Every finding on record at Upland Rehabilitation and Care Center

Based on observation, interview, and record review, the facility failed to ensure activities of daily living services were provided for one of three residents (Resident 1) in accordance with facility policy when, Resident 1 was not provided with a restorative nursing assistance (RNA) exercise for walking. This failure had the potential to cause a decline in a clinically compromised resident (Resident 1) health and ability to walk. Findings: During a review of Resident 1' admission Record (general demographics) on September 8, 2025, the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included muscle weakness, type 2 diabetes (a condition in which the body have more sugar in the blood), hypertension (a condition in with a high blood pressure) and abnormalities of gait and mobility (changes to the normal way of walking). During an observation on September 8, 2025, at 11:55 AM, Resident 1 was observed lying in bed. Resident 1 was staring at playing cards on a bedside table in front of her. During an interview on September 8, 2025, at 12:10 PM, with Certified Nursing Assistant (CNA). the CNA stated, [Name of Resident 1] usually stays in her room. She does RNA in her room. During an interview on September 8, 2025, at 12:15 PM, with Licensed Vocational Nurse (LVN). the LVN stated, I have not seen [Name of Resident 1] walk for a while, but I know she is on RNA program. During an interview on September 8, 2025, at 12:45 PM, with Restorative Nursing Assistant staff (RNAS) the RNAS stated, [Name of Resident 1] is on RNA program for only the upper body. We don't walk with her. During a concurrent interview and review of Resident 1's Physical Therapy (PT) notes, on September 8, 2025, at 1:10 PM, with Facility Rehab Staff (FRS), the FRS stated, [Name of Resident 1] should have been placed on RNA program for ambulation on July 21, 2025, after physical therapy treatment ended to work on her lower body. A review of Resident 1's care plan dated July 24, 2025, indicated, Focus: Has limited physical mobility related to weakness. Goal: Increase with functional mobility, reduce fall risk. Interventions: . improve functional mobility. During an interview on September 9, 2023, at 2:00 PM, with the Administrator (Admin), the admin stated, There was no continuation of therapy for RNA after PT ended. The Admin further stated, The resident should have been placed on RNA program for ambulation. A review of the facility's Policy and Procedure (P&P), titled, Quality of Care revised, November 2022, the P&P indicated, It is the policy of this facility that residents are given the appropriate treatment and services to maintain or improve his/her abilities. PROCEDUERS: 1. Maintenance and restorative programs will be provided to residents in accordance with the resident's comprehensive assessment.

Based on observation, interview, and record review the facility failed to store food in accordance with professional standards for food safety when employees' food was found inside 1 of 3 residents' refrigerators (Station 1 RR). This failure had the potential to expose 50 highly susceptible residents from Station 1, who were on an oral diet, to cross-contaminated (the transfer of harmful substances or disease- causing microorganisms) food. Findings: During a review of the facility's Station 1 Daily Census, dated May 4, 2025, the census indicated there were 56 residents in Station 1. During a review of the Station 1 Dietary Order Tally Report, (undated), the Dietary Order Tally Report indicated there were six residents who were not receiving an oral diet. During a concurrent observation tour and interview, on May 5, 2025, at 9:34 AM, inside the room where the ice machine and Station 1 RR were located, with the Maintenance Director (MD), the MD stated each station had a refrigerator for residents. The Station 1 RR door had a post on it which indicated, Resident's Food Only .This fridge is for RESIDENTS' FOOD ONLY. No Employees food can be stored inside . When the refrigerator was opened, a box of sponge cakes with a name and date written on it was found inside. During an interview on May 6, 2025, at 9:42 AM, with Station 1 Licensed Vocational Nurse (LVN 4), LVN 4 stated they were not sure if the name written on the box of sponge cakes was a resident or not. During an interview on May 6, 2025, at 10:28 AM, with the Clinical Resource (CR), the CR confirmed the food inside Station 1 RR belonged to the Housekeeper (HK) working at night. During an interview on May 7, 2025, at 8:20 AM, with the Administrator (ADM), the ADM acknowledged it was not appropriate to keep staff food inside Station 1 RR. The ADM stated a licensed nurse or housekeeper at each station should check the refrigerator daily. The ADM further stated staff should have understood not to put their food inside the residents' refrigerator to prevent cross-contamination. During a concurrent interview and record review on May 8, 2025, at 2:03 PM, with the ADM, the ADM reviewed and confirmed the facility's revised policy titled, Resident/Personal Food Storage, dated 11/2016 indicated, .refrigeration units, or personal/resident room refrigeration units will be monitored by designated facility staff for food safety . The ADM confirmed the finding, and stated the policy was not followed. A review of the Food and Drug Administration Food Code 2022, 3-701.11, indicated, Discarding or Reconditioning Unsafe, Adulterated, or Contaminated Food .(C) READY-TO-EAT FOOD that may have been contaminated by an EMPLOYEE who has been RESTRICTED or EXCLUDED as specified under S 2-201.12 shall be discarded.

Based on observation, interview, and record review, the facility failed to implement infection control and prevention measures when: 1. One single-dose container of acetic acid (solution to prevent blockage in tubes connected to the resident's body) was not discarded after being opened. This failure had the potential for cross contamination (unintentional transfer of germs) to residents or residents to be treated with deteriorated treatments which could negatively impact their clinical condition. 2. One non-laundry staff entered the restricted clean area of the laundry department and obtained items from a linen cart. This failure had the potential for cross contamination and spread of infection which could adversely affect the health and wellbeing of residents and staff. Findings: 1. During a concurrent observation and interview on May 5, 2025, at 12:08 PM, an inspection of Treatment Cart 1 near Nursing Station 1 was conducted with Licensed Vocational Nurse 5 (LVN 5). LVN 5 stated she was the Treatment Nurse (nurse specializing in wound care). When Treatment Cart 1 was opened, one container of [Manufacturer] 0.25% (concentration) of acetic acid was observed stored and labeled with handwritten black ink D/O 5/2/25. LVN 5 stated the acetic acid container was opened on May 2, 2025. During an interview on May 5, 2025, at 12:22 PM, with the Director of Nursing (DON), the DON was requested to provide literature from [Manufacturer] supporting the extended beyond-use-dating (written documentation from the manufacturer regarding the longer duration of the opened container) for NDC [National Drug Code - unique number assigned to each medication] 0264-2304-10 acetic acid observed stored in Treatment Cart 1. During an interview on May 7, 2025, at 11:58 PM, with the DON, the DON stated the drug manufacturer verbally told the facility the acetic acid container was single-dose. During an interview on May 7, 2025, at 12:10 PM, with the DON, the DON acknowledged the acetic acid container was labeled Sterile [clean] .Single-dose container. The DON acknowledged the opened acetic acid container had labeling which indicated it was opened on May 2, 2025, and should not have been stored in the treatment cart on May 5, 2025. During a concurrent interview and record review on May 7, 2025, at 3:22 PM, with the Infection Preventionist (IP), the [Manufacturer] package insert (document on how to safely use medications) dated August 2023, obtained from the facility, for the acetic acid container NDC 0264-2304-10 was reviewed. The IP acknowledged the package insert indicated, WARNINGS .After opening container, the contents should be used promptly in order to minimize the possibility of bacterial growth or pyrogen [fever-inducing substance] formation. Discard unused portion of irrigating [referring to the acetic acid] solution since it contains no preservative [to protect against decay]. The IP stated the unused portion of the acetic acid container should have been discarded because don't want bacterial growth. The IP stated the acetic acid solution did not contain preservatives. During a concurrent interview and record review on May 9, 2025, at 1:45 PM, with the DON, the facility policy and procedure (P&P) titled MEDICATION STORAGE IN THE FACILITY .STORAGE OF MEDICATIONS approved January 2025, was reviewed. The policy indicated, Medications and biologicals are stored safely, securely, and properly, following the manufacturer's recommendations or those of the supplier. The DON acknowledged the facility's policy. 2. During a concurrent observation and interview on May 7, 2025, at 2:20 PM, with the Environmental Services Supervisor (EVSS), in the presence of the Infection Preventionist (IP), in the laundry department, the EVSS stated laundry staff would have to dispose of their Personal Protective Equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) and perform hand hygiene prior to coming into the clean area. The EVSS explained that after removing the dried items from the dryer, the laundry staff would place the items on the sorting table in the clean area of the laundry department. The EVSS further explained that once the items were sorted and folded, they were then placed inside the clean linen carts for the laundry staff to take to each station's clean utility rooms. It was observed that a non-laundry staff took clean items, including towels and socks, from the linen cart in the clean sorting area and placed the items inside a clear plastic bag. When the EVSS was asked if non-laundry staff were allowed to be at the laundry department's clean area near the sorting table and remove items from the linen cart, the EVSS stated no. The EVSS stated only laundry staff were allowed to handle clean items in the laundry department. During an interview on May 8, 2025, at 11:15 AM, with the IP, the IP stated non-laundry staff could not enter and were to remain outside of the clean area of the laundry department. The IP stated only laundry staff could handle clean linens and place them inside a plastic bag to provide to non-laundry staff. During an interview on May 8, 2025, at 3:35 PM, with the DON, the DON stated non-laundry staff needed to call the laundry department should they need additional clean items for the residents. The DON verified non-laundry staff were not allowed to enter the clean area or handle the clean items in the laundry department. A review of the facility's Policy and Procedures (P&P) titled Infection Prevention - Control of Transmission of Infection, (undated), indicated It is the policy of this facility to implement infection control measures to prevent the spread of communicable diseases and conditions . A review of the facility's Policy and Procedures (P&P) titled Laundry Services, (undated), indicated It is the policy of this facility that careful precautionary procedures must be followed by laundry personnel to prevent the spread of infectious diseases to other staff members, residents, and visitors .2. The supervisor of laundry services will work closely with the infection control designee to establish and maintain consistent high standards .

Based on observation, interview, and record review, the facility failed to ensure medications were stored at an appropriate temperature range, in accordance with drug manufacturers' requirements, in one of three medication rooms (Station 2 Med Room). This failure had the potential for residents to be given deteriorated (reduced quality) medications which could result in suboptimal treatment. Findings: During a review of the Station 2 Daily Record of Medication Room Temperature, the log indicated the Station 2 Medication Room temperature was recorded as 78 degrees Fahrenheit (F - a temperature scale) on May 4, 2025, and May 5, 2025. During a concurrent observation and interview on May 5, 2025, at 9:41 AM, with the Assistant Director of Nursing (ADON), an inspection of the Station 2 Medication Room was conducted. When the medication room cabinet was opened, multiple medications were observed stored inside. The ADON acknowledged the product labeling for the following six (6) drug products indicated to store the medications at a maximum of 77 degrees F. a. Three (3) bottles of Extra Strength acetaminophen (pain relief medication) 500 milligrams (mg - a unit of measurement for dose) b. Two (2) bottles of acetaminophen 325 mg c. One bottle of senna (laxative to manage constipation) syrup 237 milliliters (ml - a unit of measurement for volume) d. One carton of twenty-four (24) caplets (pills) of loperamide (drug to control diarrhea) 2 mg e. Two (2) bottles of docusate sodium (stool softener) 100 mg f. Two (2) bottles of Extra Strength docusate sodium 250 mg During a concurrent interview and record review on May 9, 2025, at 1:45 PM, with the Director of Nursing (DON), the facility policy and procedure (P&P) titled MEDICATION STORAGE IN THE FACILITY .STORAGE OF MEDICATIONS approved January 2025, was reviewed. The policy indicated, Medications and biologicals are stored safely, securely, and properly, following the manufacturer's recommendations or those of the supplier. The DON acknowledged the facility's policy.

Based on interview and record review, the facility failed to ensure safe and effective pharmaceutical services when an order was not clarified before a medication was held for one of five residents (Resident 112). This failure had the potential to result in preventable medication errors resulting from incomplete or unclear orders for Resident 112. Findings: During a review of Resident 112's facesheet (demographics), the facesheet indicated the resident was readmitted on [DATE], and had diagnoses of dependence on renal (kidney) dialysis (procedure for filtering blood when kidneys stop working) and hypertension (high blood pressure). During a review of Resident 112's SNF [Skilled Nursing Facility] H&P [History & Physical], the H&P indicated Resident 112 was diagnosed with chronic (persistent) congestive heart failure (CHF- when the heart does not pump blood normally). During a review of Resident 112's medical record, an order dated April 28, 2025, indicated a medication order for furosemide (diuretic - water pill) 80 milligrams (mg - a unit of measurement for dose) tablet by mouth two times a day for CHF. During a review of Resident 112's medical record, an order dated April 29, 2025, indicated to HOLD ALL B/P [blood pressure] MEDS [medications] ON THE MORNING OF DIALYSIS DAYS. During an interview on May 7, 2025, at 8:14 AM, with Licensed Vocational Nurse 6 (LVN 6), LVN 6 stated they were going to hold Resident 112's furosemide because the resident was going to dialysis. During a concurrent interview and record review on May 7, 2025, at 2:15 PM, with LVN 6, Resident 112's medical record was reviewed. LVN 6 stated they did not administer the furosemide to Resident 112 that morning. LVN 6 acknowledged the order dated April 29, 2025, indicated to HOLD ALL B/P MEDS ON THE MORNING OF DIALYSIS DAYS. LVN 6 reviewed the furosemide medication order dated April 28, 2025. LVN 6 acknowledged the furosemide was indicated for CHF and not blood pressure. LVN 6 stated furosemide was categorized as a diuretic and water pill. LVN 6 stated the order to hold blood pressure medications on dialysis days dated April 29, 2025, and the furosemide medication order dated April 28, 2025, should have been clarified. During a concurrent interview and record review on May 9, 2025, at 1:45 PM, with the Director of Nursing (DON), the facility policy and procedure (P&P) titled, PRESCRIBER MEDICATION ORDERS, approved January 2025, was reviewed. The policy indicated, Any dose or order that appears inappropriate considering the resident's age, condition, or diagnosis is verified with the attending physician before processing. The DON acknowledged the facility's policy.

Based on observation, interview, and record review, the facility failed to ensure the side rail (also called bedrail) assessment was accurate and side rail use was indicated to meet the needs of one of 37 final sampled residents (Resident 66), who was unable to use the side rails due to functional limitations in both upper extremities. This failure had the potential for injury related to improper use of side rails for Resident 66. Findings: A review of Resident 66's Admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 66's physician's order, dated February 8, 2023, indicated an order for half (1/2) side rails up in bed to aid in bed mobility. A review of Resident 66's Minimum Data Set (MDS, a standardized assessment tool), dated June 13, 2024, indicated Resident 66 had impaired range of motion in both upper extremities. A review of Resident 66's OT [Occupational Therapy] Evaluation and Plan of Treatment, dated July 9 to August 5, 2024, indicated Resident 66 had functional limitations due to contractures (shortening or tightening of muscles causing deformity or loss of movement of the affected extremity) of both upper extremities. A review of Resident 66's Functional Abilities and Goals form, dated March 6, 2025, indicated the resident was dependent on staff for mobility, including rolling side to side in bed. In addition, the form indicated Resident 66 was dependent on staff when moving from sitting on the side of the bed to lying flat on the bed. A review of Resident 66's Bed Rail Safety Evaluation, dated March 6, 2025, indicated Resident 66 could have two (2) 1/2 siderails up to aid the resident in bed mobility. In addition, the evaluation indicated Resident 66 was able to move freely in bed and did not exhibit signs or symptoms of impaired and restricted mobility. During an initial tour observation on May 5, 2025, at 11:55 AM, in Resident 66's room, Resident 66 was observed with eyes closed while lying in bed. The resident's bed was observed to have both upper side rails raised above the mattress level of the bed and both side rails were covered with soft material. During an interview on May 7, 2025, at 2:02 PM, with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated Resident 66 was dependent on staff for care, including with the activities of daily living (ADLs- for example, bathing, personal hygiene and repositioning). CNA 2 explained Resident 66 was unable to reposition independently due to contractures of both upper and lower extremities. During a concurrent interview and record review on May 7, 2025, at 3:05 PM, with Registered Nurse Supervisor 2 (RNS 2), Resident 66's Bed Rail Safety Evaluation, dated March 6, 2025, was reviewed. RNS 2 acknowledged there was inconsistency between Resident 66's documented functional abilities in the medical record and the assessment findings on the safety evaluation regarding the mobility of Resident 66. RNS 2 stated the Bed Rail Safety Evaluation should show Resident 66 was assessed to have exhibited signs or symptoms of impaired and restricted mobility. During a concurrent observation and interview on May 9, 2025, at 8:33 AM with CNA 1, CNA 1 was observed providing a bed bath to Resident 66 inside the resident's room. Resident 66 was observed lying in bed with arms crossed over the resident's chest area. Resident 66's arms remained bent at the elbows while CNA 1 was removing the shirt of the resident. When CNA 1 rolled Resident 66 towards the left side, the CNA instructed the resident to grab on to the left side rail. Resident 66's arms remained bent, and the resident did not reach over and grab on to the side rail. CNA 1 acknowledged Resident 66 did not reach for and hold onto the side rail. During a concurrent interview and record review on May 9, 2025, at 9:00 AM, with the Director of Rehabilitation Services (DRS), Resident 66's OT Evaluation and Plan of Treatment, dated July 9 to August 5, 2024, was reviewed. The DRS stated the rehabilitation services department would evaluate a resident's mobility and the need for assistive devices. The DRS stated side rails would aid a resident in repositioning their body while in bed. The DRS stated the assessment findings for Resident 66 included functional limitations of both upper extremities due to the presence of contractures. The DRS stated the side rails of Resident 66's bed could no longer aid the mobility of the resident due to the functional limitations of the resident's upper extremities. A review of the facility's Policy and Procedure (P&P), titled Resident Assessment- Bedrail Assessment, (undated), indicated the need for ongoing monitoring and supervision for the use of side rails, which would include an ongoing assessment to assure that the bed rail is used to meet the resident's needs.

Based on observation, interview, and record review, the facility failed to ensure the provision of care and services for dialysis (a treatment to cleanse the blood of waste and extra fluids through a machine when the kidney(s) have failed) when a bandage was left on the dialysis site for more than four hours for one of two sampled residents (Resident 49). This had the potential to prevent appropriate monitoring for complications including potential for infection and malfunction of Resident 49's dialysis access site . Findings: During a review of Resident 49's Admission Record (AR), the AR indicated Resident 49 was admitted on [DATE], with diagnoses that included end stage renal disease (irreversible kidney failure) among others. During a review of Resident 49's Order Listing Report (OLR), dated May 6, 2025, the OLR indicated Resident 49 had an active order for dialysis every Monday, Wednesday, and Friday. During a concurrent observation and interview on May 6, 2025, at 8:39 AM, with Licensed Vocational Nurse 2 (LVN 2), inside Resident 49's room, Resident 49 was seen with a bandage on the left arm. LVN 2 stated she would check records to be sure but thought the bandage might be from the previous dialysis treatment. During a concurrent observation and interview on May 6, 2025, at 9:05 AM, with the Director of Nursing (DON), inside Resident 49's room, the DON stated Resident 49 received dialysis treatment. The DON removed the bandage on Resident 49's arm and stated it was from the dialysis treatment from May 5, 2025. During a concurrent interview and record review on May 6, 2025, at 9:10 AM, with the DON, the Facility/Dialysis Center Nursing Communication Record (CR) signed and dated May 5, 2025, was reviewed. The CR indicated Resident 49 had dialysis on May 5, 2025, and the resident had a bandage in place upon return to the facility. The DON stated the bandage in place referenced in the document was for the dialysis access site on the left arm. The DON stated the bandage on Resident 49's arm should have been removed within four hours following dialysis treatment. During a concurrent interview and record review on May 9, 2025, at 2:10 PM, the facility's Lesson Plan .Pre and Post Care for Dialysis Inservice, dated November 20, 2024, was reviewed. The lesson plan indicated, .Objective .Clearly define guidelines in providing pre and post care for dialysis .Post Dialysis Care .Bandages should be removed within three to four hours after treatment . The DON stated the bandage remained on Resident 49's dialysis access site for more than four hours.

Based on observation, interview, and record review, the facility failed to provide respiratory care services for 1 of 37 final sampled residents (Resident 89) when the facility failed to ensure the filter of the Continuous Positive Airway Pressure machine (CPAP- a machine that uses air pressure delivered through tubing and a mask over the mouth or nose to keep the airway open) was replaced in accordance with the manufacturer's guidelines. This failure could potentially result in nasal irritation and/or illness for Resident 89. Findings: A review of Resident 89's Admission Record, indicated the resident was admitted to the facility on [DATE]. A review of Resident 89's Care Plan Report, initiated on March 19, 2025, and revised on May 2, 2025, indicated Resident 89 had a problem of altered respiratory status and difficulty breathing related to Obstructive Sleep Apnea (OSA- a condition where the throat muscle relaxes while sleeping and blocks the airway, leading to lapses in breathing). A review of Resident 89's physician's order, dated May 2, 2025, indicated to use a CPAP machine at bedtime for OSA. During an observation and interview on May 5, 2025, at 10:30 AM, with Resident 89, in Resident 89's room, a machine was observed on the resident's nightstand and tubing was connected and hanging at the bedside. Resident 89 stated the machine was a CPAP machine Resident 89 used to help with breathing at night during sleep. Resident 89 acknowledged the facility staff would come by and check the machine; however, the resident was not able to describe what the staff would check on the machine. During a concurrent observation and interview on May 8, 2025, at 11:20 AM, with Licensed Vocational Nurse 8 (LVN 8), in Resident 89's room, LVN 8 acknowledged Resident 89 used a CPAP machine at night to help the resident with breathing. During an inspection of the machine, LVN 8 opened the compartment of the filter located on the right side of the CPAP machine. The color of the filter was observed to be a mixed light grey and dark grey. LVN 8 acknowledged the grey color of the filter. LVN 8 stated they were not sure who was responsible for checking and replacing the filter of the CPAP machine. During a concurrent observation and interview on May 8, 2025, at 11:34 AM, with the Assistant Director of Nursing (ADON) and Respiratory Therapy Supervisor (RTS), in Resident 89's room, the ADON and RTS acknowledged the color of the filter of Resident 89's CPAP machine was light grey and dark grey. The RTS stated a new filter was white in color and CPAP machine filters should be replaced routinely. During a follow-up interview and record review on May 8, 2025, at 2:40 PM, with the RTS, the CPAP machine manufacturer's user guide, (undated), was reviewed. The RTS stated the user guide indicated to check the CPAP air filter and replace the filter at least every six months and replace the filter more often if there were any holes or blockages with dirt or dust. The RTS stated there was no documentation indicating an inspection was conducted on Resident 89's CPAP machine, including a filter change for the machine. The RTS stated the purpose of the filter in a CPAP machine was to ensure the resident would be breathing clean air while the resident was using the machine at nighttime. During a follow-up interview on May 8, 2025, at 2:58 PM, with the ADON, the ADON acknowledged there was no documentation the licensed nursing staff changed the filter of Resident 89's CPAP machine. During a concurrent interview and record review on May 9, 2025, at 11:05 AM, with the Director of Nursing (DON), the CPAP machine manufacturer's user guide, (undated), was reviewed. The DON stated the nursing staff were responsible to ensure the CPAP machine was working and the Respiratory Department would ensure the machine had the correct settings, as ordered by the physician. The DON acknowledged the facility should have followed the manufacturer's user guide for filter replacement for Resident 89's CPAP machine.

Based on observation, interview, and record review, the facility failed to provide the necessary services to attain or maintain the highest practicable well-being for 1 of 37 final sampled residents (Resident 4), when Resident 4's wound was not assessed consistently in accordance with the facility's Policy and Procedure (P&P). This failure had the potential to delay identification of wound deterioration for Resident 4. Findings: A review of Resident 4's Admission Record, indicated the resident was admitted to the facility on [DATE]. A review of Resident 4's history and physical note, dated October 10, 2024, indicated the resident had diagnoses including peripheral vascular disease (narrowing of blood vessels) and chronic obstructive pulmonary disease (lung disease that blocks airflow and makes breathing difficult). A review of Resident 4's Physician's Order, dated April 12, 2025, and renewed May 3, 2025, indicated to cleanse Resident 4's moisture-associated skin damage (MASD, inflammation of the skin occurring with or without loss of the outer layer of the skin) on the right buttock extending to the left buttock with normal saline solution, pat the skin area dry, apply barrier cream, and leave the skin area open to air. The order indicated wound care would be performed every day for 21 days then a reevaluation of the skin area would be performed. A review of Resident 4's LN [Licensed Nurse]-Skin Evaluation - PRN [as needed]/weekly did not indicate an assessment of the condition of Resident 4's wound to the buttocks for the weeks of April 25, 2025, and May 2, 2025. During a concurrent interview and record review on May 8, 2025, at 10:42 AM, with Licensed Vocational Nurse 5 (LVN 5), Resident 4's medical record was reviewed. LVN 5 acknowledged Resident 4 was receiving treatment for the wound to the buttocks area. LVN 5 verified the physician's order for the resident's wound treatment. LVN 5 described the wound as redness on the right buttock that extended to the left buttock and stated the wound was moisture-associated skin damage. LVN 5 verified there was no assessment documented in Resident 5's record for the weeks of April 25, 2025, and May 2, 2025. LVN 5 explained the documentation of the assessment findings would guide the other nurses to know whether the condition of the resident's wound was getting worse, or the wound was improving. LVN 5 stated the importance was to ensure Resident 4 would receive the appropriate wound treatment. During a concurrent observation and interview on May 9, 2025, at 9:27 AM, with LVN 5 in the presence of the Director of Staff Development (DSD), LVN 5 was observed providing wound care treatment to Resident 4 in the resident's room. LVN 5 verified there were scattered areas of skin redness on Resident 4's right buttock and extending to the left buttock area. LVN 5 stated the areas were not intact, there was no drainage coming out from the open areas, and the depth of the wound was too shallow for measurement. A review of the facility's P&P, titled Skin Management System, (undated), indicated residents will have an ongoing head to toe assessment done weekly, incorporated into the weekly summary review by the licensed nursing staff.

Based on observation, interview, and record review, the facility failed to provide appropriate grooming services to one of three sampled dependent residents (Resident 47), when Resident 47 was observed with untrimmed and dirty fingernails on the right hand. This had the potential for skin problems and infection around the nail bed for Resident 47. Findings: During a review of Resident 47's Admission Record (AR), the AR indicated Resident 47 was admitted to the facility on [DATE], with diagnoses including functional quadriplegia (paralysis from the neck down, including legs and arms) among others. During a review of Resident 47's Minimum Data Set (MDS - a resident assessment tool), dated March 17, 2025, the MDS indicated Resident 47 had functional limitation in range of motion for both upper and lower extremities. The MDS further indicated Resident 47 was dependent on staff for personal hygiene. During an observation on May 6, 2025, at 2:22 PM, inside Resident 47's room, Resident 47 was observed with untrimmed and dirty fingernails on the right hand. During an observatoin and interview on May 6, 2025, at 2:30 PM, with Certified Nurse Assistant 4 (CNA 4), inside Resident 47's room, CNA 4 looked at Resident 47's right hand fingernails and stated the nails should be trimmed short and clean. CNA 4 stated the expectation was to provide grooming services to Resident 47. During a concurrent interview and record review on May 7, 2025, at 2:39 PM, with the Director of Nursing (DON), the facility's undated policy and procedure (P&P) titled, Nails, Care of Finger and Toe, was reviewed. The P&P indicated, .It is the policy of this facility to perform nail care to: 1. Clean the nail bed 2. Keep nail trimmed 3. Prevent infections .Procedures .7. Nail care includes daily cleaning and regular trimming during ADL (Activities of Daily Living- activities such as bathing, dressing and toileting a person performs regularly) care .8. Proper nail care can aid in the prevention of skin problems around the nail bed . The DON stated the expectation for grooming Resident 47 was not met, and further stated the policy was not followed.

Based on interview and record review, the facility failed to ensure the individualized care plans (the plans showing specific interventions to provide effective and person-centered care to meet a resident's needs) were developed and implemented for three of 37 final sampled residents (Residents 19, 45, and 151) when: 1. Resident 19 did not have a care plan developed for the use of apixaban (a medication used to prevent and treat blood clots). 2. Resident 45 did not have a care plan developed for dental care. 3. Resident 151's care plan intervention to monitor for bruising associated with anticoagulant (medication to prevent blood clot formation) therapy was not implemented. These failures created the risk of health complications and reduced safety from unmonitored conditions for the residents. Findings: 1. A review of Resident 19's Admission Record, indicated Resident 19 was admitted to the facility on [DATE]. A review of Resident 19's History and Physical Examination, dated January 17, 2025, indicated Resident 19's diagnoses included atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). A review of Resident 19's Order Summary Report, dated as of April 30, 2025, indicated an active physician order to administer apixaban 5 milligrams (mg - metric unit of measurement, used for medication dosage and/or amount) by mouth two times a day for atrial fibrillation starting on January 16, 2025. A review of Resident 19's Medication Administration Record, dated April 1, 2025, to April 31, 2025, indicated apixaban was administered to Resident 19 as per the physician's orders. A review of Resident 19's Care Plan Report, (undated), indicated there were no care plan problems developed related to Resident 19's use of apixaban. During a concurrent interview and record review on May 8, 2025, at 11:52 AM, with Licensed Vocational Nurse 1 (LVN 1), Resident 19's Order Summary Report, dated April 30, 2025, and undated Care Plan Report were reviewed. LVN 1 confirmed Resident 19 was receiving apixaban. LVN 1 verified there was no documented evidence indicating a care plan was developed. LVN 1 stated Resident 19 needed to have a care plan developed for apixaban. LVN 1 further stated that the purpose of having a care plan was to ensure the staff knew the resident's plan of care and how to monitor the resident properly. 2. A review of Resident 45's Admission Record, indicated Resident 45 was admitted to the facility on [DATE]. A review of Resident 45's Resident Inventory of Personal Effects, dated October 30, 2024, indicated Resident 45 had both upper and lower dentures upon admission. A review of Resident 45's Dental Progress Notes, dated February 12, 2025, indicated Resident 45 was examined by the dentist. The progress notes indicated that the dentist recommended to extract Resident 45's tooth. A review of Resident 45's Order Summary Report, dated as of May 7, 2025, indicated Resident 45 might have an extraction of the tooth and full upper and lower dentures. A review of Resident 45's Minimum Data Set (MDS - a resident assessment tool) - Version 3.0, dated April 24, 2025, indicated the BIMS (Brief Interview for Mental Status - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 15 which meant Resident 45 was cognitively intact. During an interview with Resident 45 on May 6, 2025, at 11:45 AM, Resident 45 stated their dentures were brought to the facility on admission; however, the facility lost the dentures approximately eight months ago, and they still did not have them. Resident 45 further stated they could eat without the dentures but were unable to chew tough meat. A review of Resident 45's Progress Notes, dated March 10, 2025, indicated the Director of Social Services (DOSS) informed Resident 45's responsible party that the resident was provided with the incorrect dentures upon returning from the hospital. The progress notes also indicated the DOSS spoke with Resident 45 who stated they would like to move forward with the tooth extraction and new dentures. A review of Resident 45's Care Plan Report, (undated), indicated there were no care plan problem developed related to Resident 45's dental care. During a concurrent interview and record review on May 7, 2025, at 03:08 PM, with LVN 3, Resident 45's Dental Progress Notes, dated February 12, 2025, Progress Notes, dated March 10, 2025, and undated Care Plan Report were reviewed. LVN 3 confirmed there was documentation indicating Resident 45 did not currently have dentures. When asked why Resident 45 needed a tooth extraction and still did not have dentures, LVN 3 stated they did not know. When asked if there was a care plan problem developed related to Resident 45's dental care, LVN 3 verified there was no documented evidence indicating a care plan was developed. LVN 3 stated a care plan should have been developed as soon as the staff knew about the issue. LVN 3 explained that the purpose of developing a care plan was to determine the type of care to be provided for the resident and to understand the resident's goals. During a concurrent interview and record review on May 7, 2025, at 03:27 PM, with the DOSS, Resident 45's Progress Notes, dated March 10, 2025, were reviewed. The DOSS verified they had been aware of Resident 45's dental issue since March 10, 2025. The DOSS stated Resident 45 complained about not having dentures because they were important for eating and for the resident's appearance. A review of the facility's Policy and Procedure, titled Comprehensive Person-Centered Care Planning, (undated), indicated It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment .6. The resident's comprehensive plan of care will be reviewed and/or revised by the IDT after each assessment . 3. A review of Resident 151's Admission Record indicated an admitted [DATE], with diagnoses including history of stroke (damage to the brain due to an interruption in blood supply). A review of Resident 151's care plan for anticoagulant therapy, dated September 6, 2024, indicated interventions including daily skin inspections and to monitor and document any anticoagulant complications, including bruising. A review of Resident 151's medical record, indicated a physician's order, dated October 29, 2024, for Lovenox injection (a medication used to prevent the formation of blood clots), inject 40 milligrams (unit of measure) subcutaneously (under the skin) one time a day for blood clot prevention. During a review of Resident 151's SBAR (Situation, Background, Assessment, and Recommendation) Communication Form, dated April 23, 2025, the SBAR Communication form indicated Resident 151 had a fall. A review of Resident 151's progress notes, dated April 23, 2025, indicated the resident was noted to have discoloration on the right upper back and right hip and thigh. During a review of Resident 151's Medication Administration Record (MAR) for April and May 2025, the MARs indicated Resident 151 did not have signs or symptoms of bleeding. During an observation and interview on May 6, 2025, at 08:57 AM, with Resident 151, in Resident 151's room, the resident stated he had bruises from a fall and a bruise was observed on the resident's right thigh. During a concurrent interview and record review on May 9, 2025, at 09:12 AM, with the Director of Nursing (DON), Resident 151's medical record was reviewed. The DON verified Resident 151 was receiving anticoagulant therapy, sustained a fall on April 23, 2025, and had bruising to the right back, hip, and thigh. The DON stated if a resident had any skin issues, an LVN would be responsible for initiating the skin assessment and should continue to monitor the resident until the problem is resolved. The DON verified Resident 151's bruising should have been monitored. A review of the facility's P&P titled Anticoagulation Therapy, (undated), indicated the facility would ensure the anticoagulation therapy is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person- centered care plan and the residents' goals and preferences . licensed nursing staff will monitor all residents on anticoagulants recognizing signs and symptoms of bleeding, including, but is not limited to bruising, gum bleeding, dark stools, and hematuria [blood in the urine] and document into the medical record.

Based on interview and record review, the facility failed to notify the Office of the State Long-Term Care (LTC) Ombudsman (an advocate for residents of nursing homes) before discharge for one of four sampled residents (Resident 70). This deficient practice had the potential to leave Resident 70 unprotected from improper discharge and deny them access to an advocate for their options and rights. Findings: During a review of Resident 70's Admission Record, dated May 7, 2025, the Admission Record indicated Resident 70 was admitted on [DATE], for orthopedic aftercare following left below the knee surgical amputation (surgical removal of the portion of the leg below the knee). During a review of Resident 70's History and Physical (H&P), dated February 28, 2025 , the H&P indicated Resident 70 had the capacity to understand and make decisions. During a review of Resident 70's Progress Note titled Discharge Summary - Nursing, dated May 7, 2025, the Discharge Summary indicated Resident 70 was discharged on [DATE], with a discharge reason of the resident's health has improved sufficiently, resident no longer needs the services of the facility. During a concurrent interview and record review on May 9, 2025, at 8:52 AM, with the Director of Social Services (DOSS), the DOSS presented the fax confirmation page of Resident 70's Notice of Proposed Transfer/Discharge, dated May 5, 2025. The DOSS stated the fax was sent to the Ombudsman's office on May 8, 2025. The DOSS stated the Ombudsman should be notified of a resident's discharge at least 30 days before discharge. The DOSS confirmed the Ombudsman was notified late of Resident 70's discharge. During a concurrent interview and record review on May 9, 2025, at 2:45 PM, with the Director of Nursing (DON) and the Administrator, the facility's policy and procedure (P&P) titled, Criteria for Transfer and Discharge, dated May 9, 2025, was reviewed. The P&P indicated, .a. The facility shall send a copy of the notice to the State Long Term Care Ombudsman . b. The notice shall be made at least 30 days before the resident is transferred or discharged or as soon as practicable before transfer or discharge . The DON and Administrator stated the notice should be sent to the Ombudsman at least 30 days before the resident is transferred or discharged . The DON confirmed the Ombudsman was notified after Resident 70 had been discharged .

Based on interview and record review, the facility failed to ensure documentation in the medical record demonstrated the rationale for extending the pro re nata (PRN- as needed) psychotropic (any drug that affects brain activities associated with mental processes and behaviors) anxiety medication for one of five residents (Resident 146). This failure had the potential to increase the risk of clinically significant physical dependence and/or negative clinical outcomes for Resident 146. Findings: A review of the Nursing 2024 DRUG HANDBOOK (a hardcopy drug reference book), obtained from the facility, indicated a Boxed Warning [strongest warning from the Food and Drug Administration (FDA) - a federal agency]. Continued use of benzodiazepines [a category of controlled substance medications which are regulated by the government], including clonazepam [a type of benzodiazepine to manage anxiety], may lead to clinically significant physical dependence. Risk increases with longer treatment duration and higher daily dose. During a review of Resident 146's facesheet (demographics), the facesheet indicated Resident 146 was admitted on [DATE], with a diagnosis of chronic respiratory failure (serious breathing problems). During a review of Resident 146's medical record, a medication order dated June 14, 2024, indicated a telephone order for hydroxyzine (drug to control anxiety) 50 milligrams (mg - a unit of measurement for dose) via Gastrostomy tube (G-Tube- feeding tube) every 6 hours as needed for ITCHING, MILD ANXIETY M/B [manifested by] HYPERVENTILATION [over breathing]. During a review of Resident 146's medical record, a second medication order dated February 27, 2025, indicated a telephone order to change hydroxyzine from prn to 50 mg scheduled two times a day via G-Tube. During a review of Resident 146's medical record, a Care Plan Report revised April 17, 2025, indicated Anti-anxiety medication use (Hydroxyzine r/t [related to] Anxiety disorder .4/17/2025 start on clonazepam prn. During a review of Resident 146's medical record, a progress note, dated April 17, 2025, at 12:42 PM, from the prescriber, indicated Start Clonazepam 0.5 mg Q12H [every 12 hours] PRN via G-tube. During a review of Resident 146's medical record, a medication order dated April 17, 2025, indicated clonazepam 0.5 mg tablet via G-Tube every 12 hours PRN for anxiety MB [manifested by] verbalization/communication of anxious feelings for 14 Days. During a review of Resident 146's medical record, a second medication order dated May 5, 2025, indicated clonazepam 0.5 mg tablet via G-Tube every 12 hours PRN anxiety MB verbalization/communication of anxious feelings for 14 Days. During a review of Resident 146's medical record, the Medication Administration Record indicated the resident received clonazepam 0.5 mg tablet via G-Tube on May 8, 2025, at 12:42 PM. During an observation on May 8, 2025, at 2:11 PM, in Resident 146's room, Resident 146 was observed sleeping with their mouth open. During a concurrent observation and interview on May 8, 2025, at 2:13 PM, in Resident 146's room, Certified Nursing Assistant 5 (CNA 5) stated Resident 146 was sleeping. During a concurrent interview and record review on May 8, 2025, at 3:33 PM, Resident 146's medical record was reviewed with the Director of Nursing (DON). The DON stated the prescribing practitioner did not document in the medical record the rationale for the second PRN clonazepam medication order to extend the PRN order beyond 14 days. During a concurrent interview and record review on May 9, 2025, at 1:45 PM, with the DON, the facility policy and procedure (P&P) titled, PSYCHOACTIVE [affecting the mind] DRUG MONITORING, approved January 2025, was reviewed. The policy indicated, Policy: Residents who receive .anti-anxiety .medications are monitored to evaluate the effectiveness of the medication. Every effort is made to ensure that residents receiving these medications obtain the maximum benefit with the minimum of untoward effects. Procedure: Residents receive a psychoactive medication only if designated medically necessary by the prescriber. The medical necessity is documented in the resident's medical record and in the care planning process. The continued need for the psychoactive medication is reassessed regularly by the prescriber and the care planning team. If continuation is deemed necessary, this is indicated in the medical record. The DON acknowledged the facility's policy. During a concurrent interview and record review on May 9, 2025, at 1:45 PM, with the DON, the facility P&P titled, REFERENCES, approved January 2025, was reviewed. The policy indicated, Policy: The center will have access to reference materials that include current information [on] available medications. Procedures .References that can be used include .Or any other drug reference designed for nurses (for example, Nursing Drug Handbook). The DON acknowledged the facility's policy.

Based on interview and record review, the facility failed to honor the right to formulate an Advance Directive (a legal document indicating resident preference on end-of-life treatment decisions) for five of 37 sampled residents (Residents 50, 147, 153, 175, and 497) when: 1. The Advance Directives Checklist forms did not indicate whether Residents 50, 147, and 153 were provided an opportunity to formulate an Advance Directive. 2. Resident 175's Advance Directives Checklist form was not followed up to ensure their responsible party was given the opportunity to complete an Advance Directive on behalf of the resident. 3. There was no documented evidence indicating Resident 497 was provided with written information to formulate an Advance Directive. This failure had the potential for the residents' decisions regarding their healthcare and treatment options or the decisions made on their behalf not to be honored. Findings: a. A review of Resident 50's Admission Record, (front page of the chart that contains a summary of basic information about the resident), indicated Resident 50 was readmitted to the facility on [DATE]. A review of Resident 50's Advance Directives Checklist form, dated July 3, 2024, indicated Resident 50 acknowledged being provided with written information regarding the right to formulate an Advance Directive and Resident 50 did not currently possess an Advance Directive. The checklist form did not indicate if the resident wished or did not wish to formulate an Advance Directive. During an interview on May 7, 2025, at 08:30 AM, with Resident 50, the resident stated the facility did not offer assistance to formulate an Advance Directive. During a concurrent interview and record review on May 7, 2025, at 9:42 AM, with the Director of Social Services (DOSS), Resident 50's Advance Directives Checklist form, dated July 3, 2024, was reviewed. The DOSS acknowledged the checklist did not indicate if Resident 50 wanted to formulate an Advance Directive. The DOSS stated an Advance Directive would help the family or the healthcare providers make medical decisions for the resident, particularly if the resident became incapacitated. During a follow-up interview and record review on May 8, 2025, at 08:13 AM, with the DOSS, Resident 50's Advance Directives Checklist, dated July 3, 2024, was reviewed. The DOSS acknowledged she was responsible for ensuring a resident's Advance Directive was available in the resident's medical record and the resident was provided information on how to formulate an Advance Directive. b. A review of Resident 147's Admission Record, indicated Resident 147 was readmitted to the facility on [DATE]. A review of Resident 147's POLST [Physician Orders for Life-Sustaining Treatment], dated April 18, 2025, indicated section D of the form regarding Advance Directive was incomplete. The boxes indicating whether Resident 147 had or did not have an Advance Directive were left unchecked. A review of Resident 147's Advance Directives Checklist, dated April 17, 2025, indicated Resident 147's responsible party was provided with written information regarding the resident's right to formulate an Advance Directive. A checkmark indicated Resident 147 did not currently possess an Advance Directive, but the subcategories were left unchecked and did not indicate whether Resident 147 wished or did not wish to formulate an Advance Directive. During a concurrent interview and record review on May 7, 2025 at 08:40 AM, with Registered Nurse Supervisor (RNS) 1, Resident 147's Advance Directives Checklist dated April 17, 2025 was reviewed. RNS 1 verified the Advance Directives Checklist needed to be completed to indicate whether the resident was provided with written information regarding the right to formulate an Advance Directive and if the resident wished or did not wish to formulate one. RNS 1 further stated that based on Resident 147's Advance Directives Checklist, she was unable to tell whether the responsible party and/or the resident were asked if they wanted to formulate an Advance Directive because the form was incomplete. During an interview on May 7, 2025, at 08:52 AM with Responsible Party (RP) 1, RP 1 was asked about Resident 147's Advance Directive. RP 1 stated they were unsure what an Advance Directive was or if it was offered to formulate one for Resident 147. c. A review of Resident 153's Admission Record, indicated Resident 153 was readmitted to the facility on [DATE]. A review of Resident 153's POLST, dated December 26, 2024, indicated section D of the form regarding Advance Directive was completed. The box indicated Resident 153 did not have an Advance Directive. A review of Resident 153's Minimum Data Set, (MDS- a resident assessment tool) dated March 25, 2025, indicated Resident 153's cognitive skills for decision making were severely impaired. A review of Resident 153's H&P [History and Physical],, dated December 27, 2024, indicated Resident 153 was unable to follow commands. A review of Resident 153's Advance Directives Checklist form, undated, indicated Resident 153 did not currently possess an Advance Directive. The subcategories were left unchecked, the form was unsigned and undated, and it did not indicate whether Resident 153's responsible party was provided with written information regarding the resident's rights to formulate an Advance Directive. d. A review of Resident 175's Admission Record, indicated Resident 175 was readmitted to the facility on [DATE]. A review of Resident 175's MDS, dated [DATE], indicated Resident 175's cognitive skills for decision making were severely impaired. A review of Resident 175's History and Physical, dated April 18, 2025, indicated Resident 175 did not have the capacity to understand and make decisions. A review of Resident 175's POLST, dated April 18, 2025, was found flagged and attached to a fax Transmission Verification Report, dated April 20, 2025, with a request to Resident 175's responsible party to sign and fax back. A review of Resident 175's Advance Directives Checklist form, dated April 17, 2025, indicated the form was faxed to Resident 175's responsible party to obtain signatures. The form was unsigned, and it did not indicate whether Resident 175's responsible party was provided with written information regarding the resident's right to formulate an Advance Directive. e. A review of Resident 497's Admission Record, indicated Resident 497 was admitted to the facility on [DATE]. A review of Resident 497's POLST, dated April 18, 2025, indicated section D of the form regarding Advance Directive was incomplete. The boxes indicating whether Resident 497 had an Advance Directive or not were left unchecked. A review of Resident 497's MDS, dated [DATE], indicated Resident 497 had a Brief Interview for Mental Status, (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgment status of the resident) score of 15 (highest possible score). A review of Resident 497's History and Physical, dated April 18, 2025, indicated Resident 497 had decision making capacity. During a review of Resident 497's medical record, an Advance Directive Checklist form was not located. During a concurrent interview and record review on May 7, 2025, at 08:18 AM, with the Director of Social Services (DOSS), Resident 153, Resident 175, and Resident 497's Advance Directives Checklist were reviewed. The DOSS was asked to explain the facility's process and policies concerning Advance Directives. The DOSS stated the POLST and Advance Directives Checklist were provided to a resident and/or family representative with the admission packet, and Social Services would follow up to ensure forms were completed. The DOSS verified Resident 153's Advance Directives Checklist was incomplete. The DOSS verified Resident 175's Advance Directives Checklist was incomplete and no follow up was done to ensure the resident's responsible party had received the form. The DOSS verified Resident 497's Advance Directives Checklist was not in the resident's medical record. During an interview on May 7, 2025, at 09:04 AM, with Director of Nursing (DON), the DON was asked to explain the facility's process regarding an Advance Directive and information sent via fax to a resident's responsible party. The DON stated during resident admission a nurse provided information and social services followed up to ensure it was completed within the first 5 days after admission. The DON stated Social Services was ultimately responsible for verifying the Advance Directive Checklist form was completed. The DON stated the expectation for a document sent over fax for a family representative to sign was to follow up the same day to ensure it was received. A review of the facility's policy and procedures titled Advance Directives and Associated Documentation, revised December 2023, indicated .1. Prior to, upon, or immediately after admission, a facility staff member shall: a. Provide the resident/family or responsible agent written information .regarding .the right to formulate Advance Directives. b. Document in the resident health record that, at the time of admission, the resident and/or resident representative have been provided with written information regarding advance directives 6 .a. It should be noted that a POLST is not an advance directive.

Based on observation, interview, and record review, the facility failed to treat one of three sampled residents (Resident 398) with dignity when Certified Nurse Assistant 3 (CNA 3) was standing over the resident while assisting during lunch. This deficient practice had the potential to negatively impact the self-esteem and self-worth of Resident 398. Findings: During a review of Resident 398's Admission Record (AR), the AR indicated Resident 398 was admitted on [DATE], with diagnoses that included unstable angina (a type of chest pain or discomfort caused by reduced blood flow to the heart muscle), atherosclerosis (a condition where plaque builds up inside the arteries, causing them to narrow and potentially harden), hypertension (high blood pressure), and diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing) among others. During a review of the facility's Daily Room Assignment Sheet (DRAS), dated May 5, 2025, the DRAS indicated Resident 398 was on one-on-one meal assist during breakfast and lunch. During a concurrent observation and interview on May 5, 2025, at 12:21 PM, with CNA 3, inside Resident 398's room, CNA 3 was seen standing in front of Resident 398 during feeding. Resident 398 stated they preferred CNA 3 to be seated while feeding them. CNA 3 stated the procedure in assisting residents during feeding was to be seated facing the resident. During an interview on May 7, 2025, at 9:32 AM, with the Director of Staff Development (DSD), the DSD stated the expectation for a CNA when feeding residents was to be seated at eye level. The DSD stated it was a dignity issue for a CNA to stand over residents while feeding them. During a concurrent interview and record review on May 7, 2025, at 2:02 PM, with the Director of Nursing (DON), the facility's document titled, Techniques for Safe Swallowing and Feeding, dated 2022, was reviewed. The document indicated, .Feeding Techniques .Sit close to the person so that you can see their face and mouth .Sit next to the person. Never stand above or lean over the person . The DON stated the expectation was for a CNA to be seated at eye level while feeding residents to ensure safe feeding and promotion of dignity. The DON stated CNA 3 did not follow the facility's procedure when feeding Resident 398.

Based on interview and record review, the facility failed to ensure complete and accurate documentation for one of 37 final sampled residents (Resident 151), when Restorative Nursing Assistant (RNA) services were not documented. This failure had the potential for Resident 151's care needs to go unmet due to inaccurate information in the record. Findings: A review of Resident 151's Admission Record, indicated Resident 151 was admitted to the facility on [DATE], with diagnoses including osteoarthritis (a disease where joint tissue breaks down) to both knees and history of stroke (brain damage due to an interruption in blood flow). A review of Resident 151's Physician Orders, dated October 14, 2024, indicated RNA services daily five times a week for ambulation (walking) with front wheel walker, as tolerated, to be conducted every Monday, Tuesday, Wednesday, Thursday, and Friday. A review of the Point of Care Audit Report for March 2025, indicated four RNA entries in Resident 151's medical record for March. A review of the Point of Care Audit Report for April 2025, failed to show RNA entries were made in Resident 151's medical record for April. During a concurrent interview and record review on May 9, 2025, at 8:22 AM, with the Director of Nursing (DON) and RNA 1, Resident 151's medical record was reviewed. RNA 1 stated after working with the resident, they would document their entries into the computer. RNA 1 further stated, it should be documented in the medical record if Resident 151 was provided or refused RNA services. The DON acknowledged and verified there was no documentation of RNA services for Resident 151 from March 9, 2025, through the end of April 2025. A review of the facility's Policy and Procedure (P&P), titled ROM [Range of Motion] and Contracture Prevention, (undated), indicated appropriate documentation is completed to address goals of the program and resident tolerance to the program. A review of the facility's P&P titled Charting Guide- General, (undated), indicated the purpose of proper charting and documentation is to provide a complete account of the resident's care, treatment, and response to the care, signs, symptoms, etc., as well as the progress of the resident's care.

Based on observation, interview, and record review, the facility failed to ensure one of three residents, (Resident 1) received treatment and care in accordance with professional standards of practice, when: 1. A Certified Nursing Assistant (CNA 1) left Resident 1 in bed naked and uncovered with the curtain halfway open. 2. A CNA (CNA 2) took a long time in attending to Resident 1 for a change. These failures had the potential to cause Resident 1 a psychological effect for maintaining respect and dignity. Findings: During a review of Resident 1 ' Admission Record (general demographics) on September 11, 2024, the document indicated Resident 1 was admitted to the facility on November August 29, 2024, with diagnoses internal right hip prosthesis (a condition with hip replacement), heart failure (a condition that develops when your heart does not pump enough blood for the body needs), and hypertension (a condition with a high blood pressure). A review of Resident 1 ' s care plan dated, August 29, 2024, indicated, Focus: ADL (Activities of daily living) self-care performance deficit r/t (related to) limited mobility. Goal: Will safely perform bed mobility, transfers, eating, dressing, grooming, toilet use and personal hygiene with modified independence . Interventions: . Promote dignity by ensuring privacy. 1. During an interview on September 11, 2024, at 1:25 PM, with CNA 1, the CNA 1 stated, I usually provide residents with privacy during care I forgot to cover the resident with a sheet before leaving the room. During an interview on September 11, 2024, at 3:10 PM, with the Administrator regarding CNA 1, the Administrated stated, The CNA 1 should have covered the resident with sheets during care and before leaving the room. The Administrator further stated, the CNA did not follow the facility policy and procedure. 2. During a phone interview on September 30, 2024, at 2:10 PM, with CNA 2, the CNA 2 was asked about taking long time to attend to Resident 1 for a change. The CNA 2 stated, I am usually attending to residents at that and might have taken too long with cleaning her up. During a phone interview on September 30, 2024, at 4:27 PM, with the Director of Nursing (DON) regarding CNA 2, the DON stated, The CNA should have requested for assistance so she could attend to the resident with the changing. The DON further stated the CNA 2 did not follow facility policy and procedure. A review of the facility ' s policy and procedure (P&P), titled, Resident Rights dated, January 2022, indicated, .It is the policy of this facility that all resident rights be followed per state and federal guidelines as well as other regulative agencies. The Resident has the right: 1. To be treated with consideration, respect, and full recognition of his or her dignity and individuality .

Based on record review and interview, the facility failed to provide a resident and or representative a copy of medical records following a written request for 1 of 3 residents reviewed for resident rights (Resident 1). This failure could potentially violate Resident 1 (R1) rights to access her medical records. Findings: During a review of Residents 1 ' s (R1) Admission Record (general demographics), the document indicated R1 was admitted to the facility on [DATE] , with diagnosis to include sepsis, (complication of an infection), urinary tract infection ( bladder infection), generalized muscle weakness ( decreased strength in muscle ), type 2 diabetes mellitus ( a long term condition in which the body has trouble controlling blood sugar and using it for energy ), dementia (is a condition that can be caused by a number of diseases which destroy nerve cells and damage the brain). During an interview with Medical Record Director (MRD) on September 16,2024 at 2:04 PM. MRD denies getting a fax request or e-mail requests to release R1 medical records. MRD stated that they have 48 hours to comply with a written request from the resident, responsible party, or legal representative. During an interview with R1 ' s Legal Representative (LR) on September 17,2024 at 10:05am. LR stated they have a successful fax transmittal confirmation on August 22,2024 at 1:06pm faxed to (909) [PHONE NUMBER]. LR stated that a copy of the successful transmittal was sent to California Department of Public Health (CDPH) on August 26, 2024. During a record review on September 17,2024 at 10:10 am, a successful confirmation receipt of facsimile sent to the facility was reviewed. During an interview with Administrator (ADM) on September 18, 2024, at 2:40 PM, ADM stated that the facility never received a facsimile from the law office requesting for the R1 ' s medical records on August 22, 2024. During an interview with MRD on September 18, 2024, at 3:00 pm, MRD stated that she received a fax on September 18, 2024, requesting for R1 ' s medical record and MRD stated that she also received a follow up phone call from the Law Office. During a concurrent interview and record review, on September 18, 2024, at 2:40 PM, with the Administrator (ADM). A facility Policy and Procedure (P&P), titled, Resident Rights Release of Information revised October 2022, was reviewed. The P&P indicated the following: Our facility maintains the confidentiality of each resident's personal and protected health information. Policy Interpretation .10. A resident may obtain photocopies of his or her records by providing the facility at least a forty-eight (48) hour (excluding weekends and holidays) advance notice of such request. A fee may be charged . ADM stated that R1 ' s medical records were not sent. ADM also stated, the facility did not receive a Facsimile on August 22, 2024, requesting for R1 medical records.

Based on observation, interview, and record review, the facility failed to treat a resident in a dignified manner with respect and value for one of three sampled residents (Resident 2) when a staff entered Resident 2 ' s room and removed her oxygen tubing (a plastic tube that carries oxygen from a tank or machine to a person, connecting to a nasal cannula [a tube that goes in the nose] or mask) without requesting permission from Resident 2 on August 19, 2024. This failure compromised Resident 2 ' s dignity, violated her right to respect, and affected her well-being and ability to make choices, which had the potential to cause psychosocial harm (mental distress and suffering) and lead to feelings of upset. Findings: A review of Resident 2's Admission Record (a document containing clinical and demographic data), indicated Resident 2 was admitted to the facility on [DATE], with a diagnosis which included heart failure (a condition in which the heart is unable to pump blood effectively to meet the body's needs), Type 2 diabetes mellitus (a condition that affects how your body uses sugar (glucose), which is an important source of energy) and hypertension (blood pressure that is higher than normal) A review of Resident 2 ' s History and Physical Examination dated June 24, 2024, indicated .capacity: this resident [Resident 2] has the capacity to understand and make decisions. A review of Resident 2 ' s Comprehensive Minimum Data Set (MDS) dated [DATE], indicated Resident 2 was cognitively intact and required maximal assistance - helper does more than half the effort for most activity of daily living. A review of Resident 2 ' s physician order dated June 26, 2024, indicated . continuous oxygen at 2L/min [liters/minute, a measurement of oxygen flow] via nasal canula/mask . A review of State of California Form 341 [Suspected Dependent Adult/Elder Abuse form], dated May 1, 2024, indicated, . It was reported to facility administrator on 8/20/24 [August 20, 2024] at 1:00pm that resident [Resident 2] .[ License Vocational Nurse 1 (LVN 1)] turned off her concentrator and pulled her nasal canula on 8/19/24 [August 19, 2024] . A review of Resident 2 ' s Social Service notes date August 20, 2024, indicated, . Resident [Resident 2] alleges LVN [LVN1] took off her nasal canula . Patient [Resident 2] reports . just confused and unsure why the event took place She was referred to psychology . A review of Resident 2 ' s IDT (Interdisciplinary Team is a team of professional disciplines, as appropriate, will work together to provide the greatest benefit for the resident) notes dated August 20, 2024, indicated . On August 2024 . [Resident 2 ' s daughter] reported [Resident 2] complained one of the nurse turning off her oxygen concentrator [ oxygen machines used as stationary sources to provide long-term oxygen therapy to patients] and pulling on her nasal, nurse than proceeded to walk out the room and did not return. [Resident 2] stated nurse did not explained why the concentrator turned off and her NC [nasal canula] pulled away . During an interview on August 27, 2024, at 3:30 PM with LVN 1, LVN 1 stated that she does not remember if she announced herself before entering Resident 2's room and unsure if Resident 2 was aware of her presence for the routine round. Furthermore, LVN 1 stated that while she was tidying up the area around bed #1, she decided not to announce herself to beds 2 and 3 because she didn ' t want to be stuck longer in the room. She acknowledged that she should have announced herself to respect the residents' rights and personal space, but she did not. During a follow-up interview on August 27, 2024, at 3:40 PM with LVN 1, LVN 1 admitted that she assumed the oxygen concentrator belonged to the resident at bed #1. She pulled the oxygen tubing, which she stored in a bag tied to the concentrator, and then left the room. LVN 1 further stated that she should have checked to whom the oxygen tubing belonged before removing it, but she did not. During concurrent observation and interview on August 27, 2024, at 3:55 PM, with Resident 2, Resident 2 was lying in bed, with a call light next to her. Resident 2 stated that she was aware a staff was in the room doing routine rounds and checking on the residents, and that CNA 1 had left to assist the resident in bed #1 with a shower. Resident 2 further stated she was confused when her oxygen tubing was suddenly pulled from behind her curtain, immediately after that, she saw LVN 1 leaving the room just as CNA 1 returned with the resident from bed #1. Resident 2 then asked CNA 1 to put her oxygen tubing back on her and further stated that she was very upset that day and had told her daughter about it. During a phone interview and concurrent record review with the Director of Nursing (DON), September 18, 2024, at 4:55 PM, the DON reviewed the facility's policy and procedure titled, Resident Rights revised October 4, 2016, indicated As a resident of this nursing facility, you have the right to a dignified existence, self-determination, . Planning and Implementing Care. You have the right to be informed of, and participate in, your treatment, including the right to: be fully informed, . Respect and Dignity. You have the right to be treated with respect and dignity, . The DON stated the policy and procedure was not followed.

Based on interview and record review, the facility failed to ensure proper care was provided to prevent a pressure ulcer/injury (injury to skin/tissue from prolonged pressure on the skin) for one of three sampled residents (Resident 1). This failure placed a clinically compromised Residents (Resident 1) health and safety at risk, when a facility acquired unstageable pressure ulcer to coccyx left buttocks (lower back/spine) developed while in the facility. Findings: During review of Residents 1's Admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included metabolic encephalopathy (problem in brain caused by chemical imbalance in blood), acute respiratory failure with hypoxia (not enough oxygen), tracheostomy (opening in trachea to help air and oxygen reach lungs), acute kidney failure (kidney cant filter waste from blood). During a concurrent interview and record review of Resident 1's Medical Record with the Director of Nursing (DON) reviewed and verified the following: 1. Admission Skin Integrity assessment dated [DATE], at 2249: Sacro coccyx- scar tissue to coccyx, Unstageable Tissue Depth (UTD) Right and Left heel blister, right hand open wound, neck trachea stoma (opening) and abdomen Gastrostomy stoma. 2. Braden Scale for Predicting Pressure Sore Risk dated May 15, 2024, at 2315, Score 7, High Risk. 3. Situation, Background, Assessment and Recommendation (SBAR) communication form dated May 28, 2024: Moisture Associated Skin Damage (MASD) to Bilateral Buttocks, Certified Nursing Assistant (CNA) reported to charge nurse and treatment nurse that she observed MASD to Bilateral buttocks, doctor and daughter notified . 4. Phone Order May 28, 2024, at 1739: Turn and Reposition Q 2 hours every 2 hours. Phone Order May 29, 2024, at 7:00: Order for Low Airloss mattress for skin management. 5. SBAR June 10, 2024, Unstageable to coccyx left buttocks. Since this started: WORSE, Skin evaluation: Pressure Ulcer- Unstageable pressure ulcer to coccyx (tailbone) to left buttocks, cleanse with Normal Saline pat dry apply Manuka Honey, Xeroform (gauze with petrolatum) and cover with foam dressing every day for 21 days. Primary doctor notified and daughter notified. 6. CAREPLAN: Focus: Has potential for pressure ulcer development related to disease process, history of ulcers, immobility Date initiated May 16, 2024, Goal: Will have intact skin, free of redness, blisters or discoloration by/through review date, Interventions: Administer treatments as ordered and monitor for effectiveness, Daily body checks, turn and reposition as tolerated . During an interview with the Treatment Nurse, Treatment Nurse 1 stated I remember Resident 1 had a full thickness scarring on admission. When asked, what caused the pressure ulcer? Treatment nurse stated, We were treating MASD, her comorbidities she was already fragile. We were getting the wound doctor to see this resident, but family transported her to the hospital .for a new or worsening wounds we call the wound consult, but her for her she was already gone. During an interview with the Director of Nursing (DON), DON stated When she came in, she had no open wounds, it was a scar, and we were treating it. After the wound developed the mattress was placed May 29, 2024. When she came here is was scar tissue, was not an open wound, we have put in place interventions treatment for the scar tissue, Registered Dietician with supplements. They do tent to sweat and her comorbidities and incontinent bowel and bladder .we are cleaning this resident every 2 hours and sooner making sure she was dry. During a review of the facility's policy and procedure titled, Skin Management revised [December 2019, the policy and procedure indicated: It is the policy of this facility that any resident who enters the facility without pressure ulcers will have appropriate preventive measures taken to ensure that the resident does not develop pressure ulcers, or that residents admitted with wounds will not develop signs and symptoms of infection, unless the resident's clinical condition makes the development unavoidable.

Based on interview and record review, the facility failed to ensure that one of three sampled residents (Resident C), was free from a significant medication error when Resident C received a medication, Potassium Chloride (a medication used to prevent or treat low blood levels of potassium) in excess of what the physician ordered. This failure was the result of nursing staff not clarifying multiple orders for potassium with the physician, and resulted in Resident C not receiving the prescribed dosage of medication, developing [MEDICAL CONDITION] (high potassium level), suffering [MEDICAL CONDITION] and death. Findings: An abbreviated survey was made to the facility on (MONTH) 18, (YEAR), to investigate a complaint regarding nursing services. A review of Resident C's clinical record face sheet (contains demographic information), set forth she was admitted to the facility on (MONTH) 28, (YEAR), with [DIAGNOSES REDACTED]. A review of the laboratory results received for Resident C, dated (MONTH) 28, (YEAR) documented Resident's low potassium level at 3.2 (normal 3.5 to 5.0). A review of the physician's orders [REDACTED]. A review of the Medication Administration Record (MAR) noted that beginning (MONTH) 29, (YEAR) through (MONTH) 31, (YEAR) at 9:00 AM, Resident C received KCL ER (extended release) tablet 20 meq for three days. Review of laboratory results dated (MONTH) 29, (YEAR) set forth that Resident C's potassium level was lower than the previous day at 2.4 (low-[DIAGNOSES REDACTED]). A review of the physician's orders [REDACTED]. This would be a total of 240 meq of potassium in 24 hours. A review of the medical record for Resident C did not demonstrate any documentation that nursing staff clarified with the physician whether the previous 20 meq potassium tablets were to be continued in addition to the new order for KCL liquid. A review of the MAR reflected that on (MONTH) 29, (YEAR) at 2:17 PM, Resident C received KCL ER tablet 20 meq, and was administered three tablets (60 meq) PO STAT (now) as a supplement for KCL liquid. (Resident C's physician had ordered KCL liquid). A review of the MAR noted that on (MONTH) 29, (YEAR) at 6:00 PM, Resident C received KCL liquid 20 meq/15ml (a unit of measurement) 60 meq PO. A review of the laboratory results dated (MONTH) 30, (YEAR), reflected Resident C's potassium level was within the normal range at 3.6. A review of the physician's orders [REDACTED]. A review of the medical record for Resident C did not demonstrate any documentation that nursing staff clarified if this order was to be added to the initial order of 20 meq and the secondary order of 60 meq, for a total of 120 meq daily, commencing the morning of (MONTH) 30, (YEAR). A review of the MAR noted that beginning (MONTH) 30, (YEAR), Resident C received KCL 60 meq three times a day (TID) through (MONTH) 2, (YEAR) at 7:00 AM. The physician's orders [REDACTED]. Resident C was to have a maintenance dose of 40 meq daily starting on (MONTH) 30, (YEAR). A review of the MAR noted that on (MONTH) 30, (YEAR) through (MONTH) 1, (YEAR), Resident C received KCL liquid 20 meq/15ml, 40 meq PO daily at 9:00 AM. A review of the MAR and the physician's orders [REDACTED]. a. (MONTH) 29, (YEAR)- Resident C received 20 meq. tablet, plus 60 meq (three 20 meq tablets) and 60 meq of KCL liquid= a total of 140 meq of KCL b. (MONTH) 30, (YEAR) and (MONTH) 31, (YEAR)- Resident C received a 20 meq tablet, 40 meq KCL liquid, and three doses of 60 meq KCL liquid= 240 meq of KCL c. (MONTH) 1, (YEAR)- Resident C received 40 meq KCL liquid, and three doses of 60 meq KCL liquid=220 meq KCL A review of the facility's pharmacy delivery record for KCL for Resident C noted a delivery date of (MONTH) 28, (YEAR) of Potassium CL ER 20 meq tablet. A total of three tablets were delivered. During a telephone interview with a representative from the facility's pharmacy on (MONTH) 17, (YEAR) at 11:55 AM, when asked the quantity delivered for Resident C, the representative stated, We delivered three tablets, because the order was for three days only. When asked whether the pharmacy received another potassium order for Resident C, the representative stated they received a KCL liquid order on (MONTH) 1, (YEAR) at 4:33 PM, (four days after the order was issued by the physician). A review of the pharmacy's delivery record for Resident C did not demonstrate that the facility had notified the pharmacy of the physician's orders [REDACTED]. Rather, the pharmacy delivery record documented that the pharmacy did not deliver any KCL liquid for Resident C until (MONTH) 1, (YEAR). A review of the facility's Progress Notes for Resident C, written (MONTH) 2, (YEAR), 03:13 AM, set forth:, At approx (approximately) 0000 (12 midnight), Charge nurse and RN (Registered Nurse (RN 1)) notified of pt (patient) c/o (complaint of) SOB (shortness of breath). Checked O2 SAT (saturation-the level of oxygen carried by the blood), reading at 75%. Pt was then put on O2 (oxygen). RN 1 began to review pt chart at this time and noted pt receiving very high doses of KCL . RN 1 noted . order on 3/29 (March 29) for KCL 60 meq x 1 now, then Q4H (every 4 hours) x 3 more doses. Then start KCL 40 meq in AM Q(every) daily. Order in PCC (MAR) showed start KCL meq TID (3x a day) on 3/29 with no end date. Then started KCL 40 meq QD (every day) on 3/30 with no end date. Also noted order pt starting KCL 20 meq QD x 3 days on 3/29 until 04/01/18. Called (medical practitioner on-call) .approx 0212 received call from MD (name). Explained the medication error and possible [MEDICAL CONDITION] .new order. pt was transferred to acute hospital (name) ER (emergency room ) at 0235 (AM). During an interview with the Director of Nursing (DON) on (MONTH) 18, (YEAR) at 5:15 PM, she stated, The RN Supervisor (RN 1) explained that he responded to (Resident C's) change of condition (possible [MEDICAL CONDITION]) (C[NAME]-a change in a patient's physical and safety well-being) and sent her the hospital. We also interviewed the nurse (Licensed Vocational Nurse (LVN 1)) who was writing the order, what she wrote on the MAR was TID (three times a day). During a telephone interview with LVN 1 on (MONTH) 27, (YEAR) at 2:20 PM, she stated, I did receive the (name of MD) orders for (Resident C on (MONTH) 29, (YEAR)), I carried it out, I did not put a stop date, I went ahead and faxed it to the pharmacy . they never received the order. When asked how did she know the pharmacy never received the order, she stated that she was told on Monday, (MONTH) 2, (YEAR). LVN 1 further stated that the KCL order was written for every four hours x 3 doses, and when asked to explain what happened, LVN 1 stated she transcribed the order as TID (three times a day). LVN 1 in explaining her role as a desk LVN, stated, . but me as a nurse (Charge Nurse), I would have double checked just because it was KCL, and the protocol should have been to look at the labs to see the results. LVN 1 stated that the pharmacy confirmation (of the new order) was not in the folder, but nobody brought it up the next day. LVN 1 was asked where the nurses obtained the KCL liquid that had been administered to Resident C if the pharmacy had not delivered any KCL. LVN 1 stated, We don't have it in the e-kit (emergency kit- a supply of back up medications), the first dose was a tablet, I don't know what happened after that. A telephone interview was conducted with the DON on (MONTH) 27, (YEAR) at 3:00 PM. She stated the order was faxed to the pharmacy and, We had the KCL liquid delivered on (MONTH) 2, (YEAR). When asked to clarify if no KCL liquid had been delivered for Resident C, where was the medication obtained, the DON stated, . a different resident who is on the liquid (KCL). When asked if this was the facility's protocol if the nurse does not have the medication the physician ordered, she stated, No, that is not our normal protocol. In addition, the DON stated, The protocol is that the nurse who is obtaining the order from the doctor, they have to enter the order on the PCC (MAR) program. The DON stated that the order was not confirmed by the nurse administering the medication. When asked about the KCL 60 meq liquid continuing to be given TID, along with KCL 40 meq liquid daily, the DON stated that the nurses should look at the high alert (medication most likely to cause significant harm) of the medication, not just the schedule (administration times). During an telephone interview with RN 1 on (MONTH) 28, (YEAR) at 2:40 PM, he was asked to describe what happened before Resident C was sent out to the acute care hospital. RN 1 stated, From what I can remember, the pt (patient-Resident C) complained of SOB (shortness of breath, (the) Charge Nurse administered O2 (oxygen), she (Resident C) was still talking, stated she was having trouble breathing and said she was having palpitations (a noticeably strong rapid heart rate). I went through her chart and noticed the orders, saw she was on multiple orders of KCL . noticed a discrepancy of the daily order for potassium and contacted the MD on call. RN 1 stated that after speaking with the MD on call, he called 911 emergency and when the paramedics arrived, (I) told the paramedics that Resident C may be possible KCL overload, they saw that her heart rate was a little off, and said it may be due to the extra K+, and took her immediately. RN 1 continued, The SOB (shortness of breath) and the decompensation was something new for her. When asked did the nurses recap (recapitulate-checking the new orders for correctness) physician's orders [REDACTED]. A review of the facility's procedure titled, Charge Nurse (not dated) (received (MONTH) 28, (YEAR) from the DON) The policy set forth: Drug Administrative Functions . Ensure that prescribed medication for one resident is not administered to another. Notify the Nurse Supervisor of all drug and narcotic discrepancies noted on your shift. Review medication cards for completeness of information, accuracy in the transcription of the physician's orders [REDACTED]. A review of the facility's job description titled, Registered Nurse (not dated) (received (MONTH) 28, (YEAR) from the DON). The policy set forth: Drug Administrative Functions . Ensure that prescribed medication for one resident is not administered to another. Review medication cards for completeness of information, accuracy in the transcription of the physician's orders [REDACTED]. A review of the facility's policy/procedure titled, Physician Orders, (Revised (MONTH) (YEAR)). The policy set froth: 3. When transcribing orders nurse must verify the order given to avoid errors. A review of the facility's policy/procedure titled, Medication Administration, (Revised (MONTH) (YEAR)) set forth: 17. If there is a question in regard to dosage, the person in doubt should not give the drug until she has obtained information which clarifies drug dosage. A review of a document entitled, Nursing Home to Hospital Transfer Form, for Resident C, dated (MONTH) 2, (YEAR) at 03:04 AM, occurred. The document noted reason for transfer of Resident C as follows: Shortness of Breath ([MEDICAL CONDITION], pneumonia). Also, vital signs (clinical measurement of a patient's essential functions) at transfer were documented as follows: blood pressure 98/64 (normal 120/80), heart rate 99 (normal 60-100 beats per minute), respiratory rate 20 (normal 12-20), temperature 96.7, O2 SAT 94% on oxygen at 3L (liters). The acute care hospital's emergency room (ER) physician's notes for Resident C dated (MONTH) 2, (YEAR) at 02:59 AM, set forth: Chief Compliant: Patient presents for evaluation of shortness of breath. Resident C's vital signs were recorded at 03:07 AM as follows: BP (blood pressure) 168/83, pulse 118 (rapid), respiration rate 43 (fast), temperature 97.4. Resident C's 12 lead EKG (electrocardiogram-records the electrical activity of the heart) physician interpretation, dated (MONTH) 2, (YEAR) at 03:09 AM, shows [MEDICAL CONDITION] with rapid ventricular response (rapid & irregular), Rate (beats per minute): 108, . Clinical impression: abnormal EKG. Resident C's laboratory data on (MONTH) 2, (YEAR) at 03:31 AM, set forth the following: White blood count (WBC) 20.8 H (high-leukocytosis indicates an infection or a reaction to a drug) (normal 4.0-8.6). Potassium (K+) 8.5 H (high-[MEDICAL CONDITION] can cause suppression of electrical activity of the heart and cause the heart to stop beating, as normal K+ levels maintain the heart's electrical rhythm) (normal 3.3-5.2). GFR (glomerular filtration rate) 35 L (low-a test to check how well the kidneys are working) (normal >=60). The ER physician's progress note dated (MONTH) 2, (YEAR) set forth: Discusses plan for calcium (IV-intravenous for [MEDICAL CONDITION]) and sodium [MEDICATION NAME] (IV-for kidneys) intervention with family . Dr. re-checks on pt, and discusses results indicating [MEDICAL CONDITION] and plan for breathing treatment and [MEDICATION NAME] (diuretic medicine) intervention . pt has become bradycardic (slow heart rate) at 10 bpm (beats per minute), explains to family will proceed with sodium [MEDICATION NAME] and calcium chloride intervention. Despite intervention, time of death at 0525 (AM). The physician notes dated (MONTH) 2, (YEAR) set forth the following: Attending (Physician) Note: XXX[AGE] year-old female, DO NOT RESUSCITATE, comfort measure, presents with shortness of breath. Was noted to be profoundly bradycardic. Cardiac monitor showed a wide-complex [MEDICAL CONDITION]. My initial suspicion was related to [MEDICAL CONDITION]. Was given calcium, sodium [MEDICATION NAME] empirically (based on observation and experience). This immediately improved her heart rate to above 100 and an irregular wide-complex rhythm. Laboratory results confirmed [MEDICAL CONDITION] greater than 8. Renal function was mildly abnormal but her GFR was 35 with a creatinine of 1.4 (normal -blood levels measure kidney function). Her son arrived to the ER and supplied additional history. She was recently discharged and transferred to the rehabilitation from (name) hospital. Apparently, she had a laboratory study showing [DIAGNOSES REDACTED] (low potassium) and they were supplementing her with oral potassium. This would explain the severe [MEDICAL CONDITION] in the setting of her mild to moderate renal dysfunction. [DIAGNOSES REDACTED].

Based on observation, interview, and record review, the facility failed to protect one of 18 sampled residents (Resident 20) from a Physical Therapy Aide being verbally abrasive. This resulted in Resident 20 verbalizing that she experienced emotional distress due to the derogatory comments made by the PTA. In the presence of the Administrator, Director of Nursing, Assistant Administrator, Minimum Data Set Nurse, Clinical Resource Nurse, and the Assistant Director of Nursing, an Immediate Jeopardy was called at 3:46 PM, on October 13, 2015. Findings: During an observation on October 13, 2015 at 12:12 PM, while standing outside of Resident 20's room, a Physical Therapy Aide (PTA) was overheard to have been verbally abrasive to Resident 20. After looking into the room, an observation was made of Resident 20 sitting in her wheel chair, at the bedside, with the PTA standing over the resident. The resident's roommate was in the room. Resident 20 was overheard requesting the PTA to assist her back to bed and complaining of pain and nausea. The PTA was overheard refusing to put Resident 20 back to bed and stated in a loud, verbally abrasive voice while standing over the resident, I am not a pushover and I am not going to put up with this. The PTA left Resident 20's room. Upon entering Resident 20's room on October 13, 2015 at 12:15 PM, Resident 20 was observed sitting up in her wheel chair and was visibly shaking. During a concurrent interview with Resident 20, who answered in a loud, shaky voice, Resident 20 stated, I don't like him (PTA), he is pushy. I have to put up with it. He talks down to me like that every day. I like his partner better he is more understanding. A concurrent interview was conducted with Resident 20's roommate, (Unsampled Resident A) who was present when the PTA was in the room. Resident A stated, He talks down to her like that every day. During an interview on October 13, 2015 at 12:20 PM, with the Physical Therapy Director (PTD), she stated, A therapist should be encouraging when they speak to a resident. The statement used by the PTA, I am not a pushover and I am not going to put up with this was not encouraging. The Physical Therapy Director indicated that she was aware of the abrasive manner the PTA used when he spoke to Resident 20 earlier that morning in the Physical Therapy Room. The PTD stated she planned to meet with the PTA on how to communicate with the Resident but had not done so before the second interaction. During an interview with the PTA, on October 13, 2015, at 3:00 PM, the PTA stated, We are going to battle it out a little bit. It is a unique approach. The PTA further stated, No, there is no care plan that states to be forceful. The PTA stated, I probably should not have been speaking in this way looking back. During an interview with the Certified Occupational Therapy Aide (COTA) on October 13, 2015 at 3:15 PM, the COTA stated, My approach is to ease Resident 20 into it (therapy), I know how she responds. During a record review of the care plan, dated October 1, 2015 to October 28, 2015, there was no documented evidence for the PTA to use abrasive language or a unique approach with Resident 20. During a review of the corrective action plan dated October 13, 2015, at 5:08 PM, the Immediate Jeopardy was removed. The Administrator, Director of Nursing, Assistant Administrator, Minimum Data Set Nurse, Clinical Resource Nurse, and the Assistant Director of Nursing were verbally notified. The corrective action plan included: 1. The Physical Therapy Aide had been suspended pending investigation. 2. The Resident was safe and verbalized not being afraid or mistreated in any way. 3. The Therapy Leader had conducted an in-service at 12:30 PM regarding appropriate communication techniques to the entire rehabilitation staff. 4. Administrator will conduct a full investigation During a review of the facility policy and procedure dated April, 2013, and titled, Policy/Procedure - Nursing Administration, the policy and procedure indicated,The employees of our facility are mandatory reporters and will take action to protect and prevent abuse and neglect from occurring within the facility by: Supervision of staff to identify inappropriate behaviors (i.e., derogatory language .).

Based on observation, interview, and record review, the facility failed to provide a safe environment to prevent accidents by not identifying the hazards and risks associated with the improper use of the side rails for a resident who exhibited involuntary movements while in bed for one of 31 sampled residents (Resident 21). This failure resulted in Resident 21's involuntary movements to cause his head to become completely through the vertical slats of the full side rail, which could result in serious injury, suffocation or death for Resident 21 if the side rail were to fall down while his head was between the slats, due to his wiggling in bed. An Immediate Jeopardy (IJ) was called under 483.25, Quality of Care (refer to F 323-Free of Accident Hazards/Supervision/Devices) on October 14, 2015 at 10:08 AM, and verbally notified in the presence of Administrator, Director of Nursing, Assistant Administrator, Assistant Director of Nursing, MDS Nurse, and Director of Rehabilitation. The facility failed to provide supervision to one of 31 sampled residents (Resident 21) from risk of possible harm when Resident 21 was observed with his head sticking completely within the full side rail. The corrective action plan was reviewed and accepted by the team following observation, interviews and record reviews, to ensure the corrective action plan was in place on October 14, 2015 at 4:20 PM, with the following information: a. Resident's assessment from head to toe was completed. b. Restrain/enabling device/safety device evaluation was completed. c. The resident was provided with low bed with no side rails, and floor mats to both sides when in bed. Resident was moved from 329-4 to 329-2 to accommodate the floor mats. d. Resident Care plan was updated, and the information was placed inside Resident 21's closet door on the information sheet used to communicate with the CNAs. The IJ was removed on October 14, 2015 at 4:20, PM in presence of Administrator, Director of Nursing, Assistant Administrator, and Assistant Director of Nursing. Findings: During a review of the Admission Record for Resident 21, dated October 15, 2015, the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During a review of the clinical record for Resident 21, the minimum data set (MDS- an assessment tool) dated August 6, 2015, under section G, the section for bed mobility, indicated that Resident 21 required extensive physical assistance from at least two persons for positioning. Under section P for restraint use, the section was coded as zero, which indicated Resident 21 did not have side rails for restraint use. Resident 21 was non-ambulatory, and unable to get out of bed by himself, and required at least two persons assistance to transfer from bed to chair. During a routine observation of another resident (sample Resident 1) on October 14, 2015 at 6:15 AM, Resident 21 was found with his head completely through the full side rail. His head was dangling, and his entire body was on the bed. The side rail was observed to have no padding to prevent Resident 21's head from going through the side rail when he wiggled in the bed. The side rail was observed to be a full side rail which had a latch at each end that was lifted up to let the side rail down. If the side rail were not completed locked into place, Resident 21 could wiggle and cause the rail to drop with his head between the slats,resulting in serious injury,suffocation or death. There were no facility staff in the room at that time, Resident 21 was still, eyes closed. During an interview with a certified nursing assistant (CNA 4) on October 14, 2015 at 6:25 AM, CNA 4 stated, This resident moves around a lot in bed. When asked if Resident 21 had ever been found like this before, CNA 4 replied Yes, it has happened before, he usually starts moaning and wiggling around in bed at about 4:00 AM every day. During an interview with a licensed vocational nurse (LVN 7) on October 14, 2015 at 7:00 AM, LVN 7 stated, The CNA told me that resident (Resident 21) was found with his head between the rails. It is the first time this has happened to me, on my shift. It is bad, really bad. I did a head to toe assessment and went to risk management. LVN 7 said it was identified as a non-safe incident, and it would be care planned and documented. During an observation of Resident 21 on October 14, 2015 at 7:30 AM, there was a CNA (CNA 5) at his bedside, full side rails continued to be up on both sides of bed. CNA 5 stated she has never taken care of Resident 21 before, and had only worked at the facility for three weeks. Resident 21 was awake, eyes open. He was non-verbal, and was not interviewable. Resident 21 observed with to have contractures to both hands. During an interview with the Assistant Director of Nursing (ADON) on October 14, 2015, at 8:10 AM, she stated that CNA 4, a restorative nursing assistant (RNA- a CNA with specialized training), and LVN 7 had all reported to her, and to the Director of Nursing (DON) that Resident 21 was found with his head actually between the vertical slats of the full side rail. The ADON stated that she discussed the situation with the DON. The ADON stated that side rails can be used for mobility. The ADON also stated, This resident does move around (in bed), but this has never happened to us before, a head getting stuck in the rail. During an interview with the minimum data set (MDS- an assessment tool) coordinator (MDS nurse) on October 14, 2015 at 8:40 AM, she stated that she did see Resident 21 with his head completely through the full side rails this morning, at 6:20 AM, when she entered the room at the same time the CNA and RNA had responded to the observation about Resident 21 being caught in the side rail. During an interview regarding the use of the full side rails for Resident 21, the MDS coordinator stated, The CNA's just pull them (side rails) up. The MDS coordinator verbalized that she did not know if Resident 21 was able to use his side rails to position himself in bed, and she stated I don't know, I did his MDS back in August. During an interview with the Treatment Nurse on October 14, 2015 at 8:50 AM, she stated that Resident 21 was unable to hold the side rail by himself, If I put his hand on the rail so he can hold on to it, he might let go of the rail. The full side rails were measured by the treatment nurse, and the space between the vertical slats of the full rails was eight inches. Resident 21's head was measured across the forehead from temple to temple, and measured six inches. The Treatment Nurse stated, Resident 21's head would fit through the rail. During a review of the clinical record for Resident 21, the Order Summary Report (doctor's orders), dated October 1 through October 31, 2015, reflected there was no order for side rails for a position/mobility device. There was no consent for the full side rails used for Resident 21, and there was no side rail use mentioned in the care plan. During an interview with CNA 6 on October 14, 2015 at 8:50 AM, at Resident 21's bedside, she stated, that Resident 21 cannot hold onto the side rail, or use them for mobility. CNA 6 stated that the licensed nurses told her to put the side rails up to keep the resident from getting up or falling out of bed. The facility policy and procedure entitled Side rails, dated August 2007 indicated, It is the policy of this facility to utilize side rails as a mobility enabler or when needed/requested by the resident/resident surrogate to prevent falling out of bed. They are not a restraint. There was no documented evidence that Resident 21 was able to use the side rail to reposition himself, or that Resident 21, his surrogate decision maker, or the physician had been contacted to discuss the use of any side rails. The facility failed to follow their policy and procedure for the use of side rails, in spite of a previous episode involving Resident 21 wiggling in bed and getting his head between the side rails, placing him at increased risk of choking and suffocation.

Based on interview and record review, the facility failed to ensure 1 of 3 sampled residents (Resident 1) was provided the necessary care and services, when Resident 1 was found with a left hip dislocation. A left hip X-ray was done on June 30, 2014 as ordered by Resident 1's physician (MD 1), however Resident 1's physician was never notified of the hip X-ray result; lateral dislocation of the hip bone (occurs when the ball of the thighbone moves out of place within the socket of the pelvic bone). The failure of the nursing staff to notify the physician of the hip dislocation, resulted in continued complaints of pain by Resident 1 and repeated weight placed on the dislocated hip, which had the potential for Resident 1 to develop medical complications [REDACTED]. On July 22, 2014, 22 days later, Resident 1 was discharged to another facility. Resident 1 was still complaining of pain to the left hip and transferred to the acute hospital the same day on July 22, 2014. Resident 1 was diagnosed with [REDACTED]. Findings: A review of the clinical record for Resident 1, indicated Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 1 was discharged from the facility on July 22, 2014. A review of Resident 1's admitting physician's orders [REDACTED]. During an interview with Certified Nurses Assistant (CNA) 1 on October 2, 2014, she stated whenever she provided care to Resident 1, she was complaining of constant pain to her hip. During an interview with Licensed Vocational Nurse (LVN) 1 on October 2, 2014, she stated Resident 1 was on three different pain medications and still constantly complained of hip pain. Review of Resident 1's admitting physician's orders [REDACTED].) apply 1 patch [MEDICATION NAME] one time a day for pain management. Apply to left hip daily for 12 hours to be on at 9:00 AM and off at 9:00 PM and [MEDICATION NAME] (narcotic pain medication, is used to relieve moderate to severe pain) 10-325 mg (milligrams) 1 tablet by mouth every 4 hours as needed for pain management for 30 days, not to exceed 3 GMS (grams) of [MEDICATION NAME] in 24 hours. Review of the clinical record showed the "Pain Assessment Flowsheet" documented by the nursing staff during their pain assessment times, for the dates from July 6, 2014 through July 21, 2014, which indicated the resident's pain level on a scale of 1-10 (1 having no pain and 10 being the worst pain). Resident 1's pain level was consistently at 6/10. Review of the clinical record for Resident 1, showed the X-ray results for the resident's left hip done at the hospital following surgery dated June 23, 2014 and another left hip X-ray done on June 24, 2014 which showed no dislocation of the left hip. During an interview with Resident 1's physician (MD 1) on October 2, 2014 at 10:30 AM, he stated he went to assess Resident 1 on June 29, 2014. According to the physician, he gave an order on June 29, 2014 to repeat the left hip x-ray on June 30, 2014. A review of the clinical record for Resident 1 of the physician's orders [REDACTED]. A review of the left hip X-ray results dated June 30, 2014 indicated, "There is left hip arthroplasty (surgical procedure to replace a worn out or damaged hip with a prosthesis (an artificial joint) with lateral (sideways) dislocation." During an interview with the Assistant Director of Nursing on November 20, 2014 at 12:15 PM, she stated she verified through Registered Nurse (RN) 1's documentation that the physician (MD 1) was not notified of the result of Resident 1's left hip dislocation. She stated, RN 1 no longer works for the facility. During an interview with Resident 1's physician on November 17, 2014 at 3:10 PM, he was asked if he was notified of the left hip X-ray result on June 30, 2014, he stated, "I did not receive a phone call from the facility with the X-ray result." The physician stated he was not made aware of the hip dislocation. A review of the clinical record showed a telephone physician's orders [REDACTED]. hip. During an interview with the RPT on October 2, 2014 at 11:15 AM, she was asked if she remembered treating Resident 1. She stated yes, Resident 1 received physical therapy during her stay at the facility. She further stated the resident was in a lot of pain during the course of her therapy. Review of the physical therapy notes showed Resident 1 had physical therapy that began on June 29, 2014 and ended on July 21, 2014 for a total of 16 physical therapy sessions. The physical therapy treatments included: bed mobility, transfer training and safe ambulation training. During an interview with Resident 1's physician on November 17, 2014 at 3:10 PM, he was asked if he had ordered partial weight bearing on the LLE for Resident 1 on July 1, 2014. The physician stated, "In what universe would I order partial weight bearing if I had received the X-ray result that confirmed a dislocation. No I did not order partial weight bearing on the LLE." During an interview with RPT on November 20, 2014 at 11:50 AM, she stated on July 1, 2014 she phoned the ortho doctor and received an order to advance Resident 1's weight bearing status from non weight bearing to partial weight bearing. She admitted she was not made aware of the left hip dislocation until the resident was discharged from the facility. RPT stated Resident 1 received physical therapy since June 30, 2014 through July 21, 2014 with dislocated left hip. She stated the nurse should have informed her (physical therapy) of the left hip dislocation when it was identified on the x-ray on June 30, 2014. The facility policy and procedure titled, "Change of Condition Reporting" dated 05/2007, indicated, under "Acute Medical Change", 1.; "Any sudden or serious change in a resident's condition may...will be communicated to the physician with a request for physician visit promptly and/or acute care evaluation. The ...nurse in charge will notify the physician." During a conversation with Resident 1's family member on October 1, 2014 at 10:30 AM, she stated Resident 1 was transported to acute hospital, after her discharge from the facility on July 22, 2014. She further stated that the attending ER (emergency room ) physician told her since the dislocation (left hip) had happened weeks ago, it would be difficult to "pop the hip back into place." The physician told her that she should have brought her in sooner. Review of the hospital ER records showed, Resident 1 was admitted to theER on [DATE] at 2:45 PM. She brought in by ambulance from the facility with a reported left [MEDICAL CONDITION]. Resident 1 was assessed by the ER physician and was found with "left hip with obvious deformity likely dislocated." The ER physician documented; "Spoke with (name of primary care physician) and agrees reducing hip in ER not appropriate considering the length of time hip has been dislocated (> greater than 2 weeks). (name of primary care physician) to admit and have the Orthopedic Doctor" Review of the hospital records showed a consultation report by the Orthopedic physician (bone doctor), dated July 23, 2014. The Orthopedic physician diagnosed Resident 1 with dislocated left hip prosthesis. The treatment plan for Resident 1 was to "attempt to reduce (procedure to set (reduce) a broken bone) the dislocation under anesthesia (gases to put the resident to sleep), but because of the length of time that the hip was dislocated, it may not be feasible for me to reduce the hip in a closed manner (reduce under anesthesia) and may require open reduction (making an incision in the skin and putting the fractured bones together and stabilizing with screws or plates or rods) of the hip dislocation." Review of the acute hospital records showed Resident 1 had the open reduction hip surgery on July 24, 2014 related to dislocated left hip prosthesis .

Based on interview and record review, the facility failed to notify the physician of an x-ray result for 1 of 3 sampled residents (Resident 1), when Resident 1 was found to have a left hip dislocation on June 30, 2014. The failure of the nursing staff to notify the physician of the left hip dislocation, resulted in a delay of treatment, Resident 1 continued to suffer with left hip pain. Findings: Review of the clinical record for Resident 1, indicated Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the admission physician order [REDACTED]. Review of the clinical record for Resident 1, showed the X-ray results for the resident's left hip done at the hospital following surgery dated June 23, 2014 and another left hip X-ray done on June 24, 2014 which showed no dislocation of the left hip. During an interview with Resident 1's physician on October 2, 2014 at 10:30 AM, he stated he went to assess Resident 1 on June 29, 2014. According to the physician, he gave an order on June 29, 2014 to repeat a left hip x-ray on June 30, 2014. A review of the physician's orders [REDACTED]. A review of the left hip X-ray results dated June 30, 2014 indicated, "There is left hip arthroplasty (surgical procedure to replace a worn out or damaged hip with a prosthesis (an artificial joint) with lateral (sideways) dislocation... Conclusion: Dislocation of left hip arthroplasty." Further review of Resident 1's clinical record, showed there was no documentation to show the physician was notified of the left hip x-ray result when the dislocation of the resident's left hip was identified on June 30, 2014. During an interview with Resident 1's physician on November 17, 2014 at 3:10 PM, he was asked if he was notified of the left hip X-ray result on June 30, 2014, he stated "I did not receive a phone call from the facility with the X-ray result." The physician stated he was not made aware that Resident 1 had a left hip dislocation. The physician was asked if he had ordered partial weight bearing on the LLE (left lower extremity) for Resident 1 on July 1, 2014. The physician stated, "In what universe would I order partial weight bearing if I had received the X-ray result that confirmed a dislocation. No I did not order partial weight bearing on LLE." During an interview with the Assistant Director of Nursing on November 20, 2014 at 12:15 PM, she verified through the RN documentation dated June 30, 2014, the physician was not notified of the result of the left hip dislocation when the result was received by the facility on June 30, 2014. She stated the physician should have been immediately notified of the resident's hip dislocation and communication to the physician should be reflected in the Resident 1's clinical record. The facility policy and procedure titled, "Change of Condition Reporting" dated 05/2007, indicated, under "Routine Medical Change", 1.; "All symptoms and unusual signs will be communicated to the physician promptly. Routine changes are a minor change in physical and mental...abnormal laboratory and x-ray results..."