Every finding on record at Torrance Memorial Med CTR Snf/Dp

Based on interview and record review the facility failed to notify the physician of a change of condition for one of one sampled residents (Resident 35) when Resident 35's oxygen saturation ([O2 sat]- a measurement of how much oxygen the blood is carrying as a percentage) decreased to 90 percent ([%] a number or ratio expressed as a fraction of 100) on room air (normal O2 sat is 92% -100%).This failure resulted in Resident 35 experiencing respiratory distress, agitation and being transferred to the General Acute Care Unit (GACH) for evaluation and treatment.Findings:During a review of Resident 35's admission record, the admission record indicated Resident 35 was admitted to the facility on [DATE] with diagnosis including a left femoral (thigh bone) open reduction and internal fixation (ORIF-surgery used to stabilize and heal a broken bone) that required rehabilitation (therapy given to restore an individual back to their highest possible level of physical, mental, and psychosocial well-being), stroke (loss of blood flow to part of the brain), and non-traumatic brain dysfunction (an injury to the brain caused by chemical and toxins in the body).During a review of Resident 35's Minimum Data Set( MDS- a resident assessment tool), dated 1/29/2026, the MDS indicated Resident 35 had some difficulty with daily decision making. The MDS indicated Resident 35 was dependent (helper does all the effort) on nursing staff for eating, oral hygiene, toileting, dressing, and showering. The MDS indicated Resident 35 needed substantial to maximal assistance (helper does all the effort) with sitting, standing, lying down and transferring. During an interview on 3/15/2026 at 3:06 p.m. with Registered Nurse (RN) 1, RN 1 stated on 1/28/2025 at 6:30 a.m. Resident 35's oxygen saturation was 90%. RN 1 stated Resident 35 had acute respiratory failure (the inability of the respiratory system to maintain an adequate blood oxygen level) and had a Rapid Response (a team of providers summoned to the bedside to immediately assess and treat the resident with the goal of preventing intensive care unit transfer, cardiac arrest, or death) on 1/29/2026. RN 1 stated the doctor should have been notified and 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 which without immediate intervention, may result in complications or death) should have been documented. RN 1 stated oxygen saturation of 90% is low. RN 1 stated there was no documentation in Resident 35's chart that the doctor was notified. RN 1 stated a when Resident 35's oxygen saturation decreased to 90% an assessment and notification to the doctor should have been done. RN 1 stated rapid response could have been avoided. During an interview on 3/15/2026 at 3:35 p.m. with RN 2, RN 2 stated there was no documentation of the doctor being notified or the reason Resident 35 was placed on oxygen. RN 2 stated licensed nurses are supposed to notify the doctor if a resident is distressed or having trouble breathing. RN 2 stated that an oxygen saturation of 90% is low and a COC should have been documented.During an interview on 03/15/2026 at 4:24 p.m. with the Director of Nursing (DON), the DON stated on 1/28/2026 Resident 35's oxygen dropped to 90%. The DON stated a notification to the physician for intervention needed to be done at the time of the resident's change of condition and documented in the Nursing Progress Notes.During a review of Resident 35's Physician Progress Notes, dated 1/28/2026 at 5:03 p.m., the Physician Progress Notes indicated Resident 35's oxygen saturation was 90% on 1/28/2026 at 6:32 a.m.During a review of Resident 35's Physician Progress Notes, dated 1/29/2026 at 4:32 p.m. the Physician Progress Notes indicated Nursing staff noticed Resident 35 was lethargic and noticed coughing and rales (small clicking, bubbling, or rattling sounds in the lungs) were heard during a lung exam. The Physician Progress Notes indicated Resident 35 felt hot and had changes in mental status, a cough and new hypoxia (condition when the body does not get enough oxygen ). The Physician Progress Notes indicated Resident 35 had a chest x-ray on 1/29/2026 at 4:21 p.m. that resulted in Resident 35 having a right basilar pleural-parenchymal opacity (disease that affect the air spaces of the lungs), presenting a combination of effusion (water in the lungs), atelectasis, and/or developing consolidation and mild pulmonary vascular congestion. During a review of Resident 35's Rapid Response Event Summary, dated 1/29/2026 at 9:10 p.m., the Rapid Response Event Summary indicated the Rapid Response Team was called for worsening respiratory distress and agitation of Resident 35. The Rapid Response Event Summary indicated Resident 35 respiratory rate ( the number of breaths a person takes per minute) was 42 (normal 12-20 breaths per minute), the blood pressure was 195/87, the pulse oximetry (a test used to measure the oxygen level (oxygen saturation) of the blood) was 84% with room air and the oxygen saturation improved to 95% with 3 liters of oxygen given by nasal cannula. The Rapid Response Event Summary indicated Resident 35 was transferred to the GACH on 1/29/2026 at 10:15 p.m During a review of the facility's policy and procedure (P&P), titled Change in Resident's Condition or Status, dated 7/1/2021, the P&P indicated The Transitional Care unit will inform the resident; consult with the resident's physician; and notify the resident representative when there is a change in condition or status of a resident.Nursing will notify the resident attending physician when there is a change in condition or status immediately or ASAP.

Based on interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 1 was competent in providing one to one care ([1:1 sitter] provides constant supervision to a single patient to ensure safety) for one of one residents (Resident 38) who was diagnosed with suicidal ideations (death caused by injuring oneself with the intent to die) in the facility.This deficient practice had the potential to affect Resident 38 and all residents requiring close observation, and placed them at risk for self-harm, hospitalization and death.Findings:During a review of Resident 38's admission Record, the admission Record indicated Resident 38 was admitted to the facility on [DATE].During a review of Resident 38's Minimum Data Set (MDS- a resident assessment tool) dated 3/13/2026, the MDS indicated Resident 38's cognition (ability to think, understand, learn, and remember) was intact. The MDS indicated Resident 38 was dependent (helper does all the effort) with activities of daily living (ADLs- activities such as bathing, dressing, and toileting a person performs daily).During a review of Resident 38's physician orders dated 3/13/2026 at 6:39 p.m., the physician orders indicated an order for a sitter to observe Resident 38 for suicidal ideations.During a review of Resident 38's History and Physical (H&P) dated 3/15/2026, the H&P indicated Resident 38 had diagnoses of atrial fibrillation (AFIB- irregular heart rate), paraspinal mass (tumor that develops in the area of the spine), and hypertension (HTN- high blood pressure).During a concurrent observation and interview on 3/14/2026 at 10:05 a.m., in Resident 38's room, Licensed Vocational Nurse (LVN) 1 was sitting at Resident 38's bedside. LVN 1 stated she was a 1:1 sitter for Resident 38 because he was a high-fall risk, confused, and tries to get out of bed without calling.During a telephone interview on 3/14/2026 at 11:44 a.m., with Resident 38's daughter, Resident 38's daughter stated he had a 1:1 sitter because Resident 38 told her that he wanted to hurt himself and die and if given the chance.During an interview on 3/15/2026 at 1:54 p.m., with Registered Nurse (RN) 2, RN 2 stated Resident 38 had a 1:1 sitter because he (Resident 38) made a comment about wanting to die. RN 2 stated LVN 1 should have known why Resident 38 needed to have a 1:1 sitter so she was aware of what to watch for, prevent Resident 38 from harming himself, and for Resident 38's safety.During an interview on 3/15/2026 at 5:54 p.m., with the Director of Nursing (DON), the DON stated LVN 1 should have known why she was 1:1 for Resident 38. The DON stated it should have been communicated appropriately so LVN 1 would know what to look for in Resident 38's behaviors, mood, attempts to harm himself and for the safety of Resident 38.During a review of the facility's policy and procedure (P&P) titled, Sitter, Patient Support Personnel dated 2/1/2025, the P&P indicated, The responsibilities of the sitter support staff include, obtaining a patient condition report prior to engaging in care activities, taking responsible steps to ensure that the patient does not harm him/herself or others, reporting any changes in mental status, physical status to the primary nurse immediately.

Based on observation, interview, and record review, the facility failed to maintain and observe infection control practices by failing to:Ensure staff change gloves after picking up a dirty trashcan and before passing medications to one of three sampled residents (Resident 4).Ensure visitors followed Enhanced Barrier Precautions (EBP- infection control steps requiring staff to wear gowns and gloves during high-contact care [dressing, bathing, or changing linen] for residents with, or at risk of, germ-resistant infections) for one of three sampled residents (Resident 40).These failures had the potential to result in cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another) and place all residents at risk for spread of infection.Findings:1. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility 2/3/2026.During a review of Resident 4's History and Physical (H&P) dated 2/4/2026, the H&P indicated Resident 4 was admitted with diagnoses including intracerebral hemorrhage (bleeding into the brain tissue) and acute respiratory failure (the lungs can't release enough oxygen into your blood).During a review of Resident 4's Minimum Data Set (MDS- a resident assessment tool) dated 2/10/2026, the MDS indicated Resident 4's cognition (ability to think, understand, learn, and remember) was moderately impaired. The MDS indicated Resident 4 was dependent (helper does all of effort) with activities of daily living (ADLs- activities such as bathing, dressing, and toileting a person performs daily).During a concurrent observation and interview on 3/15/2026 at 9:22 a.m., during a medication pass observation with Registered Nurse (RN) 2, RN 2 was observed preparing Resident 4's medications while wearing gloves, went to retrieve the trashcan, and then went back to preparing medications without changing gloves or performing hand hygiene. RN 2 stated she should have washed her hands and changed her gloves after picking up the trashcan because the trashcan is dirty and to prevent cross-contamination and infection for Resident 4.During an interview on 3/15/2026 at 11:03 a.m., with the Infection Prevention Nurse (IPN), IPN stated RN 2 should have washed her hands and changed her gloves after touching the trash can while passing medications because it could cause an infection for Resident 4.During an interview on 3/15/2026 at 5:54 p.m., with the Director of Nursing (DON), the DON stated RN 2 should have washed her hands and changed gloves after touching the trashcan to prevent an infection.During a review of the facility's policy and procedure (P&P) titled, Standard Transmission Based Isolation Precautions, dated 1/1/2020, the P&P indicated, Standard precautions are designed to ensure a safe environment and reduce the potential for transmission of infection to both patients and healthcare personnel. Gloves should be removed after contact with a patient and/or the surrounding environment.2. During a review of Resident 40's admission Record, the admission Record indicated Resident 40 was admitted to the facility on [DATE].During a review of Resident 40's H&P dated 3/9/2026, the H&P indicated Resident 40 was admitted with diagnoses of lip hip fracture (broken bone) and hypertension (HTN- high blood pressure).During a review of Resident 40's Social Work Adult Psychosocial assessment dated [DATE], the Social Work Adult Psychosocial Assessment indicated Resident 40's cognition was intact.During a review of Resident 40's MDS, dated [DATE], the MDS indicated Resident 4 was dependent on ADLs.During a review of Resident 40's Order's, the Order's indicated an order, dated 3/14/2026, for EBP isolation for an unhealed surgical incision.During a concurrent observation and interview on 3/14/2026 at 10:12 p.m., with the Director of Staff Development (DSD), Resident 40's visitor was observed in the room assisting Resident 40 to sit up in bed and assist to the chair without wearing appropriate personal protective equipment (PPE- clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments). The DSD stated the caregiver should be wearing PPE while providing care for Resident 40 to prevent the spread of infection.During an interview on 3/14/2026 at 10:30 a.m., with the IPN, the IPN stated the facility encourages visitors to wear the appropriate PPE if they provide high-contact care. The IPN stated visitors not wearing PPE could result in the transmission of infection to the residents.During an interview on 3/15/2026 at 5:54 p.m., with the DON, the DON stated visitors should be wearing PPE for the safety of the residents and to prevent the spread of infection.During a review of the facility's P&P titled, Standard Transmission Based Isolation Precautions, dated 1/1/2020, the P&P indicated, EBP is a resident-centered and activity-based approach for preventing multi-drug-resistant organism (MDROs) transmission during high-contact care with any resident with surgical (unhealed) wounds. Visitors are to be educated by the staff on how to wear appropriate PPE for patients in isolation.During a review of the facility's P&P titled, Visiting Hours dated, 1/1/2020, the P&P indicated, Visitors must adhere to the isolation protocol.

Based on observation, interview and record review, the facility failed to ensure: a. opened, unlabeled and undated bag of pepperonis with freezer burns was not stored in the freezer and was discarded. b. the temperature on a High Temperature Dishwasher wash cycle was 150 degrees Fahrenheit. These failures had the potential to result in residents eating compromised quality of meat due to dryness and altered texture and had the potential to result in residents being exposed to rapid growth of bacteria that can cause foodborne illness (food poisoning). Findings: During a concurrent observation and interview on 1/17/2025 at 5:00 pm, with Manager of Patient Services (MOPS) in the kitchen, Freezer #14 had an unlabeled open bag of pepperonis with freezer burns. During an interview on 1/19/2025 at 10:55 pm with Dishwasher (DW ) 1, DW 1 stated when washing dishes the temperature is 150 degrees Fahrenheit. DW 1 stated it is important to wash dishes at 150 degrees Fahrenheit to kill the bacteria. During an observation on 1/19/2025 at 11:37 am in the kitchen, the temperature on the dishwasher wash cycle temperature ranged from 144 degrees Fahrenheit to 146 degrees Fahrenheit. During an interview on 1/19/2025 at 2:10 p.m. with Lead Food Service Supervision, LFSS stated after food is opened in the freezer the food is put in a plastic bag and labeled and dated. LFSS stated all food items are labeled and dated so we know the last day it can be used and the name of the person who opened it. LFSS stated food with freezer burn is discarded because the presentation and taste will not be good. LFSS stated the temperature on the dishwasher wash cycle is 147 to 149 degrees Fahrenheit and the manger was notified to get it fixed. The LFSS stated the goal is 150 degrees Fahrenheit to kills germs and bacteria based on the facility's policy. During a review of the facility's policy and procedure (P&P) titled, Food Storage, dated 9/12/2023, the P&P indicated Date products to ensure the use of first in first out (FIFO procedures .Label and date products per regulatory standards . Store all leftovers cold food in storage containers and completely cover with plastic or foil wrap. Label and date the containers and place them in the refrigerator. During a review of the facility's policy and procedure (P&P) titled, Infection Control, Food Safety and HACCP (Hazard analysis and Critical Control Point), dated 9/12/2023, the P&P indicated the purpose is to To ensure the safety and quality of the food served to patients, visitors, and staff . Dish machine wash water should be 150 degrees Fahrenheit or greater.

Based on observation, interview and record review, the facility failed to provide services which meet professional standards of quality for one of four sampled residents (Resident 12) by failing: 1. To ensure vital signs (measurements of the body's most basic functions such as heart rate, breathing rate, blood pressure, and temperature) were obtained before administering medications that can affect blood pressure( bp- force of blood pushing against the walls of the arteries). 2. To ensure vital signs reading taken two hours ago before administration of an anti-hypertensive medicines (medicines that are used to lower high blood pressure) was not used as a parameter(limit that affects how something is done) to administer the medicine. These failures have the potential to put Resident 12 at risk for hypotension (low blood pressure) that could lead to fall. Findings: During a review of Resident 12's Admission Record, the Admission Record indicated the resident was admitted on [DATE] to the facility with diagnoses that included hypertension (high blood pressure), diabetes ( DM- a disorder characterized by difficulty in blood sugar and poor wound healing),and aphasia( a disorder that makes it difficult to speak). During a review of Resident 10's Minimum Data Set (MDS- a resident assessment tool) dated 12/28/2024, the MDS indicated the resident had moderately impaired cognitive skills for daily decision making and was dependent (helper does all the effort) on staff with eating, oral hygiene, toileting hygiene, bathing, dressing, and personal hygiene. The MDS indicated the resident required substantial assistance (helper does more than half the effort) with bed mobility and transfer to and from bed a bed to chair. During a review of Resident 12's Vital Signs Record dated 1/19/2025 indicated resident's blood pressure was 101/53, and heart rate 64 beats per minute taken at 7:07 a.m. During a medication administration observation on 1/19/2025 , at 8:40 a.m. with Registered Nurse (RN1), observed RN 1 administered Amlodipine ( medicine used to treat high blood pressure) 2.5 milligrams (mgs- unit of measurement) one tablet and lisinopril 10 mgs one tablet to Resident 12 without taking resident's blood pressure. During an interview on 1/19/2025, at 12:54 p.m. with RN 1, RN 1 stated she would usually use the blood pressure and heart rate taken by Certified Nursing Assistants from 6:30 a.m. to 7:00 a.m. when passing medicines that could lower the blood pressure. RN 1 stated she was told by the facility that it's alright to use the result of vital signs taken two hours ago before medication administration. RN 1 stated for Resident 12, she used the blood pressure reading taken around 7:00 a.m. on 1/19/2025. RN1 stated there is a possibility of hypotension (low blood pressure), dizziness and fall if lisinopril and amlodipine were given, and blood pressure was not checked before administering them. During an interview on 1/19/2025, at 4:05 p.m. with Director of Nursing (DON), DON stated the licensed nurse should reach out to the physician to discuss any changes on resident's condition and obtain a parameter to hold the medicine. DON stated there was no policy or defined time frame indicating it was alright to use vital signs taken in the morning around 7:00 a.m. or taken two hours ago to use as a basis to administer the cardiac medicines for 9:00 a.m. DON stated the resident could develop hypotension , lightheadedness or fall if the resident's blood pressure is not taken before administering it to the resident because the bp might be lower than what was taken from 7:00 a.m. During a review of an online article from National Library of Medicine updated 7/24/2024 titled Hypertensive Emergency (Nursing) indicated to monitor blood pressure frequently and know the target set by the physician. https://www.ncbi.nlm.nih.gov/books/NBK568676/. During a review of an online article from National Library of Medicine titled Blood Pressure Assessment in Adults in Clinical Practice and Clinic-Based Research: JACC Scientific Expert Panel - PMC Volume 73, Issue 3, published 1/29/2019, the online article indicated the primary purpose of measuring bp in routine clinical practice are to screen for hypertension and hypotension , and to monitor the response to antihypertensive treatment.

Based on interview and record review, the facility failed to ensure one of 12 sampled residents (Resident 2) was free from receiving an unnecessary antibiotic, to treat a skin tear (a wound that occurs when the skin separates due to friction, blunt force, or shear). This failure had the potential for Resident 2 to experience adverse side effects, antibiotic resistance and to receive an inappropriate antibiotic. Findings: During a review of Resident 2's Registration Record, the Registration Record indicated Resident 2 was admitted to the facility on [DATE]. During a review of Resident 2's History and Physical (H&P), dated 12/17/2024, the H&P indicated Resident 2 had diagnoses of but not limited to a skin tear of the lower leg without complication, pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence), and cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain) with left lower leg weakness. During a review of Resident 2's Minimum Data Set (MDS-a resident assessment tool), dated 12/23/2024, the MDS indicated Resident 2 had the ability to understand others and had the ability to express wants and ideas. The MDS indicate Resident 2 was dependent on nursing staff for lower body dressing, putting on and taking off footwear, showering and transferring from the bed to chair. The MDS indicated Resident needed substantial to maximal assistance from nursing staff with oral hygiene, toileting upper body dressing, and personal hygiene. The MDS indicated Resident 2 needed substantial to maximal assistance from nursing staff with rolling from left to right, sitting, standing and lying flat on the bed. The MDS indicated Resident 2 needed partial to moderate assistance from staff with eating. During a review of Resident 2's Physician Orders, the Physician Orders indicated Resident 2 had an order for clindamycin (medication used to treat various types of infections, including skin and vaginal infections) 300 milligrams, two capsules by mouth every eight hours for cellulitis (a skin infection that causes swelling and redness) of the right leg starting on 12/18/2024 to 12/25/2024. During a concurrent interview and record review on 1/19/2025 at 9:33 a.m. with the Infection Preventionist (IP), Resident 2's Hospitalist Progress Notes, dated 12/20/2024 was reviewed. The Hospitalist Progress Notes indicated, Resident 2 had right leg cellulitis from a skin tear. The Hospitalist Progress Notes indicated Resident 2's skin tear was red and hot. The Hospitalist Progress Notes indicated Resident 2's was started on clindamycin. The IP stated Resident 2 was admitted to the facility on [DATE] and started on clindamycin on 12/18/2024. The IP stated no culture was done before the antibiotic were administered to Resident 2. The IP stated Resident 2 did not have a fever, elevated white blood cells and had no drainage from the skin tear. During a concurrent interview and record review on 1/19/2025 at 12:48 p.m. with the IP, the facility's policy and procedure (P&P) titled Surveillance Definitions, dated 1/2025 was reviewed. The P&P indicated, Skin infections must meet at least one of the following criteria: Patient has at least one of the following purulent drainage, pustules, vesicles, boils (excluding acne). Patient has at least two of the following localized signs or symptoms: pain* or tenderness*, swelling*, erythema *, or heat* and at least one of the following: organism(s) identified from aspirate or drainage from affected site by a culture or non-culture-based testing method which is performed for purposes of clinical diagnosis and treatment The IP stated Resident 2 did meet the NHSN criteria for a skin infection. The IP stated this should have been discussed with the physician. The IP stated Resident 2 could develop c-diff or a multi drug resistant organism. During an interview on 1/19/2025 4:04 p.m. with the Director of Nursing (DON), the DON stated Resident 2 had the potential to develop side effects and resistance to antibiotics after taking antibiotics and not meeting the NHSN criteria. During a review of the facility's policy and procedure (P&P) titled, Transitional Care Unit (TCU) Drug Indication Review Protocol, date revised 4/21/2015, the P&P indicated Pharmacy, in accordance with Title 42 of the Code of Federal Regulations section 483.60c, will perform a weekly drug regimen review. If a drug and corresponding indication is clearly delineated as part of the medical record, the pharmacist will transcribe that information onto the physician orders. If a drug does not have a clear indication, the pharmacist will clarify the diagnosis with the physician or take measures to discontinue the medication.

Based on observation, interview, and record review the facility failed to notify the physician on one of four sampled residents (Resident 122) by: 1. Failing to notify the physician and document a change in condition when Resident 122 had an episode of nausea and vomiting and refusal to eat. This failure had the potential to delay treatment or care for Resident 122. Findings: During a review of Resident 122's Admission Record, the Admission Record indicated the resident was admitted on [DATE] to the facility. During a review of Resident 122's History and Physical (H & P) dated 1/7/2025, the H & P indicated the resident was admitted with diagnoses that included history of breast cancer ( a disease when an abnormal breast cells grow out of control and form tumors in the breast which was treated in the past), metastatic disease to the bone (cancer that had spread to the bone), atrial fibrillation( heart condition that causes an irregular heart beat), stage 3 pressure ulcer ( full thickness loss of skin and dead and black tissue may be visible) and hypothyroidism( when the thyroid gland does not make enough thyroid hormone which can lead to health problems). During a review of Resident 122's Minimum Data Set (MDS- a resident assessment tool) dated 1/13/2025, the MDS indicated the resident was rarely or never understood and had moderately impaired cognitive skills for daily decision making (problem with a person's ability to think, learn, remember, use judgment, and make decisions). The MDS indicated the resident is dependent on staff with transfer to and from a bed to chair, eating, oral hygiene, toileting hygiene, bathing, and personal hygiene. During a review of Resident 122's Care Plan titled LTC Gastrointestinal IPOC' initiated 1/18/2025, the Care Plan indicated interventions that included evaluating possible causes of nausea and vomiting, using nursing care measures for nausea/ vomiting as indicated and evaluating the resident for abdominal distension(swelling and becoming large by pressure from inside characterized by symptoms of trapped gas , abdominal pressure, and fullness) ,tenderness and bowel motility ( gut movement). During a review of Resident 122's Interdisciplinary Summary datedSummary dated 1/17/2025 and timed at 4:00 p.m. indicated the resident had an episode of vomiting after lunch and anti-nausea medication was refused by the Family Member (FM1). During a review of Resident 122's meals meal intake dated 1/17/2025 and 1/18/2025, the meal intake for 1/17/2025 indicated the resident ate breakfast and lunch but did not have dinner. The meal intake for 1/18/2025 indicated the resident did not eat lunch. During a review of Resident 122's meal intakes from 1/9/2025 to 1/17/2025, the resident was only eating breakfast and lunch. During an interview on 1/18/2025, at 3:54 p.m. with Certified Nursing Assistant (CNA2), CNA 2 stated Resident 122 did not receive a lunch tray today because Family Member (FM1) did not order any food due to resident's upset stomach. During a concurrent interview and record review of Resident 122's electronic Record on 1/18/2025, at 4:18 p.m. with Registered Nurse (RN3), RN 3 confirmed on 1/17/25, Resident 122 had an episode of nausea and vomiting, and the physician was not notified and change of condition was not documented. RN 3 stated on 1/18/2025, FM1 spoke to her before lunch that she cancelled the lunch tray of the resident because the resident did not want to eat. RN 3 stated she should have talked to the physician about resident's refusal to eat and ordered a lunch tray even FM1 cancelled the tray. During a concurrent interview and record review of Resident 122's electronic chart on 1/19/2025, at 3:36 p.m. with Director of Staff Development (DSD), DSD stated the licensed nurses document the change in condition in the Interdisciplinary Summary under Nurses Notes and CNA's document the meal intake in real time. DSD stated nausea and vomiting is a change in condition. DSD stated the nurse should have assessed, notify the physician about the episode of nausea and vomiting and documented a change in condition. DSD stated it is important to notify the physician for medical intervention and obtain order for treatment to prevent causing delay of treatment and care. During an interview on 1/19/2025, at 4:08 p.m. with Director of Nursing (DON), DON stated it is important for the licensed nurses to communicate directly to the physician about what the resident needs and problem because information coming from the family could be inaccurate and can cause a delay in care. DON stated it is important to notify the physician for any change in condition of a resident to obtain orders for treatment or medical intervention. During a review of facility's policy and procedure (P&P) titled Change in Resident's Condition or Status dated 4/3/2024, the P&P indicated nursing will notify the resident's attending physician when there is a change in condition. The P&P indicated the Transitional Care Unit will notify the physician, resident and resident representative when there is a change in condition including a significant change in the resident's physical, mental or psychosocial status or a need to alter

Based on interview and record review, the facility failed to ensure one of 12 sampled residents (Resident 2) was free from receiving an unnecessary antibiotic, to treat a skin tear (a wound that occurs when the skin separates due to friction, blunt force, or shear). This failure had the potential for Resident 2 to experience adverse side effects, antibiotic resistance and to receive an inappropriate antibiotic. Findings: During a review of Resident 2's Registration Record, the Registration Record indicated Resident 2 was admitted to the facility on [DATE]. During a review of Resident 2's History and Physical (H&P), dated 12/17/2024, the H&P indicated Resident 2 had diagnoses of but not limited to a skin tear of the lower leg without complication, pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence), and cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain) with left lower leg weakness. During a review of Resident 2's Minimum Data Set (MDS-a resident assessment tool), dated 12/23/2024, the MDS indicated Resident 2 had the ability to understand others and had the ability to express wants and ideas. The MDS indicate Resident 2 was dependent on nursing staff for lower body dressing, putting on and taking off footwear, showering and transferring from the bed to chair. The MDS indicated Resident needed substantial to maximal assistance from nursing staff with oral hygiene, toileting upper body dressing, and personal hygiene. The MDS indicated Resident 2 needed substantial to maximal assistance from nursing staff with rolling from left to right, sitting, standing and lying flat on the bed. The MDS indicated Resident 2 needed partial to moderate assistance from staff with eating. During a review of Resident 2's Physician Orders, the Physician Orders indicated Resident 2 had an order for clindamycin (medication used to treat various types of infections, including skin and vaginal infections) 300 milligrams, two capsules by mouth every eight hours for cellulitis (a skin infection that causes swelling and redness) of the right leg starting on 12/18/2024 to 12/25/2024. During a concurrent interview and record review on 1/19/2025 at 9:33 a.m. with the infection Preventionist (IP), Resident 2's Hospitalist Progress Notes, dated 12/20/2024 was reviewed. The Hospitalist Progress Notes indicated stated Resident 2 had right leg cellulitis from a skin tear. The Hospitalist Progress Notes indicated Resident 2's skin tear was red and hot. The Hospitalist Progress Notes indicated Resident 2's was started on clindamycin. The IP stated Resident 2 was admitted to the facility on [DATE] and started on clindamycin on 12/18/2024. The IP stated no culture was done before the antibiotic were administered to Resident 2. The IP stated Resident 2 did not have a fever, elevated white blood cells and had no drainage from the skin tear. During a concurrent interview and record review on 1/19/2025 at 12:48 p.m. with the IP, the facility's policy and procedure (P&P) titled Surveillance Definitions, dated 1/2025 was reviewed. The P&P indicated, Skin infections must meet at least one of the following criteria: Patient has at least one of the following purulent drainage, pustules, vesicles, boils (excluding acne). Patient has at least two of the following localized signs or symptoms: pain* or tenderness*, swelling*, erythema *, or heat* and at least one of the following: organism(s) identified from aspirate or drainage from affected site by a culture or non-culture based testing method which is performed for purposes of clinical diagnosis and treatment. The IP stated Resident 2 did meet the NHSN criteria for a skin infection. The IP stated this should have been discussed with the physician. The IP stated Resident 2 could develop c-diff or a multi drug resistant organism. During an interview on 1/19/2025 4:04 p.m. with the Director of Nursing (DON), the DON stated Resident 2 had the potential to develop side effects and resistance to antibiotics after taking antibiotics and not meeting the NHSN criteria. During a review of the facility's policy and procedure (P&P) titled, Medication Management-Antibiotic Stewardship Program, dated 11/1/2023, the P&P indicated, The purpose of antibiotic stewardship team is to formulate clinical, multi-disciplinary strategies around anti- infective therapy. Our mission is to mitigate over utilization of anti-infectives that may lead to adverse patient outcomes as well as promote the timely administration of appropriate, life-saving anti-infective treatments to meet the needs of our community.

Based on observation and interview the facility failed to ensure staffing information was posted and placed in a visible and prominent place daily. This deficient practice resulted in unavailable information for the number of staff and actual hours worked daily that is visible for residents, staff and visitors. Findings: During an observation 1/19/2025 at 11:30 a.m., no visible staffing information was found on station 1 or station 2. During an observation on 1/19/2025 at 11:30 a.m., no visible staffing information was found in the lobby or upon entrance to the unit. During an interview on 1/19/2025 at 11:49 a.m., with Registered Nurse (RN) 1, RN 1 stated there is no staffing information visibly posted for the residents and visitors. During an interview on 1/19/2025 at 11:52 a.m., with the Director of Staff Development (DSD), the DSD stated that there is a staffing information form posted in station 1 but is not facing outward for residents and visitors to see and probably should be. During an interview on 1/19/2025 at 3:42 p.m., with the Director of Nursing (DON), the DON stated the nurse staffing hours were not posted for residents and visitors to see but should be, so they are aware they are following the regulation and are aware of the staffing for each day.

Based on observation and interview the facility failed to ensure one of one ice machines in the facility kitchen was clean. This deficient practice had the potential to result in an outbreak of food borne illness (illness caused by food contaminated with germs). Findings: During an observation of one of one ice machine in the facility kitchen and interview on 1/12/2024 6:09 p.m., with the Food Service Lead (FSL), the ice machine bin was opened, the front panel interior bin was wiped with a clean paper towel, and dirt (dark gray colored) residue was noted. The KL stated the ice machine was dirty and it should be clean. During an interview on 1/13/2024 at 12:15 p.m. with the Patient Services Manager, Food & Nutrition Services (PSM), PSM stated the ice machine should be clean as indicated in the facility policy. During a review of the facility policy and procedure titled, Dispensing Ice, dated 10/6/2020, the policy indicated the food and nutrition services department prepares and dispense ice under strict procedures to prevent the transmission of disease. The policy indicated the ice holding bin in the kitchen will be clean.

Based on interview and record review, the facility failed to address/ implement facility assessment elements when: a. The facility failed to include the Infection Prevention Nurse (IPN) dedicating mandated hours in the Transitional Care unit (TCU) for 40 of 40 residents in the facility assessment. b. The facility failed to obtain an offsite contract for dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) center as indicated in the facility assessment. c. The facility failed to implement Certified Nurse Assistants' (CNA) 1 hour in service education to be provided twice per month, including dementia management, abuse/neglect, and patient rights and responsibilities as indicated in the facility assessment. These deficient practices had a potential to result in the provision of inadequate care and services to the facility's resident population. Findings: a. During an interview on 1/13/2024 at 12:59 p.m. with the IPN, the IPN stated she was responsible for the whole hospital, and she was the manager for the whole Infection Prevention Unit. The IPN stated she cannot provide the breakdown of hours of IPNs designated for TCU. The IPN said that she could not provide any proof that she was doing the IP role solely for the unit. During a concurrent interview and record review on 1/13/2024 at 2:26p.m. with the Director of Nursing (DON), the Facility Assessment, dated 2024, was reviewed. The facility assessment did not include the IPN, and the facility assessment did not indicate the full-time hours required for the IPN. The DON stated the facility assessment doesn't indicate about the full-time hours for IPN. The DON stated the IPN had an important role since there were outbreaks and the TCU needed someone who would implement infection Prevention Control Policy throughout the unit. b. During an entrance conference with the DON on 1/12/2024 at 6:24 p.m., the DON stated that the facility doesn't have any dialysis contract. During a concurrent interview and record review on 1/13/2024 at 9:15 a.m. with the DON the facility's assessment dated ,d+[DATE]-[DATE], was reviewed. The facility assessment indicated special care needs provided will be offsite dialysis. The DON stated that the facility assessment was reviewed last 12/2023 and indicated offsite dialysis will be provided. c.During a review of TCU in-service records, records indicated 4 staff attended on 12/19/2023 for the lines, tubes, and drain in-service and six staff attended the in-service on 12/5/2023 for the trauma informed care. During a review of the TCU In-service calendar (January, February, March 2024), the calendar indicated 2 dementia and no abuse or patient rights training. During an interview on 1/13/2023 at 1:25 p.m. with the Director of Staff Development (DSD) regarding the in-services provided to the staff, The DSD stated that she cannot mandate nurses to go to her in-services. The DSD stated there were only 4 staff who attended on 12/19/2023 for the lines tubes and drain in-service. The DSD added that on 12/5/2023 6 attended for the trauma informed care in-services. The DSD stated for the 3 months calendar TCU-In-Service (January, February, March 2024) she has scheduled 2 dementia and no abuse or patient rights training. The DSD stated education was important so staff would know any updates and to refresh their knowledge. The DSD stated although she was present during the review of the facility assessment back in December 2023, she was not aware of the facility assessment requirement to provide CNA's 1 hour of in-services twice a month for dementia management, abuse, neglect, or patient rights training. The DSD stated she would need to coordinate with the DON about the facility assessment and will provide the in-services if needed. During an interview on 1/14/2023 at 10:16 a.m. with the DON, the DON stated the facility assessment needed to be revised since the facility does not have a facility contract with any dialysis center. The DON further added that the in-services part in the assessment will also be revised if needed.

Based on interview and record review the facility failed to obtain informed consent (process by which a healthcare provider educates a resident about the risks and benefits, and alternatives of a given procedure or intervention) prior to the administration of psychotropic drugs (drug that affects brain activities associated with mental process and behavior) for two out of three sampled residents (Resident 119 and 67) as indicated in the facility's policy and procedure (P&P). These deficient practices resulted in the violation of residents' right to be informed in advanced by the physician of the risk and benefits of the drug and treatment alternatives. Findings: a. During a review of Resident 119's Registration Record, the record indicated the resident was admitted to the facility on [DATE]. During a review of Resident 119's History and Physical (H&P), dated 1/10/2024, the H&P indicated Resident 119 had a history of anxiety (feeling of fear, dread, and uneasiness) and stress at home. The H&P indicated Resident 119 recently received a kidney transplant (surgery to place a healthy kidney from a donor) on 12/1/2023. The H&P indicated Resident 173 was awake alert and oriented. The H&P indicated Resident 119's list of medication from home included Zoloft (medication to treat mood disorders)100 milligrams (mg, unit of measure) oral tablet daily, and alprazolam (medication to treat anxiety) 0.5 mg orally two times a day as needed. During a review of Resident 119's Order sheet, the order sheet indicated the following medication orders: a. On 1/10/2024 at 6:12 p.m. Zoloft 100 mg one tablet oral daily b. On 1/10/2024 Alprazolam 0.5 mg one tablet oral three times a day as needed for anxiety for fourteen days. During a review of Resident 119's Medication Administration record (MAR) Summary, the MAR indicated the following: a. Zoloft 100 mg was first at ministered in the Transitional Care Unit (TCU) on 1/11/2024 at 8:44 a.m. b. Alprazolam 0.5 mg was first administered in the on 1/11/2024 at 8:51 p.m. During a review of Resident 119's Patient Consent to Receive Psychotropic Medications, Resident 119 signed the consent, indicating she acknowledged receiving information on the psychotropic drugs on 1/13/2024 at 1:00 p.m. approximately 2 days after the medications were administered in the TCU. During a concurrent interview and record review on 1/13/2024 at 1:38 p.m. with Registered Nurse 2 (RN 2), Resident 119's MAR and psychotropic consents were reviewed. The MAR indicated Resident 119 received Zoloft and Alprazolam on 1/11/2024. The consent indicated Resident 119 consented to the psychotropic drugs on 1/13/2024, two days after the drugs were administered. RN 2 stated Resident 119 consented to the drugs two days after the psychotropics were administered. RN 2 stated the consent should have been obtained prior to the administration of the doses because these drugs are like restraints (a measure that keep someone under control or within limits) and as indicated in the policy. b. During a review of Resident 67's Registration Record, the record indicated the resident was admitted to the facility on [DATE]. During a review of Resident 67's History and Physical (H&P), dated 12/30/2023, the H&P indicated Resident 67 had a history of dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities). The H&P indicated Resident 67 became more confused disoriented and agitated at times during her hospitalization . During a review of Resident 67's Minimum Data Set (MDS-a comprehensive assessment and care planning tool), dated 1/05/2024, the MDS indicated Resident 67 sometimes understood and sometimes understand others, had impaired vision and had moderately impaired decision-making skills. The MDS indicated Resident 67 required maximal assistance (helper does more than half the effort) for rolling left to right, sit to lying and lying to sitting. During a record review of Resident 67's active orders, dated 1/14/2024, the orders indicated the following medications: a. Lorazepam (medication to relieve anxiety) 0.5mg (milligram-unit of measurement) one tab every 8 hours as needed for anxiety (a feeling of worry), b. Trazodone (medication to treat depression [mental disorder that negatively affects how the resident feels] and sedative [inducing sleep]) 75 mg, one and half tablet as needed at bedtime. During a record review of the Resident 67's psychotropic consent to receive psychotropic medications, dated 12/30/2023, the consent indicated Lorazepam 0.5 mg/0.25 millimeters intravenous ([IVP]medication administered directly to the bloodstream) push every 8 hours as needed for anxiety. During a concurrent interview and record review on 1/13/2024 at 1:38 p.m. with Registered Nurse 2 (RN 2), Resident 67's active order and psychotropic consents were reviewed. The records indicated Resident 67's consent of lorazepam to be administered IVP did not match the lorazepam physician order for oral tablet. RN 2 stated the lorazepam route of administration in the order did not match the route in the consent. RN 2 stated the consent and order should be the same. RN2 stated it was not consented medication should not be administered, and it could be considered as unnecessary medication. During an interview on 1/14/2024 at 10:16 p.m. with Director of Nursing (DON), the DON stated psychotropic medications should be consented prior to administration of the medication. During a review of the facility's policy and procedure titled, Informed Consent for Psychotherapeutic Medications and devices, reviewed 3/2022, the policy indicated: 1. Upon admission to the Transitional Care Unit, nursing will review orders and ensure an informed consent for any prescribed psychotropic medications is present in the medical record. 2. Prior to the administration of medication and within 24 hours of medication order, nursing and the physician will obtain patient signature acknowledging their informed consent. 3. Every 24 hours, the Lead Registered Nurse or designee will validate the presence of informed consent for all psychotropic medications, contact the physician if the consent form was missing to facilitate obtaining the consent or discontinuing the medication as needed. 44055

During an observation, interview and record review the facility failed to store medication in a locked compartments and not left at residents' bedside for two of four sampled residents (Resident 170 and 171). This failure had the potential for medication errors, and lack of oversight for Resident 170 and 177. Findings: During a review of Resident 170's Registration Record, the Registratin Record indicated Resident 170 was admitted to the facility on [DATE] with diagnoses including weakness and fall secondary to orthostatic hypotension (a form of low blood pressure that happens when standing up from sitting or lying down). During a review of Resident 170's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 1/10/2024, the MDS indicated Resident 170 had intact cognition (ability to learn, remember, understand, and make decision). The MDS indicated Resident 170 required supervision with oral hygiene and personal hygiene, moderate assistance with toileting, bed mobility, transfers, dressing, toilet use, and dressing. During a review of Resident 170's Physician Order dated 1/3/2024, the Physician Order indicated order for Systane (eye lubricant) eye drops one drop each eye every two hours while awake. The Physician Orders indicated albuterol 90 microgram (mcg-unit of measurement) aerosol inhaled every six hours PRN (as needed) for wheezing (symptom cause by narrowing and spasm in the small airways of the lungs). During a review of Resident 171's Registration Record, the Registration Record indicated Resident 171 was admitted to the facility on [DATE] with diagnoses including right ankle open reductio internal fixation (ORIF-a type of surgery used to stabilize and heal a broken bone). During a review of Resident 171's History and Physical (H&P) dated 1/10/2024, H&P indicated Resident 171 with diagnosis of asthma (disease that affects the lungs) During a review of Resident 171's Physician Order dated 1/8/2024, the Physician Order indicated order for Systane eye drops one drop each eye PRN (as needed) for dry eyes. The Physician Orders indicated order for albuterol 2.5 milligram (mg-unit of measurement) equals (=) three milliliter (ml- unit of measurement) inhaled every six hours PRN for wheezing. During an observation on 1/12/2024 at 7:05 p.m. inside Resident 170's rom, observed Systane eye on top of the bedside table. Observed albuterol inhaler inside Resident 1701's bedside drawer. During an observation on 1/12/2024 at 7:58 p.m. inside Resident 171's rom, observed Systane eye drops and albuterol inhaler inside a small plastic bag on top of Resident 171's the bedside table. During an interview on 1/13/2024 at 11:45 a.m. inside Medication Room with Registered Nurse (RN) 2, RN 2 stated medication should not be left at Resident 170 and 171's bedside. RN 2 stated if Residents 170 and 171 will self-administer, it should have a physician order, assessment from interdisciplinary team ([IDT] team members from different departments working together with a common purpose to set goals and make decisions that ensure residents receive the best care) and care planed. RN stated there will lack of oversight if medications were left at the bedside which had the potential for Resident 170 and 171 to double dose on their medications. During an interview on 1/14/2024 at 10:26 a.m. with the Director of Nursing (DON), the DON stated medications should not be left on Resident 170 and 171's bedside. The DON stated prior to self-administration, Residents 170 and 171 should assess by IDT team, have a physician order, document the assessment, and develop a care plan to ensure patient safety. During a review of facility's policy and procedures (P&P) titled Medication Administration dated 1/12/2022, indicated Patient self-administration of medication; Provide education to the patient ., observed the patient completing a return demonstration of the medication preparation and administration .document the education, return demonstration and administration in the medical record. Store the medication in the medication cart or automated dispensing cabinet.

Based on observation, interview and record review, the facility failed to ensure a resident with an indwelling urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) was assessed for continued need and removed according to facility's policy and procedure (P&P) for one of four sampled residents (Resident 163). This failure resulted in continued discomfort to Resident 163 and had the potential for Resident 163 to have catheter associated urinary tract infection (CAUTI- a urinary tract infection [ UTI- an infection in any part of the urinary system, the kidneys, bladder, or urethra] associated with urinary catheter use). Findings: During a review of Resident 163's Registration Record, the Registration Record indicated Resident 163 was admitted to the facility on [DATE] with diagnoses of left ankle sprain (an injury that occurs when the ankle rolls, twists, or turns in an awkward way). During a review of Resident 163's History and Physical (H&P), the H&P indicated diagnoses including fall at home, left ankle injury and diabetes (a condition in which the body fails to metabolize (process) glucose (sugar) correctly). The H&P indicated Resident 163 had a large hematoma (bruise) on the lateral portion of left ankle and was very painful to wiggle Resident 163 left ankle. During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 12/30/23, the MDS indicated Resident 163 had moderate cognitive (ability to learn, remember, understand, and make decision) impairment in daily decision making. The MDS indicated Resident 163 was dependent with oral hygiene, toileting, lower, upper, and lower body dressing. The MDS indicated Resident 163 was always incontinent in urination. During a review of Interdisciplinary Summary (Nurse Note) dated 1/2/23 timed at 6 am, the Nurse note indicated foley catheter (indwelling urinary catheter) inserted per physician order. During a concurrent observation and interview on 1/13/24 at 12:30 pm with Resident 163, observed Resident 163 with indwelling urinary catheter. Resident 163 stated her indwelling urinary catheter was uncomfortable and she wants to have it removed. Resident 163 stated she does not know the reason of having the indwelling urinary catheter. During a concurrent interview and record review on 1/13/24 1:44 pm with Registered Nurse (RN) 3, RN 3 stated a bladder scan (assess the volume of urine retained within the bladder) was done on 1/2/24 and indwelling urinary catheter was inserted secondary to urinary retention (a condition in which you cannot empty all the urine from your bladder). RN 3stated there was no order on 1/2/24, the order was entered on 1/12/24. RN 3 stated the need for continued indwelling urinary catheter should have been assessed by licensed nurses. RN 3 stated there was no documentation if indwelling urinary catheter can be removed or reason of continued used. RN 3 stated indwelling urinary catheter had the potential for Resident 163 to develop CAUTI. During a concurrent interview and record review on 1/13/2024 at 3:50 p.m. with RN 2. RN 2 stated Resident 163 had an order for indwelling urinary catheter dated on 1/12/24. RN 2 stated per Nurse Note dated 1/2/24 timed at 6 am, the Nurse Note indicated foley catheter (indwelling urinary catheter) was inserted per physician order due to bladder scan reading of 670 milliliters (ml-unit of measurement). RN 2 stated Resident 163 indwelling catheter should have been assessed for continued need by doing the bladder protocol (steps taken by the facility to assess need and/or continued use of indwelling urinary catheter) per facility's policy and procedure. RN 2 stated indwelling urinary catheter had the potential to cause CAUTI. During an interview on 1/14/24 at 10:26 a.m. with the Director of Nursing (DON), the DON stated if residents was admitted to the facility with indwelling urinary catheter, RN should assess the reason of the need of the indwelling urinary catheter. The DON stated RN will initiate a bladder protocol and will need to reassess in 24 hours the need for continued indwelling catheter. The DON stated indwelling urinary catheter was a source for infection and should be removed if it was no indication. During a review of facility's P&P titled Indwelling urinary Catheter (foley): Insertion, Maintenance, Removal; Bladder Protocol and Bladder Scan dated 3/1/2017 (revised 3/1/2020), the P&P indicated Indications of the use of indwelling urinary catheter shall be limited to patients with failed attempts of external collection .The use of indwelling urinary catheter shall be limited to patients with failed attempts of external collection device .Failure of bladder protocol .and Acute obstructive retention .

During an interview and record review the facility failed to include resident and resident representative in Interdisciplinary ([IDT]- team members from different departments working together with a common purpose to set goals and make decisions that ensure residents receive the best care) care planning and informed of any changes in care, treatment, and interventions for one of four sampled residents (Resident 166). This failure had the potential to violate Resident 166 and resident representative right to be an active participant to Resident 166's care. Findings: During a review of Resident 166's Registration Record, the Registration Record indicated Resident 166 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of altered mental status. During a review of Resident's 166's Discharge Summary (from [GACH] General Acute Care Hospital) dated 1/10/2024 indicated Resident 166 with diagnoses including glioblastoma (malignant tumor affecting the brain or spine) type 2 diabetes (a chronic disease characterized by elevated levels of blood glucose [or blood sugar] in a bloodstream), and confusion due to cerebral edema (swelling of the brain). During an interview on 1/13/2024 at 3:03 p.m. with Resident 166's family member (FM) 1, FM 1 stated family member always stayed with Resident 166 all the time (24/7 twenty-four hours a day seven days a week). FM 1 stated she was not informed when Resident 166 Decadron (medication used to decreased swelling of the brain) was tapered (lowering of doses) and discontinued. FM 1 stated other family member was not aware of what symptoms to watch. FM 1 stated on 12/28/2024, Resident 166 was transferred to the hospital due to altered mental status. FM 1 stated no family member were invited to IDT care planning meeting. FM 1 stated it was important for facility staff to inform them of any changes with medications or treatment as they were always at Resident 166 bedside, and they were the one who can see any changes right away. During an interview on 1/13/2024 at 3:50 p.m. with Registered Nurse (RN) 2, RN 2 stated IDT meeting was held every week for all residents in the facility. RN 2 stated Resident 166 and FM 1 were not included with the IDT meeting. RN 2 stated it was important to inform Resident 166 and/or family member with any changes within care, treatment, and changes in medications so they will be an active participant with their care. During an interview ion 1/14/2024 at 10:26 a.m. with the Director of Nursing (DON), the DON stated IDT meeting was held weekly. The DON stated Resident 166 and FM 1 was not invited on the IDT meeting. The DON stated it was important to include residents and resident representative in IDT meeting for them to be informed of any changes in care, treatment and interventions including medication change. The DON stated Resident 166 and or FM 1 should be an active participant with their care. During a review of facility's policies and procedure (P&P) titled Interdisciplinary Team Conference dated 1/1/1994, the P&P indicated The IDT conference committee meets at least weekly .discuss the residents' status, needs, progress in meeting goals, and the discharge plan. The resident and /or fami9y or responsible party may attend the conferences as needed.

Based on interview, and record review, the facility failed to develop a baseline care plan addressing assistance for feeding for one (1) of four (4) sampled residents (Resident 63). This deficient practice had the potential to negatively affect the delivery of necessary care and services for Resident 63 and negatively impact the resident's physical and psychosocial well-being. Findings: During a review of Resident 63's Registration Record, the Registration Record indicated Resident 63 was admitted to the facility on [DATE]. Resident 63's diagnoses included hypertension (high blood pressure), diabetes mellitus (chronic disease that impairs blood sugar regulation in the body), and anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells). During a review of Resident 63's History and Physical (H& P) dated 1/8/2024, the H&P indicated Resident 63 was alert and oriented and able to move extremities. During a record review of the Speech Therapist (ST) notes dated 01/11/2024, the ST notes indicated that Resident 63 continues to need assistance with feeding due to vision impairment. The note also indicated Certified Nurse Assistant (CNA) took over feeding. During a concurrent observation and interview on 1/12/2024 at 6:30 p.m. at Resident 63's room, while Restorative Nurse Assistant 1(RNA 1) was feeding Resident 63, RNA 1 stated Resident 63 was legally blind on both eyes and hard of hearing (HOH). RNA 1 stated if Resident 63 was not being assisted to eat Resident 63 will not eat because Resident 63 cannot see anything, even shadows. RNA 1 stated sometimes family members feed the resident. During a concurrent interview and record review on 1/13/2024 at 10:36 a.m. with the Director of Staff development (DSD), Resident 63's care plans, dated 1/7/2024, was reviewed. There were no care plans indicating Resident 63 needed assistance with feeding. The DSD stated Resident 63's need with feeding assistance was not addressed on the nutritional care plan and there was no separate care plan for feeding. During a record review of the facility's policy and procedure(P&P) titled, General Statement/ Mission of the Transitional Care Unit, reviewed 10/2020, the P&P indicated: A. The Transitional Care Unit (TCU) conducts concurrent quality management and improvement activities to promote the high quality of care given to patients. This program consists of ongoing monitoring by nursing staff to ensure that patient care plans are current and complete. B. The Multidisciplinary Team Conference meets to discuss each patient's plan of care in the Team Conference. The committee acts to: A. Assure that a plan of care has been established to meet each of the residents' needs and is coordinated between all services. B. Provide a means for multidisciplinary team members review and reassessment of each patient's plan of care on a regular basis. C.Maintain a current and updated patient care plan. During a record review of the facility's policy and procedure(P&P) titled, Standard of Care- Transitional Nursing Care, reviewed 3/2022, the P&P indicated: A.Planning: A plan that includes the priorities and interventions used to achieve the outcomes is developed by the RN. a.Physical and psychosocial measures are planned to prevent, improve, and control specific problems of the aged. b.The plan is individualized and developed with the patient and significant others in healthcare providers when appropriate. B.Implementation: the nurse implements as prescribed in the plan of care a.Nursing interventions are individualized to meet specific situations that allow for alternative approaches. b.Interventions are documented.

Based on interview and record review, the facility failed to develop a comprehensive care plan (a resident-specific plan with defined clinical goals and interventions used to manage identified medical issues or other areas of concern) and person-centered care plans for two out of four sampled residents Resident 163 and 166). 1. Ensure Resident 163 who had pain on her left ankle develop specific interventions to address pain medications and interventions to alleviate (lessen) her pain. 2. Ensure Resident 163 who have an indwelling foley catheter were care planned to assess continued need of indwelling catheter. 3. Ensure Resident 166 who was had a care plan initiated for receiving Decadron (medication used to decreased swelling of the brain) was tapered (lowering of doses) and Keppra (medication used to treat seizures [ burst of uncontrolled electrical activity between brain cells]) develop specific intervention including monitoring adverse reactions and precautions. These failures had the potential for the residents' care needs not to be addressed and the lack of ability to identify the resident's ongoing needs. Findings: During a review of Resident 163's Registration Record, the Registration Record indicated Resident 163 was admitted to the facility on [DATE] with diagnoses of left ankle sprain (an injury that occurs when the ankle rolls, twists, or turns in an awkward way). During a review of Resident 163's History and Physical (H&P), the H&P indicated diagnoses including fall at home, left ankle injury and diabetes (a condition in which the body fails to metabolize (process) glucose (sugar) correctly). The H&P indicated Resident 163 had a large hematoma (bruise) on the lateral portion of left ankle and was very painful to wiggle Resident 163 left ankle, During a review of Resident 163's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 12/30/23, the MDS indicated Resident 163 had moderate cognitive (ability to learn, remember, understand, and make decision) impairment in daily decision making. The MDS indicated Resident 163 was dependent with oral hygiene, toileting, lower, upper, and lower body dressing. The MDS indicated Resident 163 was occasionally in pain with a numeric rating scale of 10 (pain scale 0 zero being no pain and 10 as the worst pain you can imagine). During a review of Resident 166's Registration Record, the Registration Record indicated Resident 166 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of altered mental status. During a review of Resident's 166's Discharge Summary from General Acute Care Hospital [GACH] ) dated 1/10/2024 indicated Resident 166 with diagnoses including glioblastoma (malignant tumor affecting the brain or spine) type 2 diabetes (a chronic disease characterized by elevated levels of blood glucose [or blood sugar] in a bloodstream), and confusion due to cerebral edema (swelling of the brain). During a concurrent interview and record review on 1/13/2024 at 3:50 p.m. with Registered Nurse (RN) 2, RN 2 stated Resident 163's Tramadol was discontinued on 12/27/2023 due to Resident 163 developed ileus (inability of the intestine (bowel) to contract normally and move waste out of the body). RN 2 stated licensed staff did not reassess if Resident 163 can be given a different pain medication after Resident 163 Tramadol was discontinued on 12/27/2023. RN 2 stated there was no individualized care plan for Resident 163's pain on her left ankle. RN 2 stated licensed staff should informed Resident 163's physician of Resident 163's left ankle pain and ordered Tylenol does not help to alleviate (help) Resident 163 left ankle pain with Tylenol. 2.During a review of Interdisciplinary Summary (Nurse Note) dated 1/2/23 timed at 6 am, the Nurse Note indicated foley catheter (indwelling urinary catheter) inserted per physician order. During a concurrent observation and interview on 1/13/24 at 12:30 pm with Resident 163, observed Resident 163 with indwelling urinary catheter. Resident 163 stated her foley catheter was uncomfortable and she wants to have it removed. Resident 163 stated she does not know the reason of having the indwelling urinary catheter. During a concurrent interview and record review on 12/13/24 1:44 pm with RN 3, RN 3 stated a bladder scan was done on 1/2/24 and indwelling urinary catheter was inserted secondary to urinary retention (a condition in which you cannot empty all the urine from your bladder). RN 3 stated there was no order on 1/2/24, the order was entered on 1/12/24. RN stated the need for continued indwelling urinary catheter should have been assessed by licensed nurses. RN stated there was no documentation if indwelling urinary catheter can be removed or reason of continued used. RN stated indwelling urinary catheter had the potential for Resident 163 to develop CAUTI. 3.During a concurrent interview and record review on 1/13/2024 at 3:50 p.m. with RN 2, reviewed care plan for Resident 163 and 166. RN 2 stated Resident 163 care plan for pain management and indwelling catheter were not individualized to addressed Resident 163 pain management and indwelling catheter. RN 2 stated there were no care plan for Resident 166 to address Resident 166 receiving Decadron and Keppra. RN 2 stated it was important to have an individualized and comprehensive care plan for each residents including current medication to ensure licensed nurses will have guidelines on what adverse reaction and side effects to look for. During an interview ion 1/14/2024 at 10:26 a.m. with the Director of Nursing (DON), the DON stated care plan should be individualized based on the needs, diagnoses, and medications of the residents. The DON stated Resident 163 should have an individualized care plan to reflect effectiveness of her pain medication and the continued need of her foley catheter. The DON stated Resident 166 should have a care plan for tapering (reduction of doses) of his Decadron to ensure licensed nurses can monitor the effect of the medication. The DON stated Resident 166 should have a care plan for Keppra medication to ensure licensed nurses know what to monitor while residents was receiving the medication.

During an observation., interview and record review Physical Therapy (PT-health specialist that treat residents to improve movement ) 1 failed to apply gait belt (assistive device which can be used to help safely transfer a resident from a bed to a wheelchair, assist with sitting and standing, and help with walking around) to one of four sampled residents ( Resident 177). This failure had the potential for increased risk of fall for Resident 177. Findings: During a review of Resident 177's Registration Record, the Registration Record indicated Resident 177 was admitted to the facility on [DATE] with diagnosis of right hip arthroplasty (a surgical procedure in which surgeon removed the diseased parts of the hip joint and replaced them with new). During an observation on 1/13/24 at 9:24 a.m. in the hallway, observed Resident 177 walking in the hallway with a front wheeled walker (assistive device for walking) . PT 1 was on Resident 177 right side holding Resident clothing while walking. Observed a family member (name unknown) following with a wheelchair while Resident 177 was walking. During an interview on 1/13/24 at 11:05 a.m. with PT 1, PT 1 stated Resident 177 needs contract guard (healthcare provide place one or two hands on the patient's body to help with balance) assist when he walks. PT 1 stated she should have applied a gait belt to Resident to help with his balance and for safety. PT 1 stated if Resident 177 would fall, gait belt would help control a fall. PT 1 stated gait belt was used for safety and balance. During a review of Resident 177's Physical Therapy evaluation dated 1/1/2024, the Physical Therapy evaluation indicated Resident 177 gait (persons manner of walking) analysis was antalgic (abnormal pattern of walking secondary to pain that ultimately causes a limp) and decreased cadence (number of steps taken).

Based on observation, interview and record review the facility failed to ensure one of five sample residents (Resident 8) fingernails were clean. This deficient practice had the potential to result in a violation of resident's right to a dignified existence which can result in a negative psychosocial wellbeing. Findings: During a review of Resident 8's Registration Record, the record indicated the resident was admitted to the facility on [DATE]. During a review of Resident 8's History and Physical (H&P), dated 12/4/2023, the H&P indicated Resident 8 had a history of hypertension (condition in which the force of the blood against the artery walls -blood vessels that distribute blood to the entire body- is too high), alcohol abuse, anxiety (feeling of dread or worry), supraglottic (upper part of the hollow tube in the middle of the neck) mass (abnormal solid growth) and had surgery 10/12/2023. During a review of Resident 8's Minimum Data Set ([MDS]-a standardized assessment and care screening tool ), dated 12/11/2023, the MDS indicated Resident 8 was sometimes understood and sometimes had the ability to understand others. Resident 8's cognitive skills for daily decision making was moderately impaired (decisions were poor and cues/supervision was required). The MDS indicated Resident 8 needed partial assistance from others person to complete any activity regarding self-care. The MDS indicated Resident 8 was dependent on staff when it came to showering/bathing self. During an observation on 1/12/2024 at 7:49 p.m. in Resident 8's room, Resident 8 was observed to have dark gray dirty debris underneath the fingernails on both hands. During a concurrent observation and interview on 1/13/2024 at 12:42 p.m., with Restorative Nurse Aide 2 (RNA 2) in Resident 8's room, observed Resident 8's fingernails were notably dirty with dark gray debris underneath the fingernails of both hands. RNA 2 stated personal hygiene care was already provided to the resident earlier. RNA 2 stated she tried to clean Resident 8's dirty nails but was unable to do it, and the Registered nurses (RN) were not alerted to the situation. RNA 2 stated she should have alerted the RN's so maybe they can trim Resident 8's fingernails. During an interview on 1/13/2024 at 2:17 p.m. with Registered Nurse 2 (RN 2), RN 2 stated Resident 8's nails should be clean for infection control reasons and dignity issue. During an interview on 1/14/2024 at 10:16 p.m. with Director of Nursing (DON), the DON stated hand hygiene and nail cleanliness was part of resident care and it can affect the resident's dignity. If Resident 8 was refusing to the care it should have been care planned or documented and it was not documented. During a record review of the facility's policy and procedure titled, Standard of Professional performance- physical Comfort, hygiene, and activities of daily living, reviewed 2/2020, the policy indicated: a. The nurse will ensure hygiene and activities of daily living or residents are met according to patient needs, patient abilities and timing of services. Documentation supporting that this standard will be done in the electronic medical record and or as an outcome to the plan of care. b. The primary nurse and will be responsible for providing hygiene assistance according to patient conditions and needs. c. The facility will provide patient an opportunity for grooming by self, with assistance, or by the nurse daily. During a review of the facility's policy and procedure titled, Resident Rights, revised 4/1997, the policy indicated the resident has the right to a dignified existence. The policy indicated care for residents in a manner and in an environment that maintains or enhances resident's dignity and respect.

Based on observation, interview and record review, the facility failed to provide necessary care and services on one of four sample residents (Resident 63) to prevent complications during feeding by: a. Failing to obtain a physician's order for feeding assistance for Resident 63. b. Failing to create a comprehensive resident centered care plan indicating interventions to be implemented while feeding Resident 63 to prevent complications like aspiration (accidentally inhaling food or liquid through vocal cords into the airway) and choking (when person can't speak, cough, or breath because something is blocking the airway). This failure had the potential to result in Resident 63 aspirating and choking while eating. Findings: During a review of Resident 63's Registration Record, the Registration Record indicated Resident 63 admitted to the facility on [DATE]. Resident 63's diagnoses including hypertension (the force of the blood flowing through blood vessels is consistently too high), diabetes mellitus (chronic disease that impairs blood sugar regulation in the body), anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells). During a review of Resident 63's History and Physical (H& P) dated 1/8/2024, it indicated that resident 63 is alert and oriented and able to move extremities. During a record review of the Speech Therapist (ST) notes dated 01/11/2024, ST notes indicated Resident 63 continues to need assistance with feeding due to vision impairment. The note also indicated Certified Nurse Assistant (CNA) took over feeding. During a concurrent observation and interview on 1/12/2024 at 6:30 p.m. at Resident 63's room, while Restorative Nurse Assistant 1(RNA 1) was feeding Resident 63, RNA 1 stated Resident 63 was legally blind on both eyes and hard of hearing (HOH). RNA 1 stated if Resident 63 was not being assisted to eat Resident 63 will not eat because Resident 63 cannot see anything, even shadows. RNA 1 stated sometimes family members fed the resident. During a concurrent interview and record review on 1/13/2024 at 10:25 a.m. with the Director of Staff Development (DSD), Resident 63's current physician's order, dated 1/13/2024, was reviewed. The orders did not indicate Resident 63 needed feeding assistance. The DSD stated that there was no Medical Doctor (MD) to nurse order to feed Resident 63. The DSD further added that anything nurses will do to the resident should have a doctor's order (DO). During the continued concurrent interview and record review on 1/13/2024 at 10:36 a.m. with the DSD, Resident 63's care plans, dated 1/7/2024, was reviewed. There were no care plans indicating Resident 63 needed assistance with feeding. The DSD stated Resident 63's need with feeding assistance was not addressed on the nutritional care plan and there was no separate care plan for feeding. During an interview on 1/14/2024 at 10:25 a.m. with the Director of Nursing (DON), the DON stated nurses or staff should obtain a physician's order for feeding if needed or necessary for care to complete Activities of Daily Living (ADL). The DON stated it was important that anything necessary to gain the strength of the resident was communicated from rehabilitation to MD to Registered Nurse (RN). During a record review of the facility's policy and procedure(P&P) titled Standard of Professional Performance-Physical comfort, hygiene, and Activities of Daily Living reviewed 2/20, the P&P indicated the nurse provides physical comfort, hygiene, and activities of daily living. During a record review of the facility's policy and procedure(P&P) titled, General Statement/ Mission of the Transitional Care Unit, reviewed 10/2020, the P&P indicated A. The Transitional Care Unit (TCU) conducts concurrent quality management and improvement activities to promote the high quality of care given to patients. This program consists of ongoing monitoring by nursing staff to ensure that: a. Physician orders are current and new orders have been noted and appropriately implemented. b. patient care plans are current and complete. B. The Multidisciplinary Team Conference meets to discuss each patient's plan of care in the Team Conference. The committee acts to: A. Assure that a plan of care has been established to meet each of the residents' needs and is coordinated between all services. B. Provide a means for multidisciplinary team members review and reassessment of each patient's plan of care on a regular basis. C. Maintain a current and updated patient care plan. During a record review of the facility's policy and procedure(P&P) titled, Standard of Care- Transitional Nursing Care, reviewed 3/2022, the P&P indicated: A. Planning: A plan that includes the priorities and interventions used to achieve the outcomes is developed by the RN. 1. Physical and psychosocial measures are planned to prevent, improve, and control specific problems of the aged. 2. The plan is individualized and developed with the patient and significant others in healthcare providers when appropriate. B. Implementation: the nurse implements as prescribed in the plan of care 1. Nursing interventions are individualized to meet specific situations that allow for alternative approaches. 2. Interventions are documented.