident 2's redness to her groin and buttocks area. The ADON stated the RD consult and supplements for wound healing were initiated for Resident 2 late on 2/28/2020 (6 days after admission). The ADON stated medications are not to be given for residents to administer themselves. On 2/28/2020 at 3:31 p.m., during an interview, LVN 2 stated on 2/27/2020 she was informed of Resident 2 itching from her buttocks. LVN 2 stated she dispensed zinc oxide to Resident 2 for resident to apply. LVN 2 stated she did not conduct a skin assessment on Resident 2 prior to dispensing the medication nor did she document Resident 2's complained of new area with itching. LVN 2 stated medications are not to be left at residents' bedside because it can cause harm to the resident if not taken or applied correctly. On 2/28/2020 at 5:35 p.m., during an interview, Resident 2's Responsible Party 2 (RP 2) stated placing a grievance with the facility's Director of Social Services (DSS) regarding Resident 2 being left wet for two hours on the day of her admission on 2/22/2020. RP 2 stated the facility has not called her to explain or respond to her grievance of why Resident 2 was left wet. On 3/4/2020 at 4:11 p.m., during a telephone interview, LVN 4 stated a baseline care plan for Resident 2 was created upon identification of the wound after the initial assessment. LVN 4 stated if a resident had a high risk for developing wounds, measures such as a Low Air Loss ((LAL) mattress with tiny air holes that continually blow out air causing the resident to float and prevent ulcers), wound consults, supplements and diet consultations would be implemented. LVN 4 stated baseline care plans are used as guidance for implementations according to the residents needs and to measure the effectiveness of each measured implemented in the resident's care. On 3/5/2020 at 3:48 p.m., during a telephone interview and review with ADON and ADM, the ADON stated Resident 2's base-line care plans were created on 2/28/2020, six days after the initial admission on 2/22/2020. The ADON stated per the facility's Care Plan policy, an initial baseline care plans were done within 48 hours of resident's admission and was used as a guide to provide adequate care to each individual resident. The ADON stated the staff failed to follow the facility's policy. The ADM stated the facility was working on revising all residents' charts to identify those residents with no baseline care plan. A review of the facility's policy and procedure titled, Pressure Ulcer/Injury Risk Assessment, revised 7/2017 indicated the purpose of the policy was to provide guidelines for the structured assessment and identification of residents at risk of developing pressure ulcers/injuries. Risk factors that increase resident's susceptibility to develop or not to heal wounds were impaired/decreased mobility, exposure of skin to urinary and fecal incontinence, [MEDICAL CONDITION], and diabetes. The policy indicated for staff to immediately (no later than 8 hrs. after admission) conduct an assessment to identify risk factors and create resident-centered care plan. The policy indicated a resident-centered care plan with interventions would be created upon identification of a new wound and interventions to be evaluated to identify its effectiveness. A review of the facility's policy and procedure titled, Admission Assessment and Follow-up: Role of the Nurse, revised 9/2012 indicated the purpose of the policy was to guide the facility staff in the gathering of the resident's information for managing the residents' care. The policy indicated the staff was to conduct an admission assessment, list all active diagnoses, reconcile the list of all medications from the medication history and admitting orders, contact the attending physician to obtain orders and contact outside services the resident will need.

Based on observation, interview, and record review, for two of 18 sampled resident the facility failed to: 1. Ensure Resident 69, who required supervision during trial of mechanical soft food and had severe dysphagia (inability to swallow), was not left unsupervised by facility staff while eating food from a trial tray. 2. Ensure to have Resident 140's a bed in a low position in accordance with its policy for fall management and a plan of care. This deficient practices resulted in Resident 69 aspirating (breathing in a foreign object (food) into the airway), having low oxygen levels for an unknown amount of time, and subsequently being transferred to a general acute care hospital (GACH) on [DATE], and Resident 140 falling on [DATE], out of bed fracturing his nose and transferred to GACH for evaluation. Findings: A. A review of Resident 69's Admission Face Sheet indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 69's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated [DATE], indicated Resident 69 had impaired cognitive skills (ability to reason and think) for daily decision making and had a memory problems. The MDS indicated Resident 69 required supervision with one person physical assistance for eating, transferring, dressing and bed mobility (how the resident moves). According to the MDS, section K 100 under Swallowing/Nutritional status, Resident 69 was assessed to have been coughing or choking during meals and when swallowing medication. The resident required a mechanically altered diet. A review of Resident 69's physician's orders [REDACTED]. Treatment plan to include diet texture analysis, training in safe swallowing strategies, training in oral musculature assessment ((OME) evaluation of normal and abnormal patterns of the lips, tongue, jaw, cheeks, hard palate and soft palate for eating, drinking, facial expression and speech to determine functional skills), and patient caregiver education and training. According to Resident 69's care plan dated [DATE], for Activities of Daily Living (ADLs) the resident was identified to have functional/rehabilitation potential related to severe dysphagia characterized by poor safety awareness, decreased motivation, participation, delayed swallowing, pocketing (store food in cheeks) food residue, and coughing after swallow. According to Resident 69's care plan dated [DATE] for the Nutritional Status related to swallowing deficit and altered therapeutic diet the goal was for the resident not to have signs and symptoms of aspiration or choking. The interventions included to assist or feed resident as needed, and provide resident with pureed (food mechanically altered to be soft, moist and smooth) diet with thin liquids. A review of the Speech Therapy Evaluation and Plan of Treatment dated [DATE] indicated Resident 69 had severe dysphagia characterized by poor safety awareness and decreased motivation and participation, delayed swallow, pocketing, residue and coughing after swallow. Resident 69 was assessed as required close supervision during oral intake. A review of the Speech Therapy (ST) Treatment Note dated [DATE], at 2:36 p.m., indicated Resident 69's summary of daily skilled services precautions are a pureed diet, analysis of diet texture to determine safety of swallowing during oral intake, training in safe swallowing strategies to decreases signs and symptoms of dysphagia and risk of aspiration. ST documented the resident tolerated puree diet and thin liquid, self-fed following set up assistance with no cough seen, minimal oral residue and pocketing seen, swallowing abilities severe, current diet puree consistency with thin liquids. A review of a Situation Background Assessment and Recommendation (SBAR) form ) written by a Registered Nurse (RN 1), dated [DATE], at 9:53 a.m., indicated Resident 69 was transferred to the GACH at 7:55 a.m., with altered mental status (AMS). In the notes was documented that on [DATE] at 7:45 a.m., Resident 69 was alert, oriented and responsive, was able to make needs known, and followed simple commands. Resident was being assisted with morning ADLs and feeding for breakfast. No signs or symptoms of shortness of breath (SOB), chest pain or other discomfort noted at time of assessment. On [DATE] at 7:55 a.m., it was documented that ST informed staff Resident 69 was unresponsive. In SBAR was documented that upon assessment Resident 69 was noted to be not responsive to commands, tactile stimuli, or sternal rubs. No chest movement was noted at the time, skin was warm to touch and no radial pulse was palpable and vital signs were not appreciated. At 0753 a.m., Code Blue was (hospital code used to indicate a resident is requiring immediate resuscitation) was initiated and 911 emergency response called. Cardiopulmonary resuscitation (CPR) (a life-saving emergency procedure that involves breathing for the victim and applying external chest compression to make the heart pump) started with resident being on bag valve mask ((BVM)- a bag valve mask, sometimes known by the proprietary name Ambu-bag or generically as a manual resuscitator or self-inflating bag, is a hand-held device commonly used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately). Respiratory Therapist 1 (RT 1) suctioned Resident 69's airways to assist resident with breathing. In SBAR was documented that staff noted particles of food inside suctioning equipment. Same day at 8 a.m., vital signs were checked again and they were not appreciated. Resident 69 was given approximately ten cycles of CPR with oxygen given via BVM. At 8:05 a.m., emergency response (Paramedics) arrived and took over the situation. Paramedics team intubated the resident with endotracheal tube (a small plastic tube inserted into the throat through the mouth to maintain an unobstructed airway passage to deliver oxygen and to assist with breathing) and transferred the resident to GACH. MD and responsible party were made aware of the situation. According to RN 2's Progress Note dated [DATE], at 2:38 p.m., Resident 69 was awake with the head of bed at 45 degrees at 7:30 a.m. At 7:40 a.m., the breakfast tray was served at the resident's bedside and at 7:45 a.m., the resident was found unresponsive. RN 2 documented that the resident's sternal rub was implemented and there was no response. RN 2 documented there were found food particles in the resident's mouth and finger sweep was performed to remove it. Code Blue was activated and Respiratory Therapist (RT 1) suctioned the resident mouth until clear. RN 2 and RT 1 began chest compressions with BVM until Paramedics arrive and took over compressions. On [DATE] at 10:40 a.m., during a telephone interview, ST stated that she ordered Resident 69 a mechanical soft chopped food as trial for breakfast on [DATE], to test the next diet from the pureed diet. Resident 69 received a mechanical chopped diet consisted of French toast and scrambled eggs with thin liquids for breakfast. ST stated she was present while a certified nurse assistant 1 (CNA 1) fed Resident 69 with trial meal in the morning of [DATE]. ST stated CNA 1 had been thoroughly trained to feed residents with severe dysphagia. During feeding Resident 69 suddenly began to cough and choke on the French toast and aspirated on the food. ST stated she left Resident 69's room to get a RN 2 and RT 1 to assist the resident while he was choking. CNA 1 was remaining at the resident bedside. ST stated that she did not remove any food content from Resident 69's mouth because she left the room to get assistance. On [DATE] at 10:51 a.m., during a phone interview CNA 1, who was assigned to pass breakfast trays and provided supervision during meals, stated on [DATE], during breakfast at approximately 7:30 a.m., she and the ST were feeding Resident 69's with trial food consisted of bites of French toast and thin liquids. CNA 1 stated Resident 69 chewed the third bite and began to cough uncontrollably. The speech therapist gave him water and he started to cough again. CNA 1 stated Resident 69 choked on the food and ST left the room and went to get RT 1. CNA 1 stated that she was left alone with Resident 69 and he did not look good. CNA 1 stated she did not remove food from his mouth or pat him on the back to help him clear his throat. CNA 1 stated the RT 1 came and started chest compressions, and that she left Resident 69's room and does not know what happened to the resident afterwards. On [DATE] at 11:08 a.m., during an interview the Director of Rehabilitation (DOR) stated the ST was the person responsible for testing trial food of mechanical soft chopped diet for a resident who was transitioning from a purred diet. DOR stated the ST should have fed Resident 69 the trial food to ensure it was safe to prevent the resident from aspiration. On [DATE] at 11:19 a.m., during an interview RN 1 stated he heard a Code Blue for Resident 69's room. RN 1 stated when he entered to the room he saw RT 1 performing chest compressions on Resident 69. RN 1 stated staff unsuccessfully attempted to obtain Resident 69's vital signs (clinical measurements, pulse rate, temperature, respiration rate, and blood pressure, which indicate the state of a patient's essential body functions) specifically no pulse, no breaths sounds, and no blood pressure. RN 1 stated RT 1 suctioned food debris from Resident 69's mouth. On [DATE] at 11:34 a.m., during an interview RT 1 stated that he and RT 2 were at the subacute nursing station, and ST frantically asked him to come to Resident 69's room. RT 1 stated he arrived to the room at 7:52 a.m., he observed RN 2 in room with Resident 69, who had facial discoloration. According to the pulse oximeter ( a device to measure the oxygen saturation in the blood) Resident 69's oxygen saturation (amount of oxygen in the blood) was at 76 percent (normal range 95 to 100 percent) and the heart rate was inconsistent. RT 2 had arrived with the crash (a cart that contains an equipment to safe a person's life) cart and suctioned Resident 69's airways. RT 1 stated he immediately called a Code Blue and initiated chest compressions (CPR). RT 1 stated that food debris was removed from Resident 69's mouth with a suction and staff continued CPR until paramedics arrived. On [DATE] at 7:13 p.m., during an interview the Director of Nursing (DON) stated the staff did everything according to the care Resident 69 needed. The DON stated she was told Resident 69 choked and was sent to the hospital, and felt nothing wrong happened. On [DATE] at 8:14 p.m., during an interview RN 2 stated on [DATE], at approximately 7:30 a.m. Resident 69 was observed sitting upright in bed getting ready for breakfast. RN 2 stated about 7:45 a.m., ST looked frantic and scared requesting help for Resident 69. RN 2 stated CNA 1 was not in Resident 69's room with ST. RN 2 stated Resident 69 was in bed unresponsive, and he performed a finger sweep to remove food debris from Resident 69's mouth. RN 2 stated he checked for a pulse (throbbing of the arteries as blood is propelled through them, typically as felt in the wrists or neck reflecting heart rate) and no carotid or radial pulse was palpated (feeling with the hand). RN 2 stated he tried to wake Resident 69 by shaking him, and performing a rub on the sternum (is the application of painful stimulus with the knuckles of closed fist to the center chest of a person who is not alert and does not respond to verbally), but resident did not respond. RN 2 stated Code Blue was initiated, and CPR was started, and RT 1 came to suction food from Resident 69's mouth. RN 2 stated Resident 69 was provided with artificial breathing with BVM mask and CPR until Paramedics arrived. RN 2 stated before this incident Resident 69 was able to talk and have a simple conversation. On [DATE] at 1:33 p.m., during an observation of the facility's surveillance video in the presence of the DON and the Administrator (ADM), the ADM verified the events along with the various staff members on the video, which indicated the following occurred on [DATE]: 1. At 7:34 a.m., two unidentified CNAs deliver breakfast tray to room [ROOM NUMBER]-Resident 69's room. 2. At 7:35 a.m., CNA 1 entered Resident 69 room. 3. At 7:38 a.m., CNA 1 and unidentified staff member exited Resident 69's room. 4. At 7:43 a.m., CNA 1 entered room [ROOM NUMBER] with breakfast tray. 5. At 7:45 a.m., ST walked pass Resident 69's room. 6. At 7:46 a.m., ST entered Resident 69's room. 7. At 7:47 a.m., RN 2 entered room [ROOM NUMBER]. 8. At 7:49 a.m., RN 2 and ST exited Resident 69's room. 9. At 7:49 a.m., CNA 1 entered Resident 69's room. 10. At 7:49 a.m., RN 2 entered Resident 69's room. 11. At 7:49 a.m., ST and RT 1 entered Resident 69's room. 12. At 7:50 a.m., RN 2 and ST exited Resident 69's room. 13. At 7:50:45 a.m., ST entered Resident 69's room. 14. At 7:51 a.m., Code Blue announced and numerous staff entered Resident 69's room. 15. At 7:51 a.m., ST exited resident 69's room and leaves the area. 16. At 7:51 a.m., RT 2 brings crash cart to the area. 17. At 7:52 a.m., CNA 1 exited room [ROOM NUMBER] with a tray. 18. At 8:02 a.m., Paramedics arrived to Resident 69's room. On [DATE] at 2:40 p.m., during an interview, Resident 69's physician stated that it is within the scope of practice for the ST to make diet changes for a resident in therapy and that he should have been notified of the changes. The physician stated he was told Resident 69 was found unresponsive and CPR was initiated by staff. The physician also stated there was a high possibility that the resident had the [MEDICAL CONDITION] as a complication of choking with the food and that it may have changed the course of treatment ordered for Resident 69. The physician stated that if the facility would have mentioned they did finger sweep, and that during suctioning food was removed he would have ordered a CT-scan. On [DATE] at 3:43 p.m., during a second interview in the presence of the ADM and DON, ST stated she wanted to change her statement from the interview on [DATE]. That day ST ordered Resident 69 a trial tray of mechanical soft chopped breakfast. ST stated she was supposed to be with Resident 69 during the food trail. ST stated the tray was passed to Resident 69 prior to her arriving to the resident's room. ST further stated she was nervous during the first interview, and thought that she may be in some sort of trouble because the resident aspirated and choked. ST stated when she went to Resident 69's room she saw his eyes closed and his face was discolored. ST stated she went to get RN 1 and the respiratory therapist to help the resident, she did not start CPR and acknowledged that CNA 1 was not in the room with Resident 69. ST confirmed she did not document what occurred on [DATE], and that she would document a note in the resident record as Late Entry. A review of the licensed progress notes dated [DATE], at 4:30 p.m., documented by ST as a Late Entry, indicated on [DATE], ST entered Resident 69's room. Resident 69 was sitting up with eyes closed and mouth open with visible food. ST attempted to wake the resident, however the resident did not respond and had no visible chest movements. ST summoned RN 1 who finger sweep food content from Resident 69's mouth. When RT 1 entered Resident 69's room she called Code Blue, crash cart was brought in and ST left the scene. On [DATE] at 4:35 p.m., in the presence of the facility's director of operations and the nurse consultant, CNA 1 stated that she was feeding an unidentified resident in room [ROOM NUMBER] and not Resident 69. CNA 1 stated she was confused, and does not know exactly what happened to Resident 69. A review of the facility's policy titled, Assistance with meals revised ,[DATE] residents shall receive assistance with meals in a manner that meets the individual needs of each resident. According to the Prehospital Care Report Summary from Los Angeles Fire Department dated [DATE], Paramedics arrived to the facility at 8:00:02 a.m., and at 8:04:02 a.m., were at Resident 69's bed side. According to this report Resident 69's airways were patent (open, unobstructed pathway between a resident's lungs and the outside world), the resident's left and right eyes pupils were equal, round and reactive to light and accommodation ((PERRLA) a reflex action of the eye in response to focusing on a near object, then looking at a distant object and vice versa). The resident was unconscious and unresponsive. According to the Paramedics' documented history Resident 69 was found lying on his back in bed at the facility in severe distress not answering any questions. Resident 69 had [MEDICAL CONDITION] with total CPR time 20 minutes, first intubation attempted at 8:12 a.m., was unsuccessful, at 8:21 a.m., successfully intubated. According to GACH emergency room History and Physical record dated [DATE], Resident 69 arrived to GACH at 8:35 a.m. The resident was down for at least 10 minutes before Paramedics arrival. CPR was in progress when Paramedics arrived and the resident was intubated (the placement of a flexible plastic tube into the trachea to maintain an open airway) on the field. Resident 69's chest X-ray obtained in the GACH's emergency room , dated [DATE], demonstrated the resident had been developing airspace disease in the right lung representing [MEDICAL CONDITIONS] (a condition caused by excess fluid in the lungs) and obscured right hemidiaphragm (half of the diaphragm, the muscle that separates the chest cavity from the abdomen and that serves as the main muscle of respiration). GACH's assessment indicated Resident 69 had aspiration pneumonia (when food, stomach acid, or saliva are inhaled into the lungs), acute cardiogenic shock (a condition in which your heart suddenly can't pump enough blood to meet your body's needs) and acute [MEDICAL CONDITION] (not having enough oxygen in the body, most cases this failure may lead to death), and was dependent on mechanical ventilator (mechine used to assist or replace spontaneous breathing). B. A review of Resident 140's Admission Record indicated the resident was admitted to the facility on [DATE]. Resident 140's [DIAGNOSES REDACTED]. A review of Resident 140' History and Physical (H&P) dated [DATE] indicated resident had the capacity to make intermittent decision. A review of the Admission Assessment titled, Falls Risk dated [DATE] indicated Resident 140 was at moderate risk for falls. On [DATE] at 8:47 p.m., during an observation, Resident 140 was observed in the floor next to his bed facing down towards the rooms door, upper body facing one opposite and the lower body was. Resident 140 was heard grimacing and attempting to get up from the floor. No floor mats were observed and the bed was on a high position. On [DATE] at 8:49 p.m., during an interview, Resident 140's roommate stated that he called the nurses because Resident 140 had fallen. Roommate stated that Resident 140 was recently moved closer to the nurses' station because he falls. On [DATE] at 4:15 p.m., during a concurrent interview and record review, Registered Nurse 3 (RN 3) stated that Resident 140's care plan initiated on [DATE] indicated the resident would be free form fall for the next 90 days and staff would position the bed to the lowest position and assist the resident to the toilet every two hours or as needed to prevent incidents. On [DATE] at 7:12 p.m., during an interview, certified nurse assistant 2 (CNA 2) stated that on [DATE] she changed Resident 140 and then left to care for other resident's when she heard someone say that the resident was found on the floor. CNA 2 stated that the resident tents to move a lot and the bed should had been in a low position A review of the GACH's Emergency Departments (ED) report dated [DATE] and timed at 9:27 p.m., indicated that Resident 140 suffered a fall after attempting to go to the bathroom. The ED report indicates Resident 140 sustained a nasal bone (nose) fracture. A review of the facility's policy and procedure (P/P) titled, Fall-Clinical Protocol, dated ,[DATE], indicated that the staff and physician will monitor and document the individual's response to interventions intended to reduce falling of the consequences of falling.