Every finding on record at Valley Vista Post Acute

Based on interview and record review, the facility failed to ensure that four out of five sampled residents (Residents 2, 10, 19 and 49) were free from unnecessary psychotropic (affecting brain activities associated with mental processes and behavior) medications when: 1. For Resident 10, the facility did not implement resident specific non-pharmacological interventions (NPIs, behavioral treatments that do not involve medications) for the use of clonazepam (medication used to treat anxiety), mirtazapine (medication used to treat depression), risperidone (antipsychotic medication that balances certain chemicals in the brain to help a person feel calmer and think clearly), buspirone (medication used to treat anxiety) and sertraline (medication used to treat depression).2. For Resident 49, the facility did not implement resident specific NPIs for the use of duloxetine (medication used to treat depression), lamotrigine (medication used to treat mood disorders), trazodone (medication used to treat depression) and clonazepam.3. For Resident 2, the facility did not have a stop date regarding the as needed use of lorazepam (medication used to treat anxiety)4. For Resident 19, the facility did not have non-pharmacological interventions in place. These failures had the potential for residents to receive unnecessary psychotropic medications which can lead to side effects, such as sedation and falls, and a decline in psychosocial (how a person feels about themselves and their environment) well-being. 1. A review of Resident 10's medical records indicated the following physician's orders: clonazepam 0.25 milligrams (mg, unit of measure) daily for anxiety (a condition characterized by excessive worry and unease) m/b (manifested by) restlessness, repetitive questions, initiated 11/6/24; clonazepam 0.5 mg at bedtime, for anxiety m/b restlessness, repetitive questions, initiated 5/20/21; mirtazapine 15 mg at bedtime for depression (a condition characterized by persistent sadness) m/b poor intake (of food) less than 50%, dated 8/17/25; risperidone 0.25 mg daily for schizophrenia (a condition characterized by an inability to distinguish between reality and one's own thoughts) m/b paranoid delusions thinking people are talking about her, initiated 11/6/24; risperidone 0.5 mg at bedtime for schizophrenia m/b paranoid delusions (symptoms of schizophrenia in which one has unfounded suspicions of others) thinking people are talking about her, initiated 8/30/24; buspirone 5 mg by mouth three times a day for anxiety m/b yelling out, initiated 10/17/24; and sertraline 50 mg daily for depression m/b verbalizing feeling sad, initiated 12/12/24. A review of Resident 10's Medication Administration Record (MAR), dated 9/2025, indicated there was no documentation of NPIs by nursing staff for the use of Resident 10's five psychotropic medications. A review of Resident 10's undated care plan indicated NPIs will be provided with, .mental health activities.dance, music, art, exercise, leisure, recreation, orientation, education and/or skill building activities, as well as group and individual activities, such as watching the animal planet.movies, and pet therapy. During a concurrent interview and record review with the Director of Nursing (DON) on 9/10/25 at 4:31 P.M., the DON was asked if there were any NPIs on Resident 10's MAR. The DON stated, I know what you mean – redirection, offer snacks.those things. The DON confirmed there were no NPIs on the MAR; the facility did not implement NPIs for the use of Resident 10's psychotropic medications. 2. A review of Resident 49's medical records indicated the following physician's orders: Duloxetine Delayed Release (DR, designed to release slowly) 60 mg capsule every evening for depression m/b self-isolation, refusing to care, initiated 2/9/24; lamotrigine100 mg daily for schizoaffective disorder bipolar type (a condition that has symptoms of schizophrenia and bipolar disorder. Bipolar disorder, a condition characterized by a drastic shift in moods) m/b angry outburst without provocation, re-ordered 10/4/24; trazodone 50 mg at bedtime for depression m/b insomnia, difficulty sleeping, dated 3/4/25; and clonazepam 1 mg twice a day for diagnosis of anxiety m/b verbalizing feeling nervousness, dated 4/9/25. A review of Resident 49's MAR, dated 9/2025, indicated there was no documentation of NPIs by nursing staff for the use of Resident 49's four psychotropic medications. A review of Resident 49's undated care plan indicated NPIs would be provided with therapeutic activities such as dance, music, art, exercise, leisure, recreation, orientation, education and/or skill building activities. During an interview with the DON on 9/11/25 at 2:23 P.M., the DON stated, .before we start antipsychotics, we need non-pharmacological] approaches. Activities, calm environment, nourishment to make sure it's not behavior. Drugs would be the last resort, unless it's an emergency. During a telephone interview with the Consultant Pharmacist (CP) on 9/11/25 at 11:02 A.M., the CP stated she and other healthcare staff discuss NPIs at monthly meetings. The CP stated the nurse practitioner monitors NPI and encourage[s] staff to maintain a structured environment to manage orientation and agitation. During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Use, reviewed 7/2022, indicated, .10. Non-pharmacological approaches are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible. Findings: Per the facility's admission Record , Resident 2 was admitted to the facility on [DATE] with diagnoses which included Schizoaffective disorder (a mental illness that could affect thoughts, mood and behavior) and Major Depressive Disorder. A review of Resident 2's Minimum Data Set(MDS-a federally mandated assessment tool) dated 7/22/25 indicated Resident 2's Brief Interview for Mental Status (BIMS) score was 15 which indicated Resident 2's cognition (thought process) was intact. A review of Resident 2's order summary report indicated Resident 2 was on the following psychotropic medications (drugs that affect mental processes and behaviors): Fluoxetine 20 mg 1 capsule by mouth daily for depression Lorazepam 0.5 mg (anti-anxiety) 1 tablet by mouth every 12 hours as needed for anxiety Trazodone (anti-depressant) 50 mg by mouth at bedtime for depression. A review of Resident 2's medical record did not indicate non-pharmacological interventions and a stop date for Lorazepam were in placed for the use of psychotropic medications. On 9/9/25 at 3:30 P.M., an interview and record review with Licensed Nurse (LN) 1 was conducted.LN 1 stated there is no stop date for Resident 2's lorazepam as needed medication. LN 1 stated it was important to have a stop date for psychotropics as needed orders to evaluate if the medication was effective. 2 4) Per the facility's admission Record , Resident 19 was admitted to the facility on [DATE] with diagnoses which included Bipolar Disorder (mood swings that range from slows of depression to elevated periods of emotional highs) and Major Depressive Disorder. A review of Resident 19's MDS dated [DATE] indicated Resident 19 had a BIMS score of 15 which indicated Resident 19's cognition was intact. A review of Resident 19's order summary report indicated the following psychotropic medications: Aripiprazole 15 mg by mouth at bedtime for Schizophrenia Lorazepam 0.5 mg by mouth twice a day for Anxiety Sertraline 150 mg by mouth daily for Depression Divalproex 500 mg 3 tablets by mouth twice a day for Schizoaffective Disorder. A review of Resident 19's medical record did not indicate non-pharmacological interventions were in place for the use of psychotropic medications. On 9/9/25 at 3:30 P.M., an interview and record review with Licensed Nurse (LN) 1 was conducted. LN 1 stated there were no non-pharmacological interventions either in the Medication Administration Record (MAR), Order Summary Report, or in the care plan for Resident 2 and Resident 19's use of psychotropic medications. On 9/11/25 at 10:28 A.M., an interview with the Director of Nursing (DON) was conducted. The DON stated the non-pharmacological interventions were important and that she expected the licensed staff to have used non-pharmacological interventions first before administration of the psychotropic medications routine or as needed. The DON stated non-pharmacological interventions addressed the root cause of conditions, reduced the need for drugs and enhanced quality of life of the residents. The DON stated Resident 2's lorazepam should have a stop date to evaluate its effectiveness and update the Physician for continued use or not. A record review of the facility's dated 7/2022 policy titled, Psychotropic Medication Use indicated,10. Non-pharmacological approaches are used (unless contraindicated) to minimize the need for medications .12. Psychotropic medications are not prescribed or given on a PRN basis .a. PRN orders for psychotropic medications are limited to 14 days.

Based on observation, interview, and record review, the facility failed to provide pharmacy services in accordance with accepted standards of practice when:1. Random controlled medication (medications with a high abuse potential) use audit for five of six sampled residents (Residents 3, 7, 25, 40 and 55) showed that medications were signed out of the controlled drug record (CDR, count sheet used to track controlled medications), but were not documented on the Medication Administration Record (MAR) to indicate they were administered to the residents. This failure had the potential for diversion (unlawful distribution or use), mismanagement of controlled medications, and the potential to not meet the needs of the residents in the facility. 2. Medications were not available for two of five sampled residents (Residents 2 and 42) when they were scheduled to be administered. This failure had the potential for Resident 2 to experience high blood pressure and Resident 42 to experience heartburn and pain.3. Two diabetes medications (metformin and glipizide- medications used to control blood sugar) were not administered per manufacturers' specifications for one of five residents (Resident 49). This failure had the potential for Resident 49 to not get the full therapeutic benefit of her medications.4. Insulin (medication for diabetes, to control blood sugar) was not administered as ordered for one of five sampled residents (Resident 49). This failure had the potential for Resident 49 to experience hypoglycemia (low blood sugar).Findings:1. During an inspection of the North Medication Cart with Licensed Nurse (LN) 2 on 9/8/25 at 2:58 P.M., the CDRs for six random residents receiving PRN (as needed) controlled medications were requested for review.a) A review of Resident 7's clinical record indicated he had active orders for oxycodone (a controlled medication used to manage pain), including oxycodone 5 milligram (mg, unit of measure) tablet - give one tablet by mouth every 6 hours as needed for moderate pain, dated 6/29/25. During a concurrent interview and record review with the Director of Nursing (DON) on 9/9/25 at 10:31 A.M., a review of Resident 7's CDR for oxycodone 5 mg and August 2025 MAR indicated the nursing staff signed out of the CDR, but did not document the medication administration on one occasion: 8/30/25 at 9:22 P.M. The DON confirmed there was no documentation on the MAR on 8/30 at 9:22 P.M. and stated, I'm not showing anything. The DON stated it should have been documented on the MAR. b) A review of Resident 25's clinical record indicated he had an order for oxycodone-acetaminophen (a controlled medication used to manage pain) 10/325 mg tablet - give two tablets by mouth every 6 hours as needed for moderate to severe pain, dated 7/27/25.During a concurrent interview and record review with the DON on 9/9/25 at 10:33 A.M., Resident 25's CDR for oxycodone-acetaminophen 10/325 mg, and MAR dated August 2025 and September 2025 were reviewed. The CDR indicated the nursing staff signed out tablets of oxycodone-acetaminophen 10/325 mg, but did not document the medication administration on the following days: 8/28/25 at 2:15 A.M. - one tablet was signed out of the CDR and there was no documentation on the [DATE]/1/25 at 2:25 A.M. - two tablets were signed out of the CDR and there was no documentation on the MAR The DON confirmed these deficiencies. Regarding the 8/28 2:15 A.M. dose, the DON stated the CDR documentation was .signed once, and that she could not find it documented on the MAR. The DON stated, It should have been entered. The DON stated, No documentation. None, regarding the 9/1 2:25 A.M. dose. c) A review of Resident 3's clinical record indicated she had active orders for hydrocodone-acetaminophen (a controlled medication used to manage pain), including hydrocodone-acetaminophen 10/325 mg, give one tablet by mouth every 4 hours as needed for severe pain, dated 3/23/25.During a concurrent interview and record review with the DON on 9/9/25 at 10:39 A.M., Resident 3's CDR for hydrocodone-acetaminophen 10/325 mg and MAR for August 2025 and September 2025 were reviewed. Resident 3's CDR indicated nursing staff signed out one tablet of hydrocodone-acetaminophen 10/325 mg for administration, but did not document on the MAR on six occasions:8/24/25 at 5:07 A.M.8/24/25 at 11:30 P.M.8/25/25 at 4:50 A.M.8/26/25at 4:10 A.M.8/28/25 at 5:20 A.M.9/4/25 at 5:10 A.M.The DON confirmed this deficiency and could not find any documentation of administration on Resident 3's August 2025 and September 2025 MAR for the above dates and times. The DON stated, That's odd. I don't see anything. The DON stated the administrations should have been documented to make sure .patients won't be overmedicated, have records that the residents received pain meds and to make sure we followed the doctor's order. The DON stated there are risks to improper documentation, possibly drug diversion. Counts should coordinate.d) A review of Resident 40's clinical record indicated she had an active order for oxycodone-acetaminophen 10/325 mg, give one tablet by mouth every 4 hours as needed for moderate to severe pain, dated 2/13/25.During a concurrent interview and record review with the DON on 9/9/25 at 10:48 A.M., Resident 40's CDR for oxycodone-acetaminophen 10/325 mg and MAR for August 2025 and September 2025 were reviewed. Resident 40's CDR indicated nursing staff signed out one tablet of oxycodone-acetaminophen 10/325 mg for administration, but did not document on the MAR on nine occasions:8/24/25 at 9 P.M.8/25/25 at 9 P.M.8/26/25 at 9:51 A.M.8/26/25 at 2:30 P.M.8/29/25 at 8:32 P.M.9/2/25 at 5:30 P.M.9/4/25 at 5:35 A.M.9/6/25 at 9:30 A.M.9/6/25 at 3:00 P.M.The DON confirmed these deficiencies and could not find any documentation of administration on Resident 40's August 2025 and September 2025 MAR for the above dates and times. The DON stated, Not documented. Not documented, not given. I don't see it.e) A review of Resident 55's clinical record indicated she had an active order for morphine (a controlled medication used to manage pain) 15 mg, give one tablet by mouth every 6 hours as needed for breakthrough pain, dated 4/6/25.During a concurrent interview and record review with the DON on 9/9/25 at 10:56 A.M., Resident 55's CDR for morphine 15 mg and August 2025 MAR were reviewed. Resident 55's CDR indicated nursing staff signed out one morphine 15 mg tablet for administration, but did not document on the MAR on 5 occasions:8/15/25 at 7:30 P.M.8/22/25 at 1:10 A.M.8/22/25 at 9:48 A.M.8/22/25 at 9:00 A.M.8/25/25 at 12:00 A.M.The DON stated, .that's weird.I'm trying to see if there's more I can show you. The DON confirmed she could not find documentation for administration of Resident 55's morphine 15 mg on the MAR for 8/15, 8/22 and 8/25 for the above times. The DON stated proper documentation was important and the entries on the CDR and MAR must match.During an interview with the DON on 9/11/25 at 2:36 P.M., the DON stated nursing staff were expected to document administrations in both the CDR and MAR.A review of the facility's policy and procedure (P&P) titled, Controlled Substances, reviewed 2024, indicated, .Accurate accountability of the inventory of all controlled drugs is maintained at all times. When a controlled substance is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR): 1) Date and time of administration (MAR, Accountability Record) . 4) Initials of the nurse administering the dose. 2. a) During a medication administration observation on 9/9/25 at 11:17 A.M., LN 31 was observed preparing and administering nine medications for Resident 42. LN 31 stated she did not have Resident 42's tenth medication, hydralazine 25 mg, in stock for the morning dose.A review of Resident 42's clinical record indicated she had an active order since 8/13/25 for hydralazine oral tablet 25 mg. Give 1 tablet by mouth three times a day for HTN [hypertension, high blood pressure] . b) During a medication administration observation on 9/9/25 at 3:58 P.M., LN 32 was observed preparing and administering medications to Resident 2. LN 32 stated two of Resident 32's medications were out of stock for the evening dose: calcium carbonate and diclofenac gel.A review of Resident 2's clinical record indicated she had an active order since 8/31/25 for calcium carbonate tablet 600 mg. Give 1 tablet by mouth two times a day for indigestion/GERD [gastroesophageal reflux disease, acid reflux] . The review also indicated Resident 2 had an active order, reordered 9/6/25, for diclofenac external gel 1% (concentration of drug in gel) - Apply to right knee topically two times a day for pain management.During an interview with the DON on 9/11/25 at 2:34 P.M., the DON stated nurses need to check the availability of medication upon accepting the med cart. The DON stated medication ordering was important. The DON stated nurses were to call the pharmacy and, if a medication is unavailable, nurses should call the physician for a hold or ask for a substitute.A review of the facility's P&P titled, Pharmacy Services Overview, revised 4/2019, indicated, .4. Residents have sufficient supply of their prescribed medications and receive medications.in a timely manner. 5. Nursing staff communicate prescriber orders to the pharmacy and are responsible for contacting the pharmacy if a resident's medication is not available for administration. 3. A review of Resident 49's clinical record indicated she had active orders for the following diabetes medications:a) glipizide 5 mg - give one tablet by mouth two times a day for diabetes.Give with food (7:30 A.M. and 5:30 P.M.), dated 9/5/25b) metformin 1000 mg - give one tablet by mouth two times a day (9 A.M. and 5 P.M.) for diabetes, dated 8/10/25.A review of Resident 49's September 2025 MAR indicated she received glipizide at 7:30 A.M. and 5:30 P.M. and metformin was administered at 9 A.M. and 5 P.M.During an interview with the DON on 9/10/25 at 3:53 P.M., the DON was asked about the facility's mealtime schedules. The DON stated breakfast was served at 7:30 in the morning and confirmed that dinner service started at 5 P.M. The DON confirmed that glipizide was ordered to be given with food twice daily and metformin was scheduled to be given at 9 A.M. and 5 P.M.During a telephone interview with the Consultant Pharmacist (CP) on 9/11/25 at 10:18 A.M., the CP stated, metformin is advised to be taken with food to avoid GI [gastrointestinal, stomach or digestive] issues. Regarding glipizide, the CP confirmed that she recommended adding the additional direction, give with food on 9/3/25 and it was accepted on 9/5/25. The CP stated glipizide is preferred to be given before a meal to reduce the risk of hypoglycemia [low blood sugar]. At least 20-30 minutes prior to food. The CP stated the directions should have been specified. I do see it. I should have specified to give 20-30 minutes prior to a meal. Sorry.A review of metformin drug information provided by the facility, indicated, administer with a meal (to decrease GI upset) .A review of glipizide drug information provided by the facility, indicated, administer 30 minutes before a meal.to achieve the greatest reduction in postprandial hyperglycemia [post-meal blood sugar spike] .A review of the facility's P&P titled, Consultant Pharmacist Services Provider Requirements reviewed 2024, indicated, The consultant pharmacist provides consultation on all aspects of the provision of pharmacy services This includes, but is not limited to.assisting the facility in defining schedules for administering medications to maximize the effectiveness.A review of the facility's P&P titled, Medication Therapy revised 4/2007, indicated, .the staff and practitioner (assisted by the consultant pharmacist) will review an individual's current medication regimen, to identify whether.the dosage is appropriate.the frequency of administration.[is] appropriate. 4. A review of Resident 49's clinical record indicated she had a physician's order for insulin lispro (medication used to control blood sugar) - inject 5 units (unit of measure) subcutaneously (into fat under the skin) with meals for diabetes, hold for glucose (blood sugar) below 150, ordered 8/10/25. A review of Resident 49's MAR dated September 2025 indicated Resident 49 was administered insulin lispro on two occasions despite having blood sugar below 150: 9/5/25 at 7 A.M. blood sugar 137 9/6/25 at 5 P.M. blood sugar 135During an interview with the DON on 9/10/25 at 3:53 P.M., the DON verified the administrations. The DON stated the doses should've been held because the order says less than 150. The DON stated nurses should follow doctors' orders.it is insulin and could lead to low blood sugar.A drug review of the medication, insulin lispro, on Daily Med, a drug resource site, updated 6/17/25, indicated, excess insulin administration may cause hypoglycemia and hypokalemia [low potassium] (https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=c8ecbd7a-0e22-4fc7-a503-faa58c1b6f3f, accessed 9/14/25).A review of the facility's P&P titled, Diabetes - Clinical Protocol, revised 9/2017, indicated, .4. The Physician will order desired parameters for monitoring and reporting information related to blood sugar management. a. The staff will incorporate such parameters into the Medication Administration Record and care plan.

Based on observation, interview, and record review, the facility failed to ensure the facility medication error rate did not exceed five percent or greater, when observation of 42 opportunities during medication administration resulted in five errors. The calculated medication error rate was 11.9%.This failure resulted in1. Placing Resident 29 at risk of not breaking down and absorbing nutrients from food when Licensed Nurse (LN) 1 crushed and administered pancrelipase (digestive enzymes used to break down food during digestion) Delayed Release (DR, designed to release medication slowly over a period).Placing Resident 29 at risk of inadequate pain relief when LN 1 crushed and administered gabapentin (medication used for pain).2. Placing Resident 42 at risk of high blood pressure when LN 31 did not administer hydralazine (a medication used to treat high blood pressure).3. Placing Resident 2 at risk for heartburn, indigestion and upset stomach when LN 32 did not administer calcium carbonate (medication used to decrease acid in the stomach).Placing Resident 2 at risk for inadequate pain relief when LN 32 did not administer diclofenac gel (medication used to treat pain).Findings:1. During a medication administration observation on 9/8/25 at 10:30 A.M., LN 1 was observed preparing and administering a total of ten medications for Resident 29. LN 1 stated Resident 29 received most of his medications through his gastrostomy tube (G-tube, a device used to administer food and medications to individuals with difficulty swallowing).LN 1 prepared nine medications for G-tube administration, including the following two capsules (medications that are enclosed in a shell): pancrelipase oral capsule DR particles 12000 units (unit of measure) - give 1 capsule enterally (through the G-tube) every 12 hours as needed for digestive enzyme supplement, originally dated 8/24/24, and gabapentin oral capsule - give 400 milligrams (mg, unit of measure) via G-tube three times a day for dx (diagnosis of) leg pain, originally dated 8/11/25.LN 1 opened each capsule and poured the granules (medicine that is inside capsules) into separate medicine cups. LN 1 then crushed each medication separately, mixed the individually crushed medicine with water and administered the medications through Resident 29's G-tube.During an interview with LN 1 on 9/9/25 at 10:06 A.M., LN 1 confirmed he opened each capsule, crushed them separately and mixed each medication with water.During an interview with the Director of Nursing (DON) on 9/9/25 at 11:11 A.M., the DON stated nurses should refer to the package insert (product labeling information for healthcare professionals and patients) or call the pharmacy if they are not sure how to administer a medication.During an interview with the Consultant Pharmacist (CP) on 9/11/25 at 10:18 A.M., the CP stated, it's best to sprinkle the contents [of pancrelipase DR capsule] into applesauce. The CP stated, the studies [research on the medication] say to avoid crushing. The CP stated gabapentin capsules can be opened.mixed with purified water [water that is free from impurities], but not crushed to dissolve (the incorporation of a solid into a liquid) prior to administration. The CP stated, The studies show it's better to mix with water.I don't see any studies for crushing the capsule. The CP stated she can go over [medication administration] if nurses call.with a question.A review of pancrelipase DR capsule drug information provided by the facility, indicated, Open capsule and sprinkle contents onto.15 mL [milliliters, unit of measure] commercially available.applesauce or bananas. Stir gently and wait 15 minutes.A review of gabapentin capsule drug information provided by the facility, indicated, Open capsule(s) and disperse contents in 10 to 30 mL purified water; draw up mixture into enteral dosing syringe and administer via feeding tube.A review of the facility's policy and procedure (P&P) titled, Specific Medication Administration Procedures reviewed 2024, indicated, .sustained release [designed to release slowly] capsules and enteric coated [designed to dissolve in the small intestine instead of the stomach] capsules should not be crushed. Consult the prescriber and pharmacist for alternative formulations and doses.6.a) .Check the manufacturer's instructions or contact the pharmacist if there are questions about any medications.2. During a medication administration observation on 9/9/25 at 11:17 A.M., LN 31 was observed preparing and administering nine medications for Resident 42. LN 31 stated she did not have Resident 42's tenth medication, hydralazine 25 mg, in stock for the morning dose.A review of Resident 42's clinical record indicated she had an active order since 8/13/25 for hydralazine oral tablet 25 mg. Give 1 tablet by mouth three times a day for HTN [hypertension, high blood pressure] . 3. During a medication administration observation on 9/9/25 at 3:58 P.M., LN 32 was observed preparing and administering medications to Resident 2. LN 32 stated two of Resident 32's medications were out of stock for the evening dose: calcium carbonate and diclofenac gel.A review of Resident 2's clinical record indicated she had an active order since 8/31/25 for calcium carbonate tablet 600 mg. Give 1 tablet by mouth two times a day for indigestion/GERD [gastroesophageal reflux disease, acid reflux] . The review also indicated Resident 2 had an active order, reordered 9/6/25, for diclofenac external gel 1% (concentration of drug in gel) - Apply to right knee topically two times a day for pain management.During an interview with the DON on 9/11/25 at 2:34 P.M., the DON stated nurses need to check the availability of medication upon accepting the med cart. The DON stated medication ordering was important. The DON stated she expected nurses to call the pharmacy and, if a medication was unavailable, nurses should call the physician for a hold or ask for a substitute.A review of the facility's P&P titled, Pharmacy Services Overview, revised 4/2019, indicated, .4. Residents have sufficient supply of their prescribed medications and receive medications.in a timely manner. 5. Nursing staff communicate prescriber orders to the pharmacy and are responsible for contacting the pharmacy if a resident's medication is not available for administration.

Based on interview and record review the facility failed to identify and develop an effective quality assessment and performance improvement plan (QAPI- a data driven proactive approach to improvement used to ensure services are meeting quality standards) in the following areas related to:1) cross reference F 755- Pharmacy services- the facility failed to ensure the control drug record (CDR) matches the medication administration record (MAR) of controlled drugs of the residents for five out of six residents reviewed. 2) cross reference F 677- ADL care provided for dependent residents- the facility failed to provide nail care assistance for two out of 17 residents reviewed.These failures had the potential to affect the resident's health and condition. On 9/11/25 at 3:45 P.M., a QAPI meeting with the Director of Nursing (DON) and the Administrator (ADM) was conducted.The ADM stated fingernail trimming and the controlled drug record not matching the medication administration record was new to us. The DON stated it was important to identify issues affecting the residents in the facility. A review of the facility's policy and procedure (P&P), titled Quality Assurance and Performance Improvement (QAPI) Program, dated 2/2020 was conducted. The P&P indicated, . 2.the QAPI describes the process for identifying and correcting quality deficiencies. Key components of this process include.c. Identifying and prioritizing quality deficiencies.

Based on observation, interview, and record review, the facility failed to implement infection control standards of practice when an air vent blew out dust balls during meals in the dining room. This deficient practice had the potential to contaminate residents' food and affect the residents' respiratory status.Findings:During the dining room meal observation on 9/8/25 at 11:30 AM, there were 15 residents seated around eight separate tables. The air conditioner was on and a round air vent in the ceiling was directly above a table with residents. The air vent blew out three dust balls and the Activity Director (AD) swept up the dust balls from the floor. The air vent was observed with gray dust above a table with residents. At 11:51 A.M. a staff member brought the meal cart which was also near the air vent with gray dust. Staff proceeded with passing out meal trays with the cart wide open and the round dusty air vent blew air from the ceiling. Another observation in the dining room was conducted on 9/9/25 at 7:36 A.M. The air conditioner was on and the air vent still had gray dust. An interview and concurrent observation was conducted on 9/9/25 at 10:48 A.M. with the Facilities Director (FD). The FD checked the round air vent in the ceiling at the dining room. The FD stated the air vent was dusty. The FD stated the air condition unit was installed last Friday, 9/5/25 and it was expected for the vents to blow out dust. The FD stated the other vents had a filter, but the round air vent did not have a filter. The FD stated he notified staff to let him know when residents will be in the dining room so he can shut off the round vent. The FD stated it was important for air vents to be clean to prevent dust from getting into residents' food and prevent residents from inhaling dust. The FD further stated inhaling dust can lead to respiratory problems. During an interview on 9/11/25 at 9:16 A.M. with the AD, the AD stated she swept the dust bunnies that fell from the air vent in the dining room. The AD stated residents should be in a clean environment. The AD stated dust from the air vent could be inhaled by residents while they were eating in the dining room and any foreign material in residents' food may cause illness. During an interview on 9/11/25 at 3:14 P.M. with the Director of Nursing (DON), the DON stated residents could inhale the dust from the air vent in the dining room which could lead to respiratory distress. A review of the facility's undated policy and procedure (P&P) titled, Infection Prevention and Control Program was conducted. The P&P indicated, An infection prevention and control program [IPCP] is established and maintained to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections.A review of the facility's P&P titled, Grounds, revised May 2008 was conducted. The P&P indicated, Facility grounds shall be maintained in a safe and attractive manner.Maintenance shall be responsible for keeping grounds free of litter.

Based on observation, interview, and record review, the facility failed to provide an alternative call light system to one of 17 sampled residents (Resident 68). This failure had the potential for Resident 68 to experience a delay in care. Findings: According to the admission Record, Resident 68 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Parkinson's Disease (a movement disorder that worsens over time) and generalized muscle weakness. During a review of Resident 68's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 8/29/25, Resident 68 had a Brief Interview of Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) of 9 which indicated moderate cognitive impairment. On 9/8/25 at 8:24 A.M., an observation was conducted. Resident 68 was observed laying in bed and stated, I'm ready to get up.I'm waiting to eat breakfast, I can't use my hands. Resident 68 was observed with both hands bent and unable to fully open. Resident 68 had a push button call light (a button used for residents to request assistance from staff) on his bed. On 9/8/25 at 12:22 P.M., an interview was conducted with Resident 68's family member (FAM) 1. FAM 1 stated Resident 68 was unable to use his call light because he had hand contractures [stiffening/shortening at the joint, that reduces the joint's range of motion] and therefore could not always press the button. On 9/9/25 at 10:37 A.M., an interview was conducted with the Occupational Therapist (OT) 1. OT 1 stated Resident 68 had contractures to both hands .because of increased tone related to Parkinson's Disease. OT 1 stated Resident 68 was not able to consistently use the push button call light when he needed to call for assistance. On 9/10/25 at 1:08 P.M. an interview was conducted with the Director of Nursing (DON). The DON stated if Resident 68 was unable to consistently use the push-button call light when he needed assistance, the facility should have accommodated his needs. The DON stated, he needs to have something that he can tap. A review of the facility's policy titled Call System, Residents dated September 2022 indicated, Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station.If the resident has a disability that prevents him/her from making use of the call system, an alternative means of communication that is usable for the resident and documented in the care plan.

Based on interview and record reviews, the facility failed to provide a written notice and duration of bed hold for one of three residents (Resident 65) reviewed for bed hold notice. This failure had the potential for the resident and/or resident's representative to not have information regarding bed hold rights. Per the facility's admission Record, Resident 65 was admitted to the facility on [DATE] with diagnoses which included, chronic kidney disease (a condition in which the kidneys gradually lose their ability to filter waste products from the blood). A review of the progress notes dated, 6/25/25 indicated, Resident 65 was transferred to the acute hospital due to wounds on his buttocks.A review of Resident 65's medical record indicated, there was no documentation to confirm Resident 65 was notified of the bed hold when Resident 65 was transferred to the acute hospital.A review of Resident 65's Minimum Data Set (MDS-a federally mandated assessment tool) dated, 6/7/25 indicated, Resident 65's brief interview for mental status (BIMS- cognitive screening to assess residents' cognitive function) was 15 which indicated Resident 65's cognition (thought process) was intact.On 9/10/25 at 3:36 P.M., an interview with the Director of Staff Development (DSD) was conducted. The DSD stated it was important to offer Resident 65 and his family representative options for a bed hold.On 9/11/25 at 10:55 A.M., an interview with the Director of Nursing (DON) was conducted. The DON stated nursing staff, or the Social Service Director would follow up and offer a bed hold when residents were transferred to the acute care facility. The DON stated it was important to offer a bed hold to Resident 65 or his family representative regardless of the insurance. A review of the facility's policy dated 3/2022, titled Bed-Holds and Returns, Policy and Interpretation,1.all residents /representatives are provided written information regarding the facility bed-hold policies which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave).b. at the time of transfer.

Based on observation, interview, and record review, the facility failed to ensure a baseline care plan was developed for 2 of 17 residents (Residents 2 and 19) reviewed for baseline care plans. This failure had the potential for Resident 2 and Resident 19 to not receive appropriate care. Findings:1) Per the facility's admission Record , Resident 2 was admitted to the facility on [DATE] with diagnoses which included Schizoaffective Disorder(a mental illness that could affect thoughts, mood and behavior) and Major Depressive Disorder.A review of Resident 2's minimum data set (MDS-a federally mandated assessment tool) dated, 7/22/25 indicated, Resident 2's Brief Interview for Mental Status (BIMS) score was 15 which indicated Resident 2's cognition (thought process) was intact.A review of Resident 2's order summary report indicated, Resident 2 was on the following psychotropic medications (drugs that affect mental processes and behaviors): Fluoxetine 20 mg 1 capsule by mouth daily for depression; Lorazepam 0.5 mg (anti-anxiety) 1 tablet by mouth every 12 hours as needed for anxiety; Trazadone (anti-depressant) 50 mg by mouth at bedtime for depression.A review of Resident 2's medical record did not indicate a care plan for these psychotropic medications. 2) Per the facility's admission Record , Resident 19 was admitted to the facility on [DATE] with diagnoses which includes Bipolar Disorder (mood swings that range from slows of depression to elevated periods of emotional highs) and Major Depressive Disorder.A review of Resident 19's MDS dated [DATE] indicated Resident 19 had a BIMS score of 15 which indicated Resident 19's cognition was intact.A review of Resident 19's order summary report indicated the following psychotropic medications: Aripiprazole 15 mg by mouth at bedtime for Schizophrenia Lorazepam 0.5 mg by mouth twice a day for Anxiety Sertraline 150 mg by mouth daily for Depression Divalproex 500 mg 3 tablets by mouth twice a day for Schizoaffective Disorder. A review of Resident 2's medical record did not indicate a care plan for these psychotropic medications. On 9/11/25 at 10:28 a.m., an interview and record review with the Director of Nursing (DON) was conducted. The DON stated the care plans were important and that licensed staff were expected to develop and document on Resident 2 and Resident 19's medical record. The DON also stated the care plan was a basis and evidence of the care and acted as a communication of the care being provided. A review of the facility's Policy titled ,Care plans, Comprehensive Person-Centered dated 3/2022 indicated , Policy and Interpretation.2. the comprehensive person -centered care plan is developed within 7 days.and no more than 21 days after admission.

Based on observation, interview, and record review, the facility failed to ensure two of 17 residents (Resident 10 and Resident 49), who needed to carry out activities of daily living (ADL- self-care activities such as grooming, bathing, and toileting), received assistance with nail care (cleaning, trimming and/or filing of nails). As a result of this deficient practice, residents' fingernails were long and had the potential for skin injury and infection. Findings:1. Resident 10 was admitted to the facility on [DATE] with diagnoses including dementia (an impairment of brain function, such as memory loss and judgment) and chronic pain according to the facility's admission Record. During an interview and observation on 9/8/25 at 8:09 A.M., Resident 10 was in her room sitting at the edge of bed with breakfast tray calling out, Hello, hello, hello. Resident 10's fingernails were observed to be long and with gray debris under the nails. Resident 10's right forefinger nail was observed to be jagged. Resident 10 stated the nail on the right forefinger was sharp. Resident 10 stated she had asked someone to trim her nails and nobody had done it. A review of Resident 10's ADL care plan was conducted. The ADL care plan initiated on 12/11/17 indicated, at risk for Self- care Deficit As Evidenced by: Needs 1 person assistance with ADLs.Personal Hygiene - One person physical assist required. An observation was conducted on 9/9/25 at 9:58 A.M. Resident 10 was heard from the hallway calling out, I need someone. Resident 10 was sitting at the edge of the bed with breakfast tray. Resident 10's fingernails were still long with gray debris underneath. An interview and concurrent observation on 9/9/25 at 2:04 P.M was conducted with Certified Nurse Assistant (CNA) 31 in Resident 10's room. CNA 31 stated Resident 10's fingernails were long and dirty. CNA 31 stated Resident 10 can get an infection and scratch herself because of the long and dirty fingernails. CNA 31 stated all residents' fingernails were supposed to be trimmed on Sundays. During a joint observation and interview on 9/9/25 at 3:19 P.M. with Licensed Nurse (LN) 32, LN 32 stated Resident 10's fingernails were long and should be trimmed. LN 32 stated fingernails were trimmed weekly during showers for good hygiene. 2. Resident 49 was admitted to the facility on [DATE] with diagnoses including fibromyalgia (a health condition that causes pain and tenderness throughout the body) and dyspnea (difficulty breathing) according to the facility's admission Record. During an interview and observation on 9/8/25 at 8:26 A.M., Resident 49 was sitting up in bed with breakfast tray on her lap. Resident 49's fingernails were observed to be long. Resident 49 stated nobody had offered to trim her fingernails and would like them trimmed. A review of Resident 10's ADL care plan was conducted. The ADL care plan initiated on 11/24/23 indicated, at risk for Self-Care Deficit As Evidenced by impaired gait [walking] and mobility, muscle weakness.Personal Hygiene - One person physical assist required. A concurrent observation and interview on 9/9/25 at 2:04 P.M. was conducted with CNA 31. CNA 31 stated Resident 49's fingernails were long and should be trimmed to prevent infection and scratching herself. CNA 31 stated all residents' fingernails were supposed to be trimmed on Sundays. During a joint observation and interview on 9/9/25 at 3:20 P.M. with Licensed Nurse (LN) 32, LN 32 stated Resident 10's fingernails were long and should be trimmed. LN 32 stated fingernails were trimmed weekly during showers for good hygiene. An interview on 9/11/25 at 10:25 A.M. was conducted with the Director of Staff Development (DSD- a licensed nurse certified for staff training). The DSD stated nailcare should be done on shower days and every Sunday. The DSD stated if a resident had diabetes (a condition in which the body has trouble controlling blood sugar), the CNA should notify the Licensed Nurse. The DSD further stated it was important to trim residents' fingernails for infection control and prevent residents from digging into their hands. During an interview on 9/11/25 at 3:14 P.M. with the Director of Nursing (DON), the DON stated residents' fingernails should be trimmed on shower days and on Sundays for resident dignity and infection control. A review of the facility's policy and procedure (P&P) titled, Fingernails/Toenail, Care of, revised February 2018 was conducted. The P&P indicated, The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections.Review the resident's care plan to assess for any special needs of the resident.

Based on interview and record review, the facility failed to ensure intake and output (I & O- the measurement of the fluids that enter the body and the fluids that leave the body) was documented and monitored for one of 17 sampled residents (Resident 68). This failure placed Resident 68 at risk for edema (swelling), retaining fluid in the lungs or dehydration (loss of body fluids).Findings: According to the admission Record, Resident 68 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Congestive Heart Failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently) and Parkinson's Disease (a movement disorder that worsens over time). During a review of Resident 68's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 8/29/25, Resident 68 had a Brief Interview of Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) of 9 which indicated moderate cognitive impairment. The MDS further indicated Resident 68 was dependent on staff for eating/drinking and for toileting. During a review of Resident 68's Care Plan dated 8/28/25, the Care Plan indicated Resident 68 had Parkinson's Disease. The goal indicated, The resident will maintain optimal status and quality of life within limitations through review date.The resident will remain free of further s/sx [signs and symptoms], discomfort or complications related to Parkinson's disease through review date. The intervention indicated, Monitor and document intake and output as ordered. On 9/9/25 at 2:34 P.M. an interview was conducted with the Director of Staff Development (DSD). The DSD stated the assigned Certified Nursing Assistants (CNAs) were responsible for tracking and documenting Resident 68's fluid intake every shift. The DSD stated the assigned Licensed Nurse was responsible for documenting Resident 68's total fluid intake and output in the Electronic Medical Record on the P.M. shift. The DSD stated it was important to track and document Resident 68's intake and output because Resident 68 had CHF, which could result in fluid overload (too much fluid in the body). The DSD further stated, We don't want [Resident 68] to get pneumonia.[Resident 68] also has a history of dehydration and cannot drink by himself. On 9/10/25 at 3:41 P.M., a concurrent interview and record review was done with Licensed Nurse (LN) 12. LN 12 stated Resident 68's intake and output should have been documented in the Electronic Medication Administration Record (EMAR), but she did not see that it was documented since admission. LN 12 stated, For [Resident 68] we haven't been checking or documenting his intake and output. On 9/11/25 at 1:08 P.M. an interview was conducted with the Director of Nursing (DON). The DON stated it was her expectation that Licensed Nurses tracked Resident 68's intake and output as ordered by the physician. The DON stated it was important that Resident 68's intake and output were documented, .to make sure [Resident 68] is not retaining fluids, or getting dehydrated.We don't want fluid overload. If [Resident 68] retains more fluid he could have shortness of breath and decline in condition. A review of the facility's policy titled Fluid Intake and Output revised July 2017 indicated, The facility will monitor intake and output as ordered by the physician.

Based on observation, interview, and record review the facility failed to provide Restorative Nursing Assistant (RNA- a program to restore abilities or maintain function) program intervention with a hand splint (a device used to immobilize and keep the hand in one position) for one of 17 sampled residents (Resident 68). This failure had the potential for Resident 68 to experience further hand stiffening and/or skin breakdown.Findings: According to the admission Record, Resident 68 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Parkinson's Disease (a movement disorder that worsens over time) and generalized muscle weakness. On 9/8/25 at 8:19 A.M., an observation was made in Resident 68's room. Resident 68 had a red plastic device in his right hand. Both hands were stiffened and maintained in a semi-closed position. On 9/8/25 at 12:22 P.M., an interview was conducted with Resident 68's family member (FAM) 1. FAM 1 stated Resident 68's hands were contracted [stiffened] because of Parkinson's Disease. FAM 1 stated Resident 68's family members visited daily and placed splints in Resident 68's hands to make sure he did not experience any other contractures. On 9/8/25 at 3:02 P.M., a concurrent interview and record review was conducted with Licensed Nurse (LN) 11. LN 11 stated Resident 68's family members applied the hand splints to Resident 68's hands when they visited. LN 11 stated Resident 68 did not have a physician's order for the splints, and she did not see the splints addressed in Resident 68's care plan. LN 11 stated, [Resident 68] needs the splints to prevent his hands from being contracted further and to prevent skin breakdown. LN 11 stated Resident 68 should have a physician's order for hand splints. On 9/9/25 at 10:37 A.M., an interview was conducted with Occupational Therapist (OT) 1. OT 1 stated a Joint Mobility Screen (an assessment for the ability to move joints) was conducted for Resident 68 on 8/26/25. OT 1 stated according to Resident 68's Joint Mobility Screen, Resident 68 was not able to fully extend his hands due to having contractures. OT 1 stated Resident 68 should have had splints ordered for both hands to prevent further loss of movement, and to protect Resident 68's hands from skin breakdown. OT 1 stated the family had improvised and were not applying actual hand splints, but a device that was designed to be used to modify eating utensils. On 9/11/25 at 1:08 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated if a resident was admitted with contractures, OT needed to assess and a hand splint should have been ordered for Resident 68. The DON stated, The family is so involved.[the physician's order for the splint] somehow got missed. My expectation is that a splint be ordered when it's identified that a resident has a contracture. The DON further stated it was important for Resident 68 to have a physician's order and care plan for the hand contractures, .to avoid skin breakdown and losing mobility. Especially with the elderly, we want to prevent immobility and skin problems. A review of the facility's policy and procedure titled Splints and Positioning Devices, revised July 2017 indicated, Splints and Positioning Devices.To Prevent or reduce contractures.Any resident assessed with a need will be screened by the Rehab team including a qualified specialist in Rehab devices.After the screening is done.the physician will be notified and an order will be obtained.The device will be applied as ordered, and documented on the residents Care Plan and RNA [Restorative Nursing Assistant] notes.

Based on observation, interview, and record review, the facility failed to provide supervision with feeding in one of 17 residents (Resident 43) reviewed for activities of daily living (ADL- self-care activities such as feeding, grooming, bathing, and toileting) assistance.This failure had the potential to affect Resident 43's health and well being. Findings:Per the facility's admission Record, Resident 43 was admitted to the facility on [DATE] with diagnoses which included Dementia (progressive state of decline in mental abilities) and Parkinson's disease (a progressive disease of the nervous system). On 9/8/25 at 12:10 P.M., an observation was conducted during lunchtime in the main dining room. Resident 43 was seated in a reclined position on a wheelchair. Resident 43 was served a lunch tray far from her reach with the cover removed and left untouched. On 9/09/25 at 3:15 P.M., an interview and record review with Licensed Nurse (LN) 1 was conducted. LN 1stated Resident 43 gets agitated if staff gets close to her. LN 1 stated Resident 43's care plan indicated supervision and touching assistance with eating. LN 1 stated it was important to provide assistance with meals for Resident 43 to prevent possible weight loss and other complications such as choking. A review of the minimum data sheet (MDS- a federally mandated assessment tool ) dated 6/6/25 indicated Resident 43's brief interview for mental status (BIMS) score was 04 which indicated Resident 43 had severe cognitive impairment. A review of Resident 43's MDS section GG-functional abilities dated 6/6/25 indicated Resident 43 required supervision and touching assistance with eating. A review of Resident 43's undated care plan indicated supervision and touching assistance with eating as one of the interventions.On 9/11/25 at 10:40 A.M., an interview with the Director of Nursing (DON) was conducted. The DON stated she had asked the speech therapist to reevaluate Resident 43 with regards to assistance with eating and speech. The DON stated it was important to provide Resident 43 supervision and touching assistance to prevent weight loss and possible complications such as choking . A review of the facility's policy titled Activities of Daily Living (ADL), Supporting, dated 3/2018 indicated, Appropriate care and service will be provided for residents who are unable to carry out ADLs independently . Dining (meal and snacks).

Based on observation, interview and record review, the facility failed to provide urology (specialty which deals with diseases of kidneys and bladder) follow up for one of two residents (Resident 4) reviewed for urinary catheter. This failure had the potential for Resident 4 to have a recurrent urinary tract infection (UTI-an infection affecting the kidneys, bladder or urethra) and other complications.Findings:Resident 4 was admitted to the facility on [DATE] with diagnoses including obstructive and reflux uropathy (problems with urine flow in the urinary tract due to structural or functional issues) according to the facility's admission Record. During an observation and interview on 9/9/25 at 10:04 A.M., Resident 4 was in her room sitting on a wheelchair with a urine bag hanging at the back of the wheelchair. Resident 4 stated she had a urine tube because she could not control her urine and was not able to walk to the bathroom. A review of Resident 4's physician's orders titled Order Summary was conducted. The Order Summary indicated, SupraPubic catheter [SPC-a surgically inserted catheter into the bladder] 18 French [catheter's size] 10 ML [milliliter] Balloon to Gravity Drainage every shift for Obstructive Uropathy. During an interview on 9/9/25 at 2:21 P.M. with Licensed Nurse (LN) 31, LN 31 stated Resident 4 was admitted with a SPC due to obstructive uropathy (problems with urine flow in the urinary tract due to structural or functional issues). LN 31 stated she did not know if Resident 4 was followed by a urologist. On 9/10/25 at 10:04 A.M. Resident 4 was observed sitting in front of her room sitting in the wheelchair. During an interview, Resident 4 stated she would like a physician to check if the urine tube (SPC) can be removed so she can practice walking again. Resident 4 further stated the SPC should be removed because she was also urinating on her brief. A concurrent record review and interview on 9/10/25 at 10:12 A.M. was conducted with LN 33. LN 33 reviewed physician's orders for Resident 4 and stated there was no order for a urology consultation for Resident 4. LN 33 stated a urology follow up was important to check Resident 4's SPC for any problems. During an interview on 9/10/25 at 10:26 A.M. with the case manager (CM), the CM stated Resident 4 had a urology appointment on 12/28/23 due to a urinary tract infection (UTI-bladder infection). The CM stated there was no other follow up after the 2023 appointment. An interview and joint record review on 9/10/25 at 11:35 A.M. was conducted with LN 31. LN 31 stated Resident 4's SPC was changed monthly by a registered nurse. LN 31 checked Resident 4's physician's orders and stated there was no physician's order to change Resident 4's SPC. LN 31 stated Resident 4 should be referred to a urologist for evaluation since Resident 4 was also urinating on her brief. LN 31 stated it has been a while since Resident 4 was seen by a urologist and the SPC can be removed.A review of Resident 4's medical records was conducted:Hospital history and physical dated 11/27/21 indicated, Sepsis [the body's extreme and life-threatening response to an infection] .Acute cystitis [inflammation of the bladder]Hospital progress note dated 5/27/21 indicated, Urinary tract infection [UTI-an infection affecting the kidneys, bladder or urethra], acute cystitis.SNF (Skilled Nursing Facility)/NF (Nursing Facility) to Hospital transfer form dated 6/5/25 indicated, Reason(s) for transfer Other: unable to change supra pubic catheter.SNF/NF to Hospital Transfer Form dated 10/19/24 indicated, Reason(s) for transfer Other: supra pubic cath. [catheter] change.Change in Condition Evaluation dated 11/1/24 indicated, Had moderate amount of vaginal bleeding with fresh blood.Change in Condition Evaluation dated 1/6/25 indicated, Urinary tract infection.Change in Condition Evaluation dated 5/24/25 indicated, C/O [complaints of] pressure in vaginal area.An interview with the Director of Nursing (DON) was conducted on 9/11/25 at 3:14 P.M. The DON stated Resident 4 needed urology follow up due to the long-term use of SPC with history of pain. The DON stated Resident 4 was at risk for UTI and routine urology follow up was needed to assess any bladder issues. During a review of the facility's policy and procedure (P&P) titled, Catheter Care, Urinary, revised on September 2014, the P&P indicated, The purpose of this procedure is to prevent catheter-associated urinary tract infections. The P&P did not provide guidance regarding urology consultation.

Based on observation, interview and record review the facility failed to ensure nutrition interventions were implemented for one of 17 sampled residents (Resident 68). This failure had the potential to result in further weight loss and/or compromise Resident 68's health. Findings: According to the admission Record, Resident 68 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Parkinson's Disease (a movement disorder that worsens over time) dysphagia (difficulty swallowing), nutritional anemia (a deficiency in nutrients essential for red blood cell formation). On 9/8/25 at 8:46 A.M., Certified Nursing Assistant (CNA) 13 was observed walking out of Resident 68's bedroom with his breakfast tray. CNA 13 stated Resident 68 only ate the oatmeal, but did not eat anything else on the tray. CNA 13 stated Resident 68 usually ate less than half of breakfast and lunch. During a review of Resident 68's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 8/29/25, Resident 68 had a Brief Interview of Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) of 9 which indicated moderate cognitive impairment. The MDS further indicated Resident 68 was dependent on staff for eating/drinking. A review of the Mini Nutritional assessment dated [DATE] indicated Resident 68 was at risk for malnutrition. A review of the Nutritional assessment dated [DATE] indicated, .[Resident 68 is noted with fair appetite, PO [oral intake] 25-50% .RD [Registered Dietitian] met with resident and his wife at bedside. Wife was encouraging him to eat his lunch and feeding him. She states he often tells her he is not hungry and she asks him to take a few bites anyway. He also has nutrition supplement [shake] that is provided by the VA [Veteran's Administration]. He typically has 1 per day. The Nutritional Assessment indicated resident's goal was to maintain the Goal Weight Range within 158-168 pounds with no unintended weight change. A review of Resident 68's care plan dated 8/26/25 indicated, [Resident 68] has nutritional problem or potential nutritional problem r/t [related to] dysphagia, CHF [Congestive Heart Failure].Goal.Weight maintenance within GWR [Goal Weight Range] 160- 170 # [pounds] no unintended weight change. A review of Resident 68's Weights and Vitals Summary indicated the following weights:163 lbs (pounds- a unit of measurement for weight) on 8/25/25159 lbs on 9/1/25149 lbs on 9/9/25149 lbs on 9/10/25 A review of the IDT (Interdisciplinary Team- a group of professionals with different areas of expertise) Weight Variance Notes dated 9/3/25 indicated Resident 68 had unplanned weight loss of 4 lbs, 2% from 8/25/25 to 9/1/25. The IDT Weight Variance Note indicated, IDT met to discuss weight variance. Resident noted with weight loss of 4# [pounds]/2% x 1 week.He has supplement of [nutritional shake].RD encouraged resident to increase supplement to 2x per day. The IDT note indicated the new recommendation of two nutritional shakes would have provided Resident 68 with 910 extra kcal (kilocalories- a unit of energy) per day. The IDT note indicated, record ml [milliliters-a unit of measurement] taken. On 9/10/25 at 9:38 A.M., a concurrent interview and record review was conducted with the Registered Dietitian (RD). The RD stated Resident 68 should have had a physician's order for the [nutritional shake], but it was never entered in Resident 68's electronic health record. The RD stated, .honestly it was just missed. The RD stated if the facility implemented the recommendation for 2 nutrition shakes daily, his weight loss would not have been so drastic. The RD stated it was important to implement weight loss interventions to avoid further weight loss. The RD stated, Losing weight is a downward spiral.[Resident 68] was at risk for losing muscle mass, and experiencing a decrease in function and ADL's.for the elderly population it is rarely beneficial to lose weight. During an interview with the Director of Nursing (DON) on 9/11/25 at 1:08 P.M., the DON stated, we should have implemented the shakes. The DON further stated it was important to implement interventions to prevent Resident 68 from experiencing more weight loss and to prevent decline in health. The DON stated, Further weight loss will decline him more, plus he could develop pressure injuries and have further health decline. A review of the facility's policy titled Nutrition (Impaired)/Unplanned Weight Loss-Clinical Protocol revised September 2017 indicated, The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparison over time.The physician will authorize appropriate interventions, as indicated.The physician and staff will monitor.an individual's response to interventions.

Based on observation, interview and record review, the facility failed to ensure a physician's order for oxygen was placed for one of three residents (Resident 2) reviewed .This failure had the potential to affect Resident 2's respiratory condition. Findings:Per the facility admission Record , Resident 2 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure with hypoxia (absence of enough oxygen).On 9/8/25 at 8:26 A.M., an observation and interview was conducted with Resident 2. Resident 2 was on oxygen at 6 liters per minute via nasal cannula (a flexible tube with two prongs that fit into the nostrils). Resident 2 stated that she returned from the hospital last Friday, 9/5/25 due to pneumonia. Resident 2 stated she used oxygen continuously and cannot breathe without it. A review of Resident 2's Minimum Data Set (MDS- a federally mandated assessment tool) dated 7/22/25 indicated Resident 2's brief interview for mental status (BIMS) score was 14 which indicated Resident 2 had intact cognition (thought process). On 9/8/25 at 8:45 A.M., an interview and record review with Licensed Nurse (LN) 2 was conducted. LN 2 stated Resident 2 was on oxygen when she left for the acute hospital and came back last Friday. LN 2 stated there was no oxygen order on Resident 2's Order Summary Report. LN 2 stated Resident 2 should have an oxygen order in place. LN 2 stated it was important for Resident 2 to have an order for oxygen since Resident 2 used oxygen to be able to breathe and that it was included in Resident 2's plan of care. A review of Resident 2's Order Summary Report dated 9/5/25 did not indicate an oxygen order. On 9/11/25 at 10:34 A.M., an interview with the Director of Nursing (DON) was conducted. The DON stated that any care provided to any resident needed a physician's order. The DON stated a physician's order would have prevented possible complications for Resident 2. A review of the facility's Policy titled, Oxygen Administration, dated October 2010 indicated, Verify that there is a physician's order for this procedure .Review the physician's orders.

Based on observation, interview and record review, the facility failed to ensure the one of 17 residents (Resident 6) reviewed for food palatability was served meals that were palatable.As a result, Resident 6 refused his meals and was at risk for weight loss.Cross reference F805Findings:Resident 4 was admitted to the facility on [DATE] with diagnoses including gastro-esophageal reflux disease (GERD- when stomach contents flow back up into the tube that connects the mouth to the stomach) according to the facility's admission Record. During an observation and interview on 9/8/25 at 8:24 A.M. with Resident 4, Resident 4 stated he was on a puree diet, but the food did not taste good. Resident 4 stated the puree he received was gritty. During an interview on 9/10/25 at 9:17 A.M. with Certified Nurse Assistant (CNA) 3, CNA 3 stated Resident 4 had complained about the food served to him because it was not prepared correctly. An interview and joint record review on 9/10/25 at 10:30 A.M. was conducted with the Registered Dietician (RD). The RD stated Resident 4 was on puree texture due to difficulty swallowing. The RD reviewed the nutritional care plan for Resident 4. The care plan initiated on 9/13/24 indicated Resident 4 was at risk for altered nutrition.He likes to mix his own thickened liquids in his room occasionally due to being unsatisfied with preparation from the diet dept. An observation and interview on 9/10/25 at 12:23 P.M. was conducted with Resident 4. Resident 4 was sitting up in bed with lunch tray in front of Resident 4. The lunch tray had two bowls of mashed potatoes and two bowls of puree eggs. Resident 4 stated the kitchen did not cook the puree foods correctly. The mashed potatoes was observed to not have a smooth consistency and Resident 4 stated the puree eggs had no flavor. During lunch test tray observation on 9/11/25 at 12:26 P.M., the test tray had puree mashed potatoes. The puree mashed potatoes were smooth in appearance that were not similar appearance to the mashed potatoes that Resident 4 received on his tray. During an interview on 9/10/25 at 2:46 P.M. with the Dietary Supervisor (DS), the DS stated Resident 4 had complained of food being gritty. The DS stated the kitchen staff did not follow the recipe for preparing puree food and staff should follow the recipe. An interview with the Director of Nursing (DON) was conducted on 9/11/25 at 3:14 P.M. The DON stated residents should receive the correct puree food consistency to prevent swallowing issues and refusals to eat which could lead to weight loss. A review of the facility's policy and procedure (P&P) titled, Food and Nutrition Services, revised October 2017 was conducted. The P&P indicated, Food and nutrition services will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature.

Based on observation, interview and record review, the facility failed to ensure recipes were followed during the preparation of pureed foods. This failure placed the resident at risk for choking and/or aspiration (inhaling food into the lungs) and compromised the flavor and texture of the foods. Findings: On 9/10/25 at 10:20 A.M., a joint observation and interview was conducted with [NAME] 1 in the kitchen. [NAME] 1 stated she was preparing instant mashed potatoes for residents who were on a pureed diet. [NAME] 1 was observed pouring flaked potatoes from the manufacturer's bag into a stainless steel container. [NAME] 1 then poured approximately 1000 ml (milliliters- a unit of measurement) into the container. [NAME] 1 stated, I put in about [2000 ml of water]. [NAME] 1 was observed putting a white powdery substance into the container of mashed potatoes. [NAME] 1 stated, I put too much water [in the mashed potatoes]. This is to make it thicker. [NAME] 1 stated there is a recipe with instructions available, but she did not use it to prepare the mashed potatoes. On 9/10/25 at 10:41 A.M. a joint observation and interview was conducted with [NAME] 1. [NAME] 1 was observed preparing cooked chicken for the pureed diets. [NAME] 1 pointed to a binder on a top shelf and stated, The recipes to make pureed foods are there. but stated she did not use a recipe for pureed foods. [NAME] 1 was observed using a slotted spoon to place 5 scoops of diced chicken into a blender. [NAME] 1 stated one serving size was half a cup, but did not use exact measurements. [NAME] 1 stated the slotted spoon represented, about a half a cup. [NAME] 1 placed about 1000 ml of hot water into the blender and one white plastic teaspoon of broth mixture into the blender. [NAME] 1 stated she added thickener to the blender if the chicken mixture appeared too thin. [NAME] 1 stated, I usually just guess [the amount of thickener].I just add in tablespoon to tablespoon. You know its thick enough if it's a jelly type of texture. On 9/10/25 at 11:30 A.M., a joint observation and interview was conducted with Dietary Aide (DA) 1 in the kitchen. DA 1 was observed placing 25 pieces of whole wheat bread into the blender, then added about 1000ml of water into the blender. DA 1 stated, I add about six teaspoons of thickener. I just guess [the amount of thickener].we don't have a recipe for bread. 'On 9/10/25 at 12:26 P.M., a concurrent observation and interview was conducted with the Dietary Supervisor (DS) during food sampling of pureed foods for the test meal tray. The pureed mashed potatoes had a [NAME]/grainy texture. The pureed chicken had small chunks of chicken, and had a grainy texture. The DS stated the [NAME]/grainy texture was due to an excessive amount of thickener. The DS further stated it was his expectation that kitchen staff followed recipes when preparing pureed foods. The DS stated, We follow the recipe so we have consistency in flavor, quality, and texture. It's important because it's a safety issue for swallowing purposes. Food needs to be smooth with little or less granulation so [residents on pureed diets] can swallow it without any issues. The DS stated it was important to follow recipes to ensure all textures and consistencies are correct. During a review of the Production Recipe for Grilled Chicken, the recipe indicated, Grilled Chicken.Portions.#8 SCOOP.FOOD THICKENER BULK .2 Tablespoon 1 1/2 Teaspoon.Stock Chicken/Soup Base.1 1/4 Cup. Prepare Slurry.Add 1 oz slurry per portion and process until smooth. During a review of the Standard Recipe Report for Wheat Roll, the recipe indicated, Wheat roll.96.FOOD THICKENER BULK.24 Tablespoon.WATER OR JUICE 3 Quart. prepare slurry and process until smooth adding 1oz slurry per portion.

Based on observation, interview and review of the analysis of client accommodations , the facility failed to meet the required minimum square footage requirements of at least 80 square feet per resident (sq/ft/resident) in three resident rooms (6,8,and 11) This failure had the potential to impact resident care and quality of life. A record review was conducted from 9/8/25 through 9/11/25. The following resident rooms contained less than 80 square feet for each resident.Room Number Room Size6 accommodated 3 residents 216 (72 sq ft/ resident)8 accommodated 3 residents 216 (72 sq ft/ resident)11 accommodated 2 residents 138 (69 sq ft /resident) Additionally, observations were conducted. There were no observed quality of care , or quality of life concerns that negatively affected the residents residing in the identified rooms during the recertification survey visit. A continuance of the waiver (variation) from the requirements of code 42 of the federal regulations (cfr) sections 483.70 (d)(I)(ii) as granted, allowing less than 80 square feet per resident room, is hereby recommended. This recommendation is also made with the expectation that the facility will obtain a timely renewal of the current waiver granted by CMS.

Based on observation, interview and record reviews the facility failed to develop and implement a comprehensive person focused care plan for one of one resident (Resident 1) related to Oxygen use. This failure had the potential to affect Resident 1 ' s health condition and possible decline. Findings. Per the undated admission Record , Resident 1 was admitted to the facility on [DATE] with diagnoses that included Unspecified Atrial Fibrillation (irregular heart rhythm). On 6/10/25 at 11 A.M., an observation and interview with Resident 1 was conducted. Resident 1 was alert, verbal, and receiving oxygen through nasa cannula (NC- a device that delivers oxygen through the nose) at 2 liters per minute while sitting up in her wheelchair in her room. Resident 1 stated, she used the oxygen all the time because she cannot breathe without the oxygen. A record review of Resident 1's Minimum Data Set ( MDS- an assessment tool) dated, 5/14/25 indicated, Resident 1's brief interview for mental status (BIMS) was 13 which meant Resident1's cognition (thought process) was intact. On 6/10/25 at 11:10 A.M., an interview and record review of Resident 1's Physician orders dated, 10/29/21 was conducted with Licensed Nurse (LN) 1. LN 1 stated, Resident 1 had an order for oxygen at 2 liters per minute as needed for shortness of breath. On 6/10/25 at 11:20 A.M., an interview and record review with Minimum Data Set Nurse (MSDN) was conducted. The MDSN stated he does the care plan of the residents on admission, quarterly and annually. The MDSN stated, he did not know why Resident 1 ' s care plan related to oxygen use was written resolved. The MDSN stated, he knew Resident 1 continued to use the oxygen as needed for shortness of breath. On 6/10/25 at 11:35 A.M., an interview and record review with the Director of Nursing (DON) was conducted.The DON stated there was no care plan regarding Resident 1's oxygen use . The DON stated it was important to have a care plan as it showed the care the facility had provided for Resident 1 and the care plan acted as a communication for healthcare providers. A record review of the undated facility ' s policy titled , Oxygen Administration dated 8/2014 indicated , Care Plan Documentation Guidelines . Problem: Identify the appropriate problem under which to list oxygen administration as an approach .Goal: List measurable goal (s) to be accomplished .list target date. A record review of the facility's policy dated 12/2017, titled Care Plan Comprehensive indicated, Procedure .3. Resident progress is regularly evaluated, and approaches revised or updated .7. Care plans should be reviewed within 21 days after admission and quarterly therafter .

Based on observation, interview and record review the facility failed to ensure residents were safe from abuse when a one to one (1:1) supervision was not consistently followed as recommended for one resident (Resident 1), who had a history of abusive behavior. As a result, Resident 1 hit another resident (Resident 2). In addition, this failure placed all residents at the facility at risk of being harmed by Resident 1. Findings: Resident 1 was admitted to the facility on [DATE] with a diagnosis of dementia (condition that impairs mental function, reasoning, and memory), with behavioral disturbance, per the resident's admission record. Resident 2 was admitted to the facility on [DATE] with a diagnosis of down syndrome (a genetic disorder that causes intellectual delays and physical disabilities), per the resident's admission record. A review of Resident 1's clinical record, titled SBAR-Alleged Abuse Report of Incident - 8hr -V3 (Incident Report), dated 11/29/23 at 8:47 A.M., indicated that on 11/29/23 at 6:45 A.M., Resident 1 struck Resident 2 on the right side of the face. The Incident Report indicated the event was witnessed by the housekeeper (HK). On 12/8/23 at 11:20 A.M., an interview with the HK was conducted. The HK stated she witnessed Resident 1 hitting Resident 2 on 11/29/23 at approximately 6:25 A.M. The HK stated Resident 2 was at the nurses ' station yelling. The HK stated she heard Resident 1 yell, shut up and watched Resident 1 walk over to Resident 2 and hit him on the face with his hand. On 12/8/23 at 11:35 A.M., an interview with certified nursing assistant (CNA) 1 was conducted. CNA 1 stated Resident 1 and Resident 2 were standing in front of the nurses ' station on 11/29/23 at 6:30 A.M. CNA 1 stated she heard the HK scream. CNA 1 stated she heard the HK telling Resident 1 to not hit Resident 2. CNA 1 stated Resident 1 was on a 1:1 supervision at the time of the incident because he had previously hit another resident. CNA 1 stated no other staff members witnessed the incident. CNA 1 stated she did not know what CNA was assigned to Resident 1. On 12/8/23 at 11:48 A.M., an interview with CNA 2 was conducted. CNA 2 stated Resident 1 had a history of hitting other residents. CNA 2 stated Resident 1 had been on 1:1 supervision and she was not sure why Resident 1 was not being monitored by someone at the time of the incident. A review of Resident 1's care plan, titled Risk for Decline in Psychosocial Well Being, related to hitting another resident, dated 9/16/23 was conducted. This record indicated Resident 1 hit another resident on 9/16/23. Resident 1's care plan indicated Resident 1 hit another resident again on 11/29/23. Per this record, an intervention for, .1:1 close supervision for safety . was initiated for hitting another resident on 10/26/23. A review of the facility document, titled Resident Visual Check Flow Sheet, dated 11/29/23, indicated staff did not document Resident 1 received 1:1 supervision at the 6:15 A.M. and 6:30 A.M. time slots. On 1/10/23 at 4:05 P.M. an interview with the director of nursing (DON) was conducted. The DON stated it was facility protocol for staff to document the monitoring of residents on 1:1 supervision every 15 minutes on the facility form titled, Resident Visual Check Flow Sheet. The DON stated staff were expected to be next to a resident on 1:1 supervision at all times to ensure a safe environment. The DON stated the facility did not have a policy on 1:1 supervision.

Based on interview and record review, the facility failed to provide two of three residents (Resident 1 and 2) care and treatment based on professional standards of practice when: 1 A. Resident 1's wound care needs for her foot were not addressed. B. Resident 1's change of condition related to slurred speech, nausea and vomiting were not addressed and communicated with the resident's physician. C. Resident 1's laboratory orders were not carried out. In addition, abnormal lab results were not communicated with the resident's physician. D. Resident 1's blood sugar levels were not monitored. 2. Resident 2's wound dressing change to the forehead was not implemented in accordance with the resident's physician order. As a result, Resident 1 developed wound infection on the right foot which lead to a below the knee amputation. Failure to carry out ordered labs, monitor blood sugar levels, notify Resident 1's physician of the resident's change of condition and abnormal lab results, had the potential to result in delayed treatment. In addition, failure to provide wound dressing changes as ordered by the physician, for Resident 2, could have led to a wound infection. Findings: A review of Resident 1's undated facility face sheet was conducted. Resident 1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The face sheet also indicated Resident 1 was her own responsible party. A review of Resident 1's hospital Discharge Summary, that was sent to the facility when Resident 1 was admitted , dated 9/1/2021, was conducted. Resident 1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS - an assessment tool), dated 9/10/2021, indicated Resident 1 had a Brief Interview for Mental Status (cognitive assessment) score of 14 (13-15 score means cognitively intact). 1A. A review of Resident 1's hospital discharge orders, dated 9/1/2021, indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's facility admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's facility progress notes, dated 9/1/2021, indicated, . Wound vac is on and working well. A review of Resident 1's vascular surgeon's note from appointment on 9/9/2021 was conducted. This note indicated that Resident 1's right foot wound was not infected and appeared to be slightly improved. The note also indicated that Resident 1 complained that the dressing had not been changed by the facility. Note indicated that Resident 1 had a date on her dressing of 9/1/2021. A review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Cleanse with wound cleanser every day [sic] shift Mon, Wed, Fri. A review of Resident 1's Treatment Administration record (TAR) for the month of September was conducted. The TAR indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Cleanse with wound cleanser every day [sic] shift Mon, Wed, Fri. The record indicated that the Wound Vac/dressing change was not conducted on 9/13/2021. A review of Resident 1's progress note, dated 9/10/21, indicated Resident 1's right foot wound had .No exudate, drainage or swelling. Redness around edges noted . A review of Resident 1's medical record showed no other documented evidence that Resident 1's right foot wound was assessed by the facility nurses, except on 9/10/21. A review of Resident 1's progress notes, dated 10/4/21, indicated that Nurse Practitioner (NP) 2, who worked with the Vascular Surgeon (surgeon that specializes on blood vessels), requested to be contacted and be given a description of Resident 1's wound. On 11/16/21 at 12:48 P.M., an interview and concurrent record review was conducted with License Nurse (LN) 1. LN 1 stated he was the treatment nurse for the facility. LN 1 stated he was the primary nurse that changed the dressings for Resident 1's right foot wound and wound vacuum. LN 1 acknowledged there was no documented evidence that Resident 1's right foot wound, and wound vacuum dressing was changed on 9/13/21. LN 1 acknowledged, after reviewing Resident 1's medical record, there was no documented evidence that Resident 1's right foot wound was assessed from 9/1/21 through 10/16/21, except on 9/10/21. LN 1 acknowledged there was no documented assessment related to Resident 1's right foot wound for 45 days. LN 1 stated I don't know why I didn't do an assessment. LN 1 stated he should have done a wound assessment on Resident 1's right foot wound every time he changed the dressing and documented it in the resident's medical record. LN 1 stated wound assessment was important to track the wound's progression. LN 1 stated if the wound was not improving or if the wound worsened, the resident's physician should be contacted. LN 1 stated Resident 1's right foot wound was all yellowish with slough (layer of dead skin). LN 1 stated he could not see the wound bed of Resident 1's right foot wound, the week the resident was discharged , due to the slough that covered the wound bed. On 12/1/21 at 4:08 P.M., a telephone interview and concurrent record review was conducted with LN 1. LN 1 reviewed and acknowledged a progress note written by himself (LN 1) regarding NP 2's instruction to be notified of Resident 1's right foot wound assessment on 10/4/21. LN 1 stated he was not sure if he called NP 2 regarding Resident 1's right foot wound on 10/4/21 because there was no documentation that an assessment was done or that NP 2 was notified regarding the condition of Resident 1's right foot wound. LN 1 also acknowledged there was no treatment ordered for Resident 1's right foot wound, when Resident 1 was admitted to the facility. LN 1 stated he should have called NP 2 to get a treatment order for Resident 1's right foot wound on admission. On 12/2/21 at 10:45 A.M., a telephone interview was conducted with Nurse Practitioner (NP 1). The NP 1 stated he worked at the facility as the wound care practitioner. The NP 1 stated he was not able to evaluate and treat any resident's wound without a written physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The NP 1 stated it was his understanding that the facility would be following the vascular surgeon's orders to assess and treat Resident 1's right foot wound and wound vacuum. A review of Resident 1's vascular surgeon's note, from an appointment on 10/15/21 was conducted. The note indicated that Resident 1's right foot wound was well perfused (has blood supply), malodorous (bad odor), necrotic (tissue is dead) and was not healing well. The note indicated that NP 2 recommended a below the knee amputation. A review of Resident 1's facility record was conducted. The undated record titled Discharge Information/Recapitulation of Stay indicated Resident 1 was discharged from the facility on 10/16/21 with orders for homecare. On 11/15/21 at 12:42 P.M., a telephone interview was conducted with LN 3. LN 3 stated she worked for the home care agency that was contracted to care for Resident 1 post discharge from the facility. LN 3 stated she was assigned to care for Resident 1 on 10/17/21, the day after Resident 1 was discharged from the facility. LN 3 stated when she arrived at Resident 1's home on 10/17/21, Resident 1's Family Member 1 (FM 1) had called 911. LN 3 stated Resident 1 was on the couch pale and diaphoretic (sweaty). LN 3 stated Resident 1's vital signs and appearance was consistent with septic shock (a life-threatening condition caused by a severe localized or system-wide infection that requires immediate medical attention). A review of Resident 1's acute care hospital record was conducted. The record titled Emergency Department Record, dated 10/17/2021, indicated that Resident 1 was admitted to the emergency department with acute renal failure (kidneys were not functioning), [CONDITION(S)] (high potassium level in the blood), [CONDITION(S)] (bleeding in the stomach and/or intestine) and a white blood cell (cells in the body that fight infection) count of 13.5 (normal range 4.2-9.1). The record indicated that Resident 1 was admitted to the intensive care unit at the hospital. A review of Resident 1's Vascular Surgery Consult Note, dated 10/18/21, was conducted. The note indicated that Resident 1's wound condition was causing the renal failure and that a below the knee amputation of the right leg was needed to help improve Resident 1's survival. A review of Resident 1's Surgical Report, dated 10/18/22, was conducted. The report indicated that Resident 1 had a below the knee amputation of her right leg. The report also indicated that the wound on Resident 1's foot before the amputation was necrotic (tissue was dead) and foul smelling. On 12/20/21 at 10:48 A.M., a telephone interview was conducted with NP 2. The NP 2 stated it was her expectation that the facility would assess Resident 1's wound and change the resident's wound vacuum dressing on admission. The NP 2 stated if the facility did not receive orders for Resident 1's right foot wound dressing on admission, the facility should have called the vascular surgeon's office for orders. The NP 2 stated she requested, on 10/4/21, for the facility nurse to provide her with the result of the wound assessment or to provide her with an updated photograph of Resident 1's right foot wound. The NP 2 stated she was not provided with Resident 1's right foot wound assessment as requested. The NP 2 stated it was her expectation that the nurses assessed Resident 1's right foot wound and provide wound treatment as ordered. The NP 2 stated the facility's lack of wound assessment and wound vacuum dressing changes, were contributing factor to Resident 1's wound healing and infection that led to Resident 1's right leg amputation on 10/18/21. A review of the 2021 Lippincott's Guide to Negative Pressure Wound Therapy (wound vacuum), obtained from website https://www.nursingcenter.com/clinical-resources/nursing-pocket-cards/guide-to-negative-pressure-wound-therapy-(npwt) was conducted. The guide indicated that orders for wound vacuum should include, .Wound dressing material (foam or gauze) and wound adjunct (protective non-adherent, petroleum or silver dressing) .Negative pressure setting (-20 to -175 mmHg). Therapy setting (continuous, intermittent [not continuous], or variable). Frequency of dressing change; varies between 1 and 7 days . A review of the 2021 Lippincott's Guide to Negative Pressure Wound Therapy (wound vacuum), obtained from website https://www.nursingcenter.com/clinical-resources/nursing-pocket-cards/guide-to-negative-pressure-wound-therapy-(npwt) was conducted. The guide indicated, Nursing Considerations. Assess your patient for wound healing issues, such as poor nutrition (low protein levels), diminished oxygenation, decreased circulation, diabetes .infection . A review of the facility document titled (name of corporation) Care Skin Integrity Standard, dated July 2018, was conducted. The Director of Nursing (DON) presented the document as the facility's skin and wound policy. The document indicated, .Comprehensive Wound Assessment Specifics: a. Location of wound .b. Wound Measurement .c. Drainage type and amount .d. Description of the wound bed tissue .e. Odor present/or not .f. Signs/symptoms of infection .g. Description of peri-wound (surrounding) tissue .Identify wound type . On 5/26/22 at 10:08 A.M., a phone interview was conducted with the facility's current Director of Nursing (DON 2) and the Administrator (ADM). DON 2 stated it was her expectation that the staff would carry out all wound care orders for the residents as ordered. DON 2 stated if wounds are not cared for per the physicians orders the resident's wound could regress or could become infected. The ADM stated the nurses must follow all physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 1B. On 10/19/21 at 4:12 P.M., a phone interview was conducted with Family Member (FM 1). FM 1 stated Resident 1 had nausea and vomiting before she was discharged on [DATE] and the facility did not give her anything to help with the nausea and vomiting. FM 1 also stated Resident 1 had high blood pressure and headaches that the facility did not address. FM 1 stated she was concerned that Resident 1 would have another stroke. A review of Resident 1's homecare agency record was conducted. The homecare record titled Client Coordination Note Report, dated 10/17/21, entered by License Nurse (LN) 3 indicated, that Resident 1 had vomited 3 times since 10/16/21 (discharged from the facility) and that the vomit was dark bloody in color and grainy. The record indicated Resident 1's blood pressure was 90/54 and she was pale, cold to touch and lethargic. A review of Resident 1's facility record was conducted. The record titled SNF (Skilled Nursing Facility) Progress Note, dated 10/3/21 at 6:10 P.M., written by LN 5 indicated, Resident 1's Family Member 1 contacted the facility because she was concerned that Resident 1 was having another stroke. LN 5 documented, stroke scale utilized resident passed .To which none was a concern . There was no documented evidence that a change of condition form was completed. There was no documented evidence of Resident 1's potential stroke symptoms, the stroke scale used by LN 5, or the data that was collected by LN 5 during the stroke scale assessment. There was no documented evidence that the physician was notified of Resident 1's stroke symptoms or stroke assessment. Further review of Resident 1's facility record was conducted. There was no documented evidence that Resident 1 had abdominal pain, nausea or vomiting in the medical record. There was no documented evidence that Resident 1 had an ordered medication for nausea and vomiting. There was no documented evidence that any physician was notified about Resident 1's abdominal pain or nausea and vomiting. The record also indicated that Resident 1's [MEDICATION(S)] (protein) level in her blood was low at 2.3 on 10/11/21. On 11/15/21 at 12:42 P.M., a phone interview was conducted with LN 3, a home care agency nurse contracted to care for Resident 1 post discharge from the facility. LN 3 stated she was assigned to care for Resident 1 on 10/17/21, one day after the resident was discharged from the facility. LN 3 stated when she arrived at Resident 1's home on 10/17/21, Resident 1's Family Member (FM 1) had called 911. LN 3 stated Resident 1 was on the couch pale and diaphoretic (sweaty). LN 3 stated Resident 1's vital signs and appearance was consistent with septic shock (a life-threatening condition caused by a severe localized or system-wide infection that requires immediate medical attention). LN 3 stated FM 1 showed her Resident 1's emesis (vomit) in a bowl after she had just vomited, and it was brown and red in color that was coffee ground in appearance consistent with a gastrointestinal (stomach or intestine) bleed. LN 3 stated FM 1 told her that Resident 1 was having the same emesis in the facility that week before she was discharged . On 11/16/21 at 11:26 A.M., an interview and concurrent interview were conducted with LN 2. LN 2 stated Resident 1 had nausea and vomiting mostly in the morning. LN 2 stated we medicated Resident 1 with [MEDICATION(S)] (medication for nausea) for her nausea. LN 2 stated Resident 1 seemed uncomfortable in the bed and was always moving around. On 12/2/21 at 11:05 A.M., a telephone interview and concurrent record review was conducted with LN 2. LN 2 stated 2 weeks ago the facility's Director of Nursing, the facility's corporate auditor, and herself (LN 2) reviewed Resident 1's medical record and they were not able to find documentation that Resident 1 had abdominal pain or nausea and vomiting. LN 2 stated she did not assess or document Resident 1's abdominal pain or nausea and vomiting in the medical record the entire time she took care of Resident 1. LN 2 stated, Well the other nurses didn't document or assess either. LN 2 stated, There were 3 other nurses that took care of Resident 1. LN 2 stated she did not notify the physician of Resident 1's regarding the resident's abdominal pain or nausea and vomiting. LN 2 stated looking at Resident 1's medical record, she did not see an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LN 2 stated there was no documented evidence in the medical record that Resident 1 was medicated for abdominal pain. LN 2 stated Resident 1 had abdominal pain and nausea and vomiting but, we did not chart it or treat her. LN 2 stated Resident 1 would point to her stomach a lot, but she (LN 2) did not assess her abdominal pain. LN 2 stated she (LN 2) spoke Spanish and could communicate with Resident 1 with no problem. LN 2 stated she should have called the physician to get orders for nausea and vomiting and report Resident 1's abdominal pain. LN 2 stated it was important to assess resident complaints of abdominal pain with nausea and vomiting, because it could indicate that the resident had [CONDITION(S)] (serious infection in the blood), [CONDITION(S)] (bleeding in the stomach), infection in a wound or a [CONDITION(S)]. LN 2 stated the physician should have been notified so they could have assessed the situation and could order what was needed for Resident 1 to prevent weight loss and other medical complications. On 12/2/21 at 12:26 P.M., a phone interview and concurrent record review were conducted with the facility's Registered Dietitian (RD). The RD stated the facility's staff never told her that Resident 1 had abdominal pain with nausea and vomiting. The RD stated there was no documented evidence in Resident 1's medical record that she had abdominal pain with nausea and vomiting during her stay at the facility. The RD stated it was important to know if a resident was having nausea and vomiting because it could affect the resident's weight and nutritional needs, which could then complicate their health. The RD stated protein and good nutrition was important for proper wound healing. On 12/2/2021 at 2:10 P.M., an interview was conducted with Certified Nursing Assistant (CNA 2). CNA 2 stated Resident 1 had continuous nausea and vomiting 2-3 days before her discharge when she cared for Resident 1 at the facility. CNA 2 stated Resident 1's vomiting occurred before and after she ate her meals. CNA 2 stated she reported Resident 1's nausea and vomiting to both LN 1 and LN 2. On 12/2/21 at 3:45 P.M., a record review and concurrent interview were conducted with LN 5. LN 5 reviewed her notes in the medical record and stated she received a phone call on 10/3/21 during her shift from Resident 1's FM 1, concerned that Resident 1 was having a stroke while she was talking to Resident 1 on the phone. LN 5 stated FM 1 told her Resident 1 didn't sound right and was having difficulty speaking when she was talking to Resident 1 on the phone. LN 5 stated she went into the room and did vital signs and used a stroke scale assessment tool to assess Resident 1. LN 5 stated the stroke scale assessment tool was not issued to her by the facility. LN 5 stated her assessment using the unapproved stroke assessment tool led her to believe that Resident 1 was not having a stroke. LN 5 stated she was a licensed vocational nurse and was not really able to do assessments on residents. LN 5 stated only registered nurses were allowed to assess residents. LN 5 stated there were no registered nurses assigned to the facility during her shift on 10/3/21. LN 5 stated she should have put more details in her note about what symptoms Resident 1 was having and what the results were of her unapproved stroke scale assessment on Resident 1. LN 5 stated she did not complete a change in condition form per the facility's policy when Resident 1 showed potential stroke symptoms. LN 5 stated she contacted the physician about Resident 1 having potential stroke symptoms, but her notes were not clear what was said during the conversation. LN 5 stated she should have made her notes more detailed as to what she said to the physician and what the stroke assessment findings were of Resident 1 on 10/3/21. LN 5 stated it was important to contact the registered nurse, Director of Nursing and/or the physician if a resident was having stroke symptoms so they could decide if the resident needed medical intervention or if 911 was needed. A review of Resident 1's acute care hospital record was conducted. The record titled Emergency Department Record, dated 10/17/2021, indicated that Resident 1 was admitted to the emergency department with acute renal failure (kidneys were not functioning), [CONDITION(S)] (high potassium level in the blood), [CONDITION(S)] (bleeding in the stomach and/or intestine) and a white blood cell (cells in the body that fight infection) count of 13.5 (normal range 4.2-9.1). The record indicated that resident 1 was admitted to the intensive care unit at the hospital. According to the 2021 Lippincott's Stroke Guidelines, obtained from website https://www.nursingcenter.com/ce_articleprint?an= 247- 2000- , indicated, Assessment stat The NINDS (National Institutes of Neurological Disorders) recommends utilizing a specific stroke assessment tool to evaluate patients suspected of having a stroke . A facility document review was conducted. The facility document titled (name of corporation) Care Operating Standard Managing Change of Condition Within PCC, dated 2015, indicated, Objective: To appropriately assess, document, and communicate changes of condition (COC) to the primary care provider. To provide treatment and services to address changes in accordance with patient needs .1. Select and complete the (name facility form) Change of Condition Evaluation. 2. Notify physician .4. Document assessment findings and communications .6. Report change of condition to DON, ED, and other members of the IDT per facility practice . On 12/2/21 at 9:20 A.M., a telephone interview was conducted with Physician (PH 1). PH 1 stated the facility did not notify him that Resident 1 had abdominal pain with nausea and vomiting. PH 1 stated the facility did not notify him that Resident 1 had stroke symptoms or what concerns FM 1 had about Resident 1 on 10/3/21. PH 1 stated he was aware that Resident 1 had a stroke at the acute care hospital 2 days before she was admitted to the facility. PH 1 stated if he was notified by the facility that Resident 1 was having any symptoms of a stroke, he would have sent Resident 1 to the hospital. On 12/2/21 at 2:30 P.M., an interview was conducted with the facility's Director of Nursing (DON 1). DON 1 stated the facility did not use a stroke scale assessment tool or documentation form, when assessing for stroke. DON 1 stated the facility did not have a policy or procedure for assessing strokes in residents. DON 1 stated the licensed nurses were to use the change of condition form when a resident was having signs and symptoms of a stroke. DON 1 stated the facility process was to call the physician or 911 depending on the severity. On 5/26/22 at 10:08 A.M., a telephone interview was conducted with the facility's current Director of Nursing (DON) 2 and the Administrator (ADM). DON 2 stated it was her expectation that the staff would assess the resident then notify the physician if the resident had any change of their condition like nausea and vomiting. DON 2 stated any change in condition should be reported to the physician. 1C. A review of Resident 1's facility record was conducted. On 9/9/21, Physician 1 wrote laboratory (Lab) orders for Resident 1 that included CMP (complete metabolic panel), CBC (complete blood count, HGA1C (hemoglobin A1C), TSH ([CONDITION(S)] stimulating hormone) and CRP (C-reactive protein). There was no documented evidence that the labs ordered on 9/9/21 were completed for Resident 1. Further review of Resident 1's record indicated, on 10/8/21, Physician 1 wrote laboratory (Lab) orders that included CMP (complete metabolic panel), CBC (complete blood count, HGA1C (hemoglobin A1C), TSH ([CONDITION(S)] stimulating hormone) and CRP (C-reactive protein). Resident 1 had abnormal labs that resulted on 10/11/21 from the 10/8/21 lab order. Abnormal labs included Glucose 125 (normal range 70-99), [MEDICATION(S)] 2.3 (normal range 3.2-4.8), A/G ratio .50 (normal range 0.70-3.00), Alkaline Phos 128 (normal range 35-120), CKD 53 (normal range greater than or equal to 60), CRP 5.65 (normal range 0.00-0.75), and white blood cell count 9.5 (normal range 4.2-9.1). There was no documented evidence that the ordering physician or the vascular surgeon were notified of the abnormal labs. On 12/1/21 at 3:43 P.M., a phone interview was conducted with the facility's Director of Nursing (DON) 1. DON 1 stated she was unable to locate any proof in the facility's lab binder or any documentation that Physician 1 or any other physician was notified about Resident 1's abnormal labs that were received on 10/11/21. DON 1 stated the facility did not have a procedure or policy for staff on how they process labs or how they report labs to the physicians. On 12/2/21 at 9:20 A.M., a telephone interview was conducted with Physician (PH) 1. PH 1 stated he did not recall that the facility notified him of Resident 1's abnormal labs that were received on 10/11/21. PH 1 stated if he was notified, he would have signed the bottom of the 10/11/21 lab result page and then faxed it back to the facility for their records. On 12/20/21 at 10:48 A.M., a phone interview was conducted with the Nurse Practitioner for Vascular Surgery (NP) 2. NP 2 stated the facility did not notify her of Resident 1's abnormal labs that were received on 10/11/21. A facility document review was conducted. The facility document titled (name of corporation)Care Operating Standard Managing Change of Condition withing PCC dated 2015 indicated, Objective: To appropriately assess, document, and communicate changes of condition (COC) to the primary care provider. To provide treatment and services to address changes in accordance with patient needs .1. Select and complete the (name facility form) Change of Condition Evaluation. 2. Notify physician .4. Document assessment findings and communications .6. Report change of condition to DON, ED, and other members of the IDT per facility practice . On 12/2/21 at 3:30 P.M., an interview was conducted with DON 1. DON 1 stated she could not locate Resident 1's abnormal lab report form received on 10/11/21, that would have been signed by PH 1. DON 1 stated she did not have any proof that PH 1 was notified regarding Resident 1's abnormal labs received on 10/11/21. DON 1 stated the facility needed a better process for obtaining labs and reporting labs to physicians. DON 1 acknowledged that it was important to report all abnormal labs to the physician,s as soon as possible, to ensure residents receive proper medical intervention(s), if needed, to prevent medical complications. On 1/5/22 at 1:05 P.M., DON 1 confirmed via email that the facility did not have a policy or procedure for staff on implementing physician orders. 1D. On 10/19/21 at 4:12 P.M., a telephone interview was conducted with Resident 1's Family Member (FM) 1. FM 1 stated the facility was not monitoring Resident 1's blood sugar and Resident 1 was diabetic. A review of Resident 1's acute care hospital record was conducted. The record titled Discharge Orders, dated 9/1/21, did not indicate any orders for blood sugar monitoring A review of Resident 1's facility record was conducted. The admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The record did not indicate any blood sugar monitoring orders for Resident 1 the entire admission to the facility from 9/1/21 -10/16/21. The record did not indicate that Resident 1 had laboratory (Lab) orders completed per the order written on 9/9/21 for a CBC (complete blood count), that included a glucose (blood sugar) level. There was also no documented evidence that the facility notified any physician of Resident 1's abnormal labs that were drawn on 10/08/22 that indicated Resident 1's blood glucose level was 125 (normal range 70-99). On 12/1/21 at 3:43 P.M., a telephone interview was conducted with the facility's Director of Nursing (DON) 1. DON 1 stated she was not able to locate any proof in the facility's lab binder or any documentation that labs were completed on 9/9/21, as ordered by the physician. The DON 1 also stated she could not find any documentation that Resident 1's abnormal labs that were ordered on 10/8/21 were communicated to Resident 1's physicians. DON 1 stated the facility did not have a procedure or policy for staff on how to process labs or how to report labs to the physicians. On 12/2/21 at 9:20 A.M., a phone interview was conducted with Physician (PH) 1. PH 1 stated the facility did not notify him that Resident 1 did not have orders for blood sugar monitoring when she was admitted to the facility on [DATE]. PH 1 stated he did not recall the facility notifying him of Resident 1's abnormal laboratory (lab) results that included the blood glucose level, that was ordered on 10/8/21. PH 1 stated poorly controlled blood sugar could contribute to poor wound healing. On 12/2/21 at 3:30 P.M., an interview was conducted with DON 1. DON 1 acknowledged that the facility did not monitor Resident 1's blood sugar while the resident was admitted at the facility. DON 1 stated blood sugar monitoring was important for residents with diabetes especially if they have a wound. DON 1 stated elevated blood sugar levels in diabetic patients could affect wound healing. On 12/2/21 at 3:45 P.M., a record review and concurrent interview were conducted with LN 5. LN 5 stated Resident 1 did not have orders for blood sugar monitoring. LN 5 stated the resident's family requested, on 10/4/21, to bring their own blood glucose monitoring machine so they could monitor Resident 1's blood sugar. LN 5 stated she got an order, on 10/4/21 from PH 1, for the family to use their own blood sugar monitoring machine so the family could monitor Resident 1's blood sugar. On 12/20/21 at 10:48 A.M., a telephone interview was conducted with the Nursing Practitioner for Vascular Surgery (NP) 2. NP 2 stated the facility did not notify her of Resident 1's abnormal glucose levels that was received on 10/11/21. NP 2 stated diabetes management and blood sugar monitoring was very important for proper wound healing for Resident 1. According to the 2021 Lippincott's Guide to Negative Pressure Wound Therapy (wound vacuum), Nursing Considerations. Assess your patient for wound healing issues, such as poor nutrition (low protein levels), diminished oxygenation, decreased circulation, diabetes .infection . Obtained 12/23/2021 from website https://www.nursingcenter.com/clinical-resources/nursing-pocket-cards/guide-to-negative-pressure-wound-therapy-(npwt) According to Wound Source (December 4th, 2017), High blood glucose causes stiffening of the arteries, narrowing of blood vessels, and diabetic [CONDITION(S)], which is nerve damage throughout the body, particularly the limbs. The effect of these body changes causes increased risk of wounds as well as more complications in diabetes wound healing. Obtained 1/5/21 from website https://www.woundsource.co [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure Resident 19, a vulnerable resident (person who cannot move or think independently), received care that was provided in a respectful and dignified manner and was free from physical restraints, when: -Certified nursing assistant (CNA) 30 used a bath towel to physically restrain Resident 19 when the resident refused care. -Resident 19's privacy curtain was left open during brief changes and personal care. Resident 17 (the roommate of Resident 19) was able to observe the personal care provided to Resident 19. As a result of these deficient practices, Resident 19 experienced care that a reasonable person would find humiliating, embarrassing, and distressing. In addition, Resident 17 experienced psychosocial distress as a result of witnessing her roommate, Resident 19, being held down when staff were forcing care. Findings: A review of Resident 19's Admission Record, dated 11/8/21, indicated the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Record further indicated Resident 19 was not her own responsible party (RP) or medical decision maker. A review of Resident 19's Minimum Data Set Assessment (MDS, an assessment tool) dated 9/14/21, indicated the resident scored 00 on the brief interview of mental status (a score of 00 meant the resident was severely cognitively impaired). The MDS further indicated Resident 19 required extensive assistance from staff for activities of daily living (ADLs, such as toileting, personal hygiene, and dressing) and extensive to total staff performance for bed mobility and locomotion on the unit. A review of Resident 19's medical provider assessment titled Annual Wellness Visit, dated 1/4/22, indicated the resident had contractures (shortening and hardening of muscles or other tissue leading to deformity and rigidity of joints) of the left hand, hips and knees, and appeared to have poor judgement and poor insight, and was severely disoriented. The Annual Wellness Visit further indicated Resident 19's memory appeared to have been severely impaired, and . [Resident 19] spends most days in bed, unable to string 6 words together A review of Resident 17's Admission Record, dated 11/8/21, indicated the resident was admitted on [DATE] and readmitted to the facility on [DATE]. The Admission Record further indicated Resident 17 was her own RP and medical decision maker. A review of Resident 17's MDS assessment dated [DATE], indicated the resident scored 14 on the brief interview of mental status (a score of 14 meant the resident was cognitively intact). On 11/5/21 at 1:26 P.M., an interview with the facility's administrator (ADM) was conducted during an onsite visit to investigate a facility reported incident (reported on 10/29/21) related to quality of care. The ADM stated he had reported an allegation made by Resident 17 that she had overheard sounds described as abuse during the care of her roommate (Resident 19). The ADM stated he was unable to substantiate the allegation because Resident 17 stated to him that she did not know who the staff were or when the incident was alleged to have taken place. The ADM stated that Resident 17 had told the police she was not accusing anyone of hurting her roommate, she was just trying to look out for Resident 19 because the resident could not speak for herself. On 11/5/21 at 2:35 P.M., an observation and interview was conducted with Resident 17 while inside the resident's room. Resident 17 was lying in bed and the resident's bed was positioned next to the window. Resident 19 was observed in the same room while in bed and was positioned near the door. Resident 19 was fully visible from the location of Resident 17's bed. Resident 17 stated the CNAs were extremely rough with Resident 19. Resident 17 stated they throw Resident 19 around like a rag doll from the resident's bed to the wheelchair and back to the bed. During the interview with Resident 17, Resident 19 started making soft vocal sounds in a lyrical cadence. Resident 17 pointed toward Resident 19 and stated, See, she usually does that sound, but when they [CNAs] get a hold of her she yells, and they make her cry. Resident 17 stated she was afraid to name the CNA who had done this to her roommate because the CNA had a lot of friends, and the other CNAs did what she told them to do. Resident 17 stated she had confided in her family member about the care she witnessed Resident 19 had received and they encouraged her to report what she had seen. Resident 17 stated she reported the concern about Resident 19's care to the ADM but did not want anyone to know she had reported it. Resident 17 stated she knew who the staff involved were and reported it because she, Couldn't take seeing what was done to her roommate any longer. Resident 17 began to cry and then sobbed. Resident 17 asked for confidentiality. The situation was discussed with Resident 17 and the resident stated she was willing to continue the interview and was aware confidentiality would be difficult to maintain because she had already discussed the concern with the ADM. Resident 17 stated she wanted the interview to continue and wanted to tell what happened because it was important and serious. Resident 17 stated she was afraid of CNA 40 and of retaliation. Resident 17 stated CNA 40 and CNA 30 would frequently work together providing care to Resident 19. Resident 17 stated, [CNA 40] is so rough and pushes and pulls her [Resident 19] in bed. Resident 17 stated that CNA 40 would tell CNA 30, You don't have to be gentle with her [Resident 19], she doesn't understand and can't say anything. Resident 17 stated on one occasion when CNA 40 was changing Resident 19's soiled brief and forgot a washcloth, she used the dirty diaper to wipe the resident and then put a new brief on. Resident 17 stated, They [CNA 30 and CNA 40] never pull the curtain. I see everything. Resident 17 stated, It's humiliating, and I'd be embarrassed if it was happening to me. Resident 17 stated she saw CNA 30 and CNA 40 on more than one occasion physically holding Resident 19 down on the bed, and that it looked like fighting and abuse. Resident 17 stated watching the care provided to Resident 19 made her personally feel afraid and she felt afraid for Resident 19. Resident 17 stated she would cry often by herself when thinking about Resident 19's care and that her eyes would get red. Resident 17 stated, I tell them [staff] I have allergies. Resident 17 stated this situation was the first time she had complained about staff during her stay at the facility. Resident 17 then discussed other areas of concern. Resident 17 was asked if only one concern could be addressed, which was the most important? Resident 17 pointed again to Resident 19 and stated, The way she's treated . It's really terrible what they [CNA 30 and CNA 40] do to her. On 11/5/21 at 3:35 P.M., an interview was attempted with Resident 19. Resident 19 did not respond to interview attempts. On 1/27/22 at 12:20 P.M., an interview was conducted with CNA 42. CNA 42 stated she was familiar with both Resident 17 and Resident 19. CNA 42 stated Resident 17 was alert, pleasant, and was not known to accuse staff or make things up. CNA 42 stated Resident 19 was very confused and did not fluently speak English. CNA 42 stated there was a nurse who spoke the same native language as Resident 19 and nurse said the resident was confused and did not make sense. CNA 42 stated Resident 19 was incontinent (could not control the release of urine and feces) and bed bound (unable to independently get out of bed). CNA 42 stated Resident 19 was sometimes difficult to care for during peri-care (cleaning the person's private areas). CNA 42 stated Resident 19 would push staff away and then scratch and pinch the staff. On 1/27/22 at 1:35 P.M., an interview was conducted with CNA 45. CNA 45 stated Resident 19 was confused and spoke a non-English language. CNA 45 stated Resident 19 was paralyzed on one side of her body, but strong on her good side. CNA 45 stated Resident 19 was known to pinch, push, and scratch at staff during care with her strong arm. On 1/27/22 at 2:45 P.M., an interview was conducted with CNA 50. CNA 50 stated Resident 19 was confused and sometimes resistive to care. CNA 50 stated the resident showed restiveness to care by pushing away staff and pinching and scratching. CNA 50 stated when Resident 19, Is resisting we still need to do care because she'd soiled [with urine and/or feces]. CNA 50 stated when Resident 19 was resisting, staff had to move the resident's hand, so they did not get scratched or pinched. CNA 50 stated if Resident 17 had witnessed staff providing care to Resident 19, while the resident was resisting care, that It could look like abuse. CNA 50 further stated staff providing care while Resident 19 was resisting could also look like, Fighting with the resident. CNA 50 stated when providing care to Resident 19, she would try to calm the resident down by talking to her. CNA 50 stated it took a long time about half an hour to provide care and keep Resident 19 calm when she was in a bad mood and resisting. On 1/28/22 at 8:32 A.M., an interview was conducted with the director of nursing (DON). The DON provided copies of the CNA Room Assignments for July, August, and October of 2021. The DON stated the facility's records of room assignments were incomplete during the time frames requested. A review of the CNA Room Assignments for July, August, and October of 2021 indicated out 40 days of recorded room assignments, CNA 30 and/or CNA 40 were assigned to provide care to Resident 17 and Resident 19 for 17 of the 40 recorded days. On 1/28/22 at 8:48 A.M., an interview was conducted with CNA 30. CNA 30 stated Resident 17 was alert and knew what was going on. CNA 30 stated Resident 17 would sometimes get involved in Resident 19's care by asking CNA 30, what are you doing and why are you doing that? CNA 30 stated Resident 19 was very confused and scratches and pinches like a crab during peri-care. CNA 30 stated Resident 19 could not move the left side of her body well but was strong on the right side of her body. CNA 30 stated when Resident 19 was resisting care, I get a towel and control her arm. CNA 30 stated she would get a bath towel and place over Resident 19's stronger right forearm to pin it to the bed while another CNA did the peri-care. CNA 30 stated CNA 40 was often her partner when providing resident care. CNA 30 stated using a bath towel to physically restrain Resident 19's right arm had been her own idea. CNA 30 stated she chose a bath towel because a towel is soft and won't bruise her [Resident 19]. CNA 30 stated the towel was also used to prevent the CNAs from getting injured by pinches and scratches while the resident resisted care. CNA 30 stated if she had used her hand to restrain Resident 19, it would have left a bruise. CNA 30 stated Resident 19 still tried to scratch staff while being restrained with the towel. CNA 30 stated Resident 19 was not capable of verbalizing what she wanted and expressed refusals by pushing staff away and scratching. CNA 30 stated Resident 19 was probably doing that [resisting] because she doesn't want us touching her at that time. CNA 30 stated Resident 19 did not always refuse care but refused most of the time. CNA 30 was asked if all residents had the right to refuse care, and CNA 30 stated, Yes. CNA 30 stated she should have stopped providing care and reported to the licensed nurse when she felt the need to get a bath towel to physically restrain Resident 19. CNA 30 stated if Resident 17 had observed care provided to Resident 19 when the towel was used as a restraint, It wouldn't look good, it would look like fighting with Resident 19. CNA 30 was asked how it would feel to refuse care, but then be restrained with a towel and have care provided. CNA 30 stated, I wouldn't like it. A review of Resident 19's written plan of care dated 9/4/18, indicated, The resident has a behavior of scratching and biting when staff are doing ADL care The plan of care did not include the use of physical restraints. The plan of care also did not provide resident-specific guidance to nursing staff on how the resident's behavior should have been addressed during ADL care. On 1/28/22 at 1:35 P.M., an interview was conducted with the MDS nurse (MDS) 1. MDS 1 stated Resident 19 was confused and was not capable to verbalize a refusal. MDS 1 stated Resident 19 demonstrated refusals by pushing the staff away. MDS 1 stated confused residents still had the right to refuse care. MDS 1 stated all care should have stopped when Resident 19 became resistive to care. MDS 1 stated it was unacceptable for staff to use a towel to physically restrain Resident 19 and to force care. MDS 1 stated it was understandable why Resident 17 would think something inappropriate was going on after witnessing care forced on the resident. MDS 1 stated Resident 17's descriptions of care provided to Resident 19 matched the descriptions of the staff who had provided care. MDS 1 further stated Resident 19 should have been provided privacy as a matter of dignity during care. On 1/28/22 at 2 P.M., an interview was conducted with licensed nurse (LN) 60. LN 60 stated Resident 19 was confused and had a behavior of pushing at staff and scratching during care most of the time. LN 60 stated Resident 19 was not capable of verbalizing her wants or needs. LN 60 stated residents who were confused or could not verbalize needs would push or scratch as a means of saying no. LN 60 stated she thought Resident 19 pushed and scratched at staff during care because the resident was trying to protect herself and didn't want anyone touching. LN 60 stated using a towel to restrain Resident 19's right arm was the use of a physical restraint and that wasn't okay. LN 60 further stated she did not think Resident 19 scratched very hard and expected the staff providing care to power through the scratches and pinches. On 1/28/22 at 2:23 P.M., a joint interview and record review was conducted with the DON. The DON stated Resident 19 was cognitively impaired, could not communicate clearly, and just mumbles. The DON stated when Resident 19 pushed at or scratched staff it was considered refusing and all care should have stopped immediately. The DON stated holding Resident 19's arm down with a towel was the use of a physical restraint and that was unacceptable and inappropriate. The DON stated all care should have stopped the moment staff thought to go get a towel to restrain the resident and force care. The DON stated stopping and coming back 10 minutes later to offer care again could change the resident's mood and the resident may have then been in a different frame of mind and accepting of care. The DON stated it was also unacceptable for staff to power through a resident's refusal of care. The DON stated the facility did not use restraints and they would not have been a part of Resident 19's written plan of care. The DON reviewed Resident 19's plan of care dated 9/4/18, for The resident has a behavior of scratching and biting when staff are doing ADL care The DON stated the plan of care would need to be reviewed for individualized interventions and developed to give clear direction to staff on how to handle the resident's refusal. The DON stated the plan of care would need to guide staff to stop when the resident refused care and to try again later. The DON further stated privacy should also have been provided to Resident 19 during personal care. On 1/28/22 at 2:55 P.M., an interview was conducted with the ADM. The ADM stated using a towel to restrain a resident who was refusing care was unacceptable. The ADM stated residents had the right to refuse care. The ADM stated he did not want any care provided in the facility to look like, or to be perceived as, abusive or fighting. The ADM further stated restraining a resident who was refusing care could lead to staff or resident injury. On 2/2/22 at 12:45 P.M. and at 3:30 P.M., calls were placed to CNA 40 requesting an interview. CNA 40 did not respond to interview requests. On 2/3/22 at 10:41 A.M., an interview was conducted with LN 63. LN 63 stated he was familiar with Resident 19. LN 63 stated Resident 19 could be resistive to care and would refuse by pushing staff away with her hand. LN 63 stated he interpreted Resident 19's pushing staff away with her hand as come back later, no, not right now, and as a refusal. LN 63 stated it would be inappropriate and wrong to restrain Resident 19's arm with a towel and to force care on her. LN 63 stated that experience would have been disrespectful and undignified to the resident. LN 63 stated if care had been delivered in that way to him, I'd be angry, and I'd remember who they were. LN 63 stated, I'd be afraid if they took care of me again and I'd fight harder the next time. On 2/3/22 at 11 A.M., an interview was conducted with CNA 42. CNA 42 stated when Resident 19 pushed staff's hands away it was a refusal. CNA 42 stated, All residents had the right to refuse even the confused ones. CNA 42 stated if staff held her down with a towel and forced care on her after she refused, she would feel, Awful. Mistreated. Like I wouldn't want to be here. CNA 42 further stated, I'd feel unsafe and afraid to receive care. On 2/3/22 at 11:13 A.M., an interview was conducted with LN 65. LN 65 stated if staff held her down with a towel and forced care on her after she refused, she would feel, Terrified and it'd be horrible. LN 65 stated a resident witnessing a situation like that happen to another resident would make them also feel afraid. On 2/3/22 at 11:30 A.M., an interview was conducted with CNA 45. CNA 45 stated if staff held her down with a towel and forced care on her after she refused, she would feel, Traumatized. I'd be upset, scared, mad. On 2/3/22 at 11:40 A.M., an interview was conducted with CNA 50. CNA 50 stated Resident 19 did not refuse or resist when eating, changing clothes, or showers. CNA 50 stated, She [Resident 19] likes showers. CNA 50 stated Resident 19 was shy about her private parts and when receiving peri-care. CNA 50 stated, That's the only time she's hesitant or resists. CNA 50 stated if staff held her down with a towel and forced care on her after she refused, she would feel, Undignified, disrespected, and scared to get care again. On 2/3/22 at 11:13 A.M., an interview was conducted with MDS 1. MDS 1 stated if staff held her down with a towel and forced care on her after she refused, It would give me nightmares. MDS 1 stated a reasonable person would have felt afraid and helpless to experience the care that had been provided to Resident 19. On 2/4/22 at 9:53 A.M., a telephone interview was conducted with Resident 19's RP. The RP stated Resident 19 was able to recognize him but did not know where she was at or the time and date. The RP stated, Some days are better than others but overall, she [Resident 19] doesn't make sense even when speaking [native language]. The RP stated if Resident 19 did not want something that she would push it away or push the person's hand away. The RP stated, That's how she says no. The RP stated when Resident 19 refused or demonstrated no, during care, he expected staff to stop. The RP stated it was his hope that facility staff would provide comfort to Resident 19 and be gentle with her. On 2/22/22 at 12:40 P.M., another call was placed to CNA 40. CNA 40 did not respond to the request for an interview. A review of the facility's policy titled Residents' Rights, revised June 2015, indicated, . A. Each resident must be treated with respect .Employees are expected to protect the rights of each resident . D. [Company Name] expects every resident to be treated with consideration and full recognition of dignity and individuality, including privacy in treatment and care of personal needs A review of the facility's policy titled Restraint Policy, revised October 2017, indicated, Residents will be free from physical restraints that are not required to treat the resident's medical symptoms . Equipment [:] Appropriate device to meet the residents need as ordered by a physician

Based on observation, interview and record review, the facility failed to ensure LN staff were knowledgeable, performed and documented glucometer quality control testing per policy and procedure and manufacturer guidelines, for 2 of 2 glucometers. In addition, a consistent system for documenting glucometer quality control test results was not in place, and facility Glucometer Testing Logs were incomplete and inaccurate. This failed practice affected 5 of 14 sampled residents (13, 36, 37, 40, and 41), and 7 unsampled residents (6, 11, 24, 35, 38, 49, and 51) who had a [DIAGNOSES REDACTED]. The blood sugar testing for all 12 residents was measured using the facility glucometers. As a result, 12 of 12 residents were at risk for inaccurate measurement of blood sugar and overdosing or under dosing of insulin, related to the failed system quality control testing of the facility glucometers. Findings: 1. On 7/8/16 at 7 A.M., a joint observation and interview was conducted with LN 2. LN 2 obtained a glucometer, a test strip bottle and control solutions from a drawer located in the medication room. LN 2 proceeded to demonstrate a quality control test of the glucometer. LN 2 activated the glucometer by inserting a test strip. LN 2 applied a large drop of the Low control solution directly on the test strip, which resulted in a reading of 40 milligrams per deciliter. LN 2 then removed the test strip and obtained a second test strip and inserted it into the glucometer. LN 2 applied a large drop of the High control solution directly on the test strip, which resulted in a reading of 220 milligrams per deciliter. LN 2 was unable to state what the acceptable quality control ranges were for the Low and High control test results. LN 2 was also unable to state where she could obtain the quality control test result ranges. On 7/8/16 at 8:08 A.M., the DON provided a list of residents with diabetes, who had their blood sugar levels tested with the facility's glucometers and received sliding scale insulin. On 7/8/16 at 12 P.M., an interview was conducted with the DSD. The DSD confirmed neither LN 2 nor LN 4 (LN 4 was identified as the second LN conducting quality control testing) had competencies (skill or ability) for the glucometer quality control tests, in their employee files. On 7/8/16, the manufacturer's guidelines for the facility's glucometers was reviewed. The manufacturer's guidelines instructed the user (LN) to: 1) Insert a test strip into the glucometer. 2) Squeeze a drop of Low or High control solution onto a clean dry non- absorbable surface. Do no apply control solution directly from the control solution bottle. Gently touch the tip of the strip to the drop of control solution. 3) After 6 seconds the control solution test result will appear on the meter display screen. Compare the reading on the screen to the Low or High range printed on the test strip bottle. If the reading falls outside the Low or High range, see control solution trouble shooting for possible causes. Possible causes listed, wrong brand of control solution being used, control solution not at room temperature, expired or contaminated control solution or damaged test strip and meter malfunction. According to the manufacturer's guidelines, .Failure to follow instruction may cause out of range (blood sugar) results . Per the facility's policy and procedure, dated 2006 and titled Blood Sugar Monitoring, .follow the manufacturer's instructions for the type of equipment used in the facility .Procedure .3. follow manufacturer's directions for use and care . Attached to this policy and procedure was a copy of the manufacturer's guidelines for control solution testing. A review of the U.S. Food and Drug Administration website (http://www.fda.gov.MedicalDevices/Safety/AlertsandNotices/TipsandArticlesoneviceSafety/ucm 9.htm) pertaining to glucometer operations indicates, All operators, from patients to non-lab healthcare workers to medical technologists and physicians, should be thoroughly familiar with any device prior to using it. The best way to do this is to read the package insert and user manual carefully before using a device for the first time. If you have any questions, ask someone who is familiar with the device. Another option is calling customer service telephone number located on most package inserts. The people on the other end are there to help. Another good tip is to reread the package insert every few months. It is a good practice and there may be changes. 2. On 7/8/16 at 7:50 A.M., a review of the Glucometer Testing Log was conducted. The log date ranged from 10/23/15 through 7/8/16. Lot numbers for the test strips, and control solutions were missing. Acceptable control solution ranges were missing. Time of day the tests were conducted and any action required for out of range test results was not noted. The Glucometer Testing Log did not include any testing data or documentation on the following dates: October 24, 25, 30, 31 of 2015 November 1, 4, 6, 7, 8, 12, 13, 14, 15, 21, 22, 30 of 2015 December 1, 3, 11, 12, 13, 14, 15, 16, 17, 18, 19, 22, 23, 25, 28, 29 of 2015 January 1, 4, 5, 6, 7, 12, 13, 14, 16, 17, 18, 19, 25 of 2016 February 20 of 2016 April 2, 28 of 2016 May 3, 11, 20, 27, 28 of 2016 June 3, 8, 9, 11, 12, 13, 14, 15, 16, 20, 25 of 2016 On the Glucometer Testing Log for March 2016, the results for the tests were not in chronological order for the dates of: 3/19, 3/21, 3/22, 3/27, 3/28 and 3/29. On the Glucometer Testing Log dated 4/6/16 through 5/5/16, there was documentation at the bottom the log out of solution with a sad face drawn, dated 6/10/16 with LN 4's signature. On 7/8/16 at 11:30 A.M., a joint interview and record review was conducted with the DON in the presence of the facility's Regional Director of Clinical Operations. The DON stated, she could not identify what the numbers documented in the log represented. The DON further stated, no one was monitoring the glucometer quality control test log. The Glucometer Testing Log records, dated 10/23/15 through 4/5/16, were reviewed by the DON. From 10/23/15 through 1/11/16, the Low and High quality control test results were documented on Nurse's Notes sheets, not on the log. From 1/15/16 through 2/6/16, the Low and High quality control test results were documented on black lined white paper, not on the log. From 2/7/16 through 4/5/16, the Low and High quality control test results were documented on plain white paper, not on the log. From 4/6/16 through 7/8/16, the Low and High quality control test results were documented on a Glucometer Testing Log. On 7/8/16 at 11:40 A.M., a telephone interview was conducted with the facility's pharmacy consultant (PC). The PC stated, the pharmacy consultant nurse (PCN) audited the Glucometer Testing Log. On 7/8/16 at 11:45 A.M., a telephone interview was conducted with the PCN. The PCN stated the Glucometer Quality Testing Log was reviewed monthly and and a written pharmacy audit was provided to the DON. On 7/8/16 at 12:30 P.M., the pharmacy audits for March, April, May and June of 2016 were reviewed. There was no documented evidence the Glucometer Quality Testing Log was reviewed monthly by the PC or PCN. On 7/8/16 at 4:13 P.M., a meeting was held with the Administrator (ADM). A determination of Immediate Jeopardy (IJ) was relayed to the ADM. The determination of an IJ was based on: Obsevation and interviews with LN staff and review of the Glucometer Testing Logs. The LNs lacked knowledge and failed to follow the manufacturer's guidelines when performing quality control testing of the glucometers. A system for documenting glucometer quality control test results was not in place, and the facility Glucometer Testing Logs were incomplete and inaccurate. In addition, there was no documented evidence of the LN staffs competency related to quality control testing of the glucometers. With the lack of evidence of correct glucometer quality control testing, the concern was the residents who received blood sugar testing with the glucometer, had the potential to have unreliable results. The facility submitted a plan of correction (POC) on 7/11/16 at 10:35 A.M. Each item in the POC was observed to be completed before it was accepted. The POC and evidence of correction indicated: Eight of 12 LNs received inservice training with return demonstration related to: glucometer quality control testing, the correct use and documentation of the Glucometer Test Log and, the Change of Condition (COC) policy and procedure. Also, training was provided to LN staff and information was posted in the Medication Room, related to the correct procedures and measures to take if quality control testing results fell outside of the parameters. In addition the POC indicated, any LN who had not completed the training, including return demonstration, would not perform glucometer testing. The manufacturer's guidelines for the glucometer quality control testing were also placed at the nurse station. The Medical Director provided inservice training to LNs on diabetic management and the importance of blood glucose monitoring. The facility performed quality control checks on all glucometers based on manufacturer guidelines. Twelve residents (2 of which were admitted after survey start date of 7/5/16) were rechecked. The facility policy and procedure for glucometer quality control testing was amended as follows: glucometer testing will be done by day shift LNs, revised Glucometer Testing Logs were placed on both medication carts. The DON, DSD or designee would monitor completion of glucometer testing, and review both Low and High results outside parameters daily. The DON, DSD or designee would daily ensure that any glucometers that tested outside parameters would be removed from use and replaced. The pharmacist consultant would review all residents with blood sugar testing orders twice a month, and make recommendations when necessary. The Health Information Manager, LN, or designee would audit daily, all residents' blood sugar test results and orders for completion and appropriate interventions, using the required audit reports. The DON or designee would be responsible to correct any deficiencies found in the audit. The DON or designee would be responsible for monitoring weekly, residents with blood sugar testing orders to ensure any negative trends were reported to the physician and corrective action taken. Interdisciplinary team (department leaders) walking rounds would be conducted per the DON recommendation related to trends identified. Results of the Health Information Manager audits and any deficient practices would be forwarded by the DON or designee and presented to the Quality Assurance Committee for the next 90 days. On 7/11/16 at 1:20 P.M., the deficient practice was corrected, and the IJ was removed.

Based on observation, interview and record review, the facility failed to ensure: 1. The hot water temperatures did not exceed 120? F, as required per regulation, in 4 of 16 resident bathrooms (Rooms 10, 11, 15 and 27) and 2 of 2 resident shower rooms. 2. A temperance valve (a device that automatically mixes hot water with cold water to achieve a set temperature), was installed on 1 of 2 water heaters (#1) which supplied hot water to resident care areas and 1of 2 water heaters (#2), used as a back-up to the main water heater. 3. An audible/visible hot water alarm (to alert the facility when hot water temperatures in the resident care areas were above the set limit), was installed in 1 of 1 nursing stations. These failed practices led to the potential for residents using the hot water in 4 of 16 bathrooms and 2 of 2 shower rooms to be exposed to water that could be hot enough to cause burns. Findings: During the initial tour of the facility on 9/16/13 at 9 A.M., a surveyor reported to the team the hot water from the faucet in the bathroom in Rooms 11 and 15, felt hot to the touch. During a joint observation and interview on 9/16/13 at 10:05 A.M., with the Acting Maintenance Supervisor (AMS), the AMS used the facility's thermometer and measured the hot water temperature at the bathroom faucet in Room 11. The AMS said the hot water temperature measured 123? F (Fahrenheit). The AMS used the facility's thermometer and measured the hot water temperature at the bathroom faucet in Room 15. The temperature measured at 121? F. The AMS stated, "I have to check the water heater. The water temperature should not be over 120? F." On 9/16/13 at 10:20 A.M., the Administrator said, when interviewed and asked for a policy and procedure on hot water temperatures, "We don't have a policy, we use Title 22" (State regulations). Title 22 (d) instructs facilities to maintain hot water temperatures in compliance with Title 24, California Administrative Code. Per Title 24, 2010 California Plumbing Code 612.5, "Temperature control valves shall be provided to automatically regulate the temperature of hot water delivered to plumbing fixtures used by patients to a range of 105? F (41? C) minimum to 120? F (49?C) maximum." On 9/16/13 at 10:25 A.M., a copy of the facility's water temperature logs for the months of July 2013 through September 2013 were reviewed with the Administrator. The Administrator stated during a joint interview with the AMS on 9/16/13 at 10:25 A.M., if the temperatures were measured at 120? F or above, she would, "Follow up with a phone call to the plumber" who told her to, "Let the water run 5-7 minutes." According to the State Operations Manual (SOM), (Federal regulations) Section F 323, at 120? F a 3rd degree burn can occur after 5 minutes exposure. At 124? F a 3rd degree burn can occur after 3 minutes exposure. A 3rd degree burn is a burn that peneatrates the entire thickness of the skin and permanently destroys tissue. Also according to the SOM, "Many residents in long-term care facilities have conditions that may put them at increased risk for burns caused by scalding. These conditions include: decreased skin thickness, decreased skin sensitivity, peripheral neuropathy (a nerve disorder which causes pain or loss of feeling in the toes, feet, legs, hands ans arms), decreased agility (reduced reaction time), decreased cogntion or dementia, decreased mobility, and decreased ability to communicate." During the same interview on 9/16/13 at 10:25 A.M., the Administrator stated the water heater needed a, "mixing valve" (temperance valve) to control the water temperatures and said the facility did not have the mixing valve. The Administrator also stated that currently there was no way to lower the water heater temperature setting below 120? F. During observation and interview on 9/16/13 at 10:35 A.M. the water heater, designated as the hot water supply used by residents for showering/bathing, was identified by the Administrator and AMS who confirmed the temperature was set at 120? F. The Administrator also said the nursing station was not equipped with a hot water alarm to alert the staff if the hot water temperature rose above 120? F. Per Title 24, 2010 California Plumbing Code 612.5, "High temperature alarm set at 125? F (52? C) shall be provided. The audible/visual device for the high temperature alarm shall annunciate (sound) at a continuously occupied location." The Administrator said she didn't know how long the water heater had been without an alarm, "Maybe 5 years." On 9/16/13 at 10:55 A.M., the AMS was observed using the facility's thermometer to measure the hot water temperatures in resident bathrooms and shower rooms. The following results were observed and verbally confirmed with the AMS: On 9/16/13 at 10:55 A.M., the hot water temperature measured 121.2 ? F in Room 10. On 9/16/13 at 10:58 A.M., the hot water temperature measured 123.0 ? F in Room 11. On 9/16/13 at 11 A.M., the hot water temperature measured 121.0 ? F in Room 15. On 9/16/13 at 11:03 A.M., the hot water temperature measured 121.5 ? F in Room 27. On 9/16/13 at 11:05 A.M., the hot water temperature in the left hand sink, which was one of two sinks in Shower Room 2, measured 120.2 ? F. On 9/16/13 at 11:10 A.M., the hot water temperature in Shower Room 1 measured 120.1 ?F. On 9/16/13 at 12:55 P.M., the plumbing contractor (PC 1) was interviewed. PC 1 said he informed the Administrator on 6/24/13, the water heater needed to have a temperance valve installed in order to regulate the hot water supplied to the resident care areas. In addition, PC 1 said the Administrator contacted the plumbing company more than 5 times since late June 2013, regarding the resident water temperature being too hot. PC 1 said he repeatedly informed the Administrator the only way to fix the excessive water temperature in the resident care areas was to have the temperance valve installed. PC 1 also said the hot water heater was located in the same room as the facility's electrical panel in which electrical work was being done. According to a written proposal from the facility plumbing contractor, dated 7/18/13, " Re: Install Tempering Valve. (The plumbing contractor) was called because the domestic hot water temperature is greater than 120? F. Per health code, domestic hot water must be greater than 110? F and less than 120? F. (The plumbing contractor) recommends installing a hot water tempering valve to regulate the water temperature ... " Although the proposal indicated that the facility called to report water temperatures in excess of 120? F, the water temperature monitoring logs had maximum water temperatures documented on 7/17/13 as 119?? F and 118.5? F on 7/18/13. On 9/16/13 at 3:52 P.M., PC 2 (owner of the plumbing company used by the facility) said when interviewed, he informed the Administrator there was no way to know what the actual water temperature was inside of the water heater tank without a temperance valve. PC 2 also said he informed the Administrator the maximum water temperature inside of the water heater tank could reach up to 160? F. The facility failed to install a temperance valve to ensure that water delivered to resident care areas was 120? F or less. The facility failed to ensure that there was an audible/visual alarm at the nursing station to alert staff if the water temperature exceeded 120? F. The facility was unable to provide a policy for water temperature monitoring. On 9/16/13, water temperatures in 4 resident bathrooms and 2 resident shower rooms were above 120? F even though the temperature was set on the water heater at 120? F. The Administrator stated that the set temperature could not be lowered and the plumbing contractor said that the temperature in the water heater could rise to 160 F. As a result, on 9/16/13 at 4: 35 P.M., an Immediate Jeopardy was called and the Administrator and the Clinical Nurse Consultant were informed. On 9/16/13 at 6:10 P.M., the Administrator stated during interview, the immediate measures taken to ensure resident safety were: 1. The maintenance technician (AMS) turned off the hot water heater which supplied hot water to resident care areas. 2. The hot water heater room was locked to prevent access. 3. A sign will be posted on the hot water heater to keep the hot water supplied to resident care areas off until further notice. 4. Residents and or their responsible party would be informed verbally or by phone that there would not be hot water. 5. Residents would be provided disposable wet clothes for hygiene. 6. Staff would be informed of the above information by shift to shift reporting. On 9/18/13 at 10:30 A.M., an addendum to the original Plan of Correction was received from the Administrator. According to the POC addendum, the facility would: 1. Have a tempering /mixing valve and temperature gauge installed. 2. Install an enunciator alarm visible to staff to alarm if the water temperature reached 125? F or greater. 3. This work would be inspected by OSHPD (California Office of Statewide Health Planning and Development). 4. Upon OSHPD inspection and approval, the hot water would be turned on in the resident care areas for use. 5. The date of completion for the above identified remedies was expected to be on Thursday, 9/19/13. On 9/19/13 at 4:40 P.M. the Immediate Jeopardy was abated with the Administrator as a result of the completion of the work and inspection as outlined in the POC addendum.