Every finding on record at Vermont Healthcare Center

Based on interview and record review, the facility failed to ensure one two of three sampled residents (Resident 1), who had an indwelling urinary catheter ([foley catheter] a hollow tube inserted into the bladder to drain or collect urine), order was received prior to irrigating (process of washing out a body area with a prescribed sterile solution to remove blockages such as mucous or blood clots) Resident 1's indwelling urinary catheter. This deficient practice had the potential to cause trauma, infection, obstruction or other complications to Resident 1. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnoses including malignant neoplasm of the prostate (prostate cancer) and obstructive and reflux uropathy (when urine stops flowing normally through the urinary tract). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 6/10/2026, the MDS indicated Resident 1's cognition (mental action or process of acquiring knowledge and understanding ability) was intact. Resident 1 was dependent (helper does all the effort) on staff with toilet hygiene, shower/bath, lower body dressing, putting on and taking off shoes. During a review of Resident 1's Order Summary Report (Physician's Order) dated 2/22/2026, the Physician's Order indicated to apply a foley catheter anchor for prevention of pulling on foley catheter and to monitor placement every shift. During a review of Resident 1's Physician's Order dated 3/31/2026, the Physician's Order indicated to change Resident 1's foley catheter 16 French ([fr] size of tubing) with a 10 cubic centimeter ([cc] unit of measurement balloon) balloon monthly. During a review of Resident 1's untitled Care Plan dated 12/23/2025, the Care Plan indicated Resident 1 had a foley catheter 16 fr with 10 cc balloon for obstructive uropathy due to prostate cancer. The Care Plan interventions indicated to flush the catheter as per physician's orders. During an interview on 8/18/2026 at 1 p.m. with Resident 1, Resident 1 stated he experienced an acute life-threatening emergency with his foley catheter on 8/13/2026 and stated his foley catheter stopped draining urine and he felt lower body pain. Resident 1 stated he complained to Licensed Vocational Nurse (LVN) 1 that he felt pressure and pain. Resident 1 stated on 8/13/2026 sometime during the day shift, LVN 1 irrigated his foley catheter with no relief. Resident 1 stated Registered Nurse (RN) 1 inserted a new foley catheter which relieved his pain. During a review of Resident 1's Physician's Order, there were no orders indicating to irrigate Resident 1's foley catheter. During a concurrent interview and record review on 8/18/2026 at 11:59 a.m. with RN 1, RN 1 stated on 8/13/2026, Resident 1 complained of pain and bladder distention. RN 1 stated LVN 1 told her he irrigated Resident 1's foley catheter 30 minutes before she arrived at around 12 p.m. RN 1 stated Resident 1 was still in pain after his foley catheter was irrigated so she helped in assisting RN 2 in inserting a new foley catheter. RN 1 stated upon reviewing Resident 1's medical records, RN 1 stated there was an order to change Resident 1's foley catheter but no orders to irrigate it. RN 1 stated before doing a procedure such as irrigation of a foley catheter you must check for the written orders. RN 1 stated if there are no orders, you must call the physician to get the order before irrigating the foley catheter. During an interview on 8/18/2026 at 12:30 p.m. with LVN 1, LVN 1 on 8/13/2026 at an unknown time, Resident 1 told him his foley catheter was not draining and he was having pain. LVN 1 stated he looked at Resident 1's foley catheter and noticed it was not draining any urine. LVN 1 stated he then irrigated the foley catheter with 50 cc syringe of normal saline. LVN 1 stated after irrigating Resident 1's foley catheter, Resident 1 continued to complain that his catheter was not draining urine, so LVN 1 notified RN 1. LVN 1 stated he did not check first to see if there were orders to irrigate Resident 1's foley catheter because he was too busy. LVN 1 stated it is important to obtain orders to irrigate a foley catheter because this is an invasive procedure and you can cause injury and possible infection. During an interview on 8/19/2026 at 2 p.m. with the Director of Nursing (DON), the DON stated nurses are not allowed to practice medicine, and before irrigating a foley catheter we must always make sure there is an order in place. During a review of the facility's policy and procedure (P&P) titled, Catheter Care, revised 10/2010, the P&P indicated it is the policy of this facility to ensure that the resident will receive indwelling catheter care and prevent if not minimize urinary tract infection. The P&P indicated to notify the RN Supervisor or Charge Nurse in the event of bleeding, if the catheter is pulled out or is dislodged, leaking or clogged, to notify the attending physician.

Based on interview, and record review, the facility failed to ensure two Certified Nursing Assistants (CNA 1 and CNA 2) did not shave the beard of one of five sampled residents (Resident 1), without Resident 1's Responsible Party's (RP) consent. This deficient practice resulted in Resident 1, who had his beard for many years, beard being completely removed without approval from Resident 1's RP. This deficient practice had the potential for Resident 1 and/or Resident 1's RP to feel disrespect and undignified. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnoses including dementia (a progressive state of decline in mental abilities) and Alzheimer's disease (a disease characterized by a progressive decline in mental abilities). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 7/24/2026, the MDS indicated Resident 1's cognition was moderately impaired, and he was dependent (helper does all of the effort) on facility staff to complete his activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During an interview on 7/30/2026 at 11:28 a.m., Resident 1's RP stated Resident 1's beard was shaved without her knowledge or consent. The RP stated Resident 1 had his beard for many years and she had not seen him without it. During an interview on 7/31/2026 at 11:05 a.m., the Director of Nursing (DON) stated the RP should have been notified prior to Resident 1's beard being shaved because Resident 1 did not have capacity to make decisions for himself. The DON stated CNA 1 and CNA 2 informed her that Resident 1 looked unkempt and dirty when he was admitted to the facility, and they felt he needed to be groomed. During a review of the facility's Policy and Procedure (P/P) titled, Resident's Preferences dated 1/2026, the P/P indicated staff will ask the resident and when appropriate, the resident representative about preferences upon admission prior to initiation of treatment/therapy and/or during initial interdisciplinary (IDT) meeting. Preferences may include bathing, grooming and clothing.

Based on observation, interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 1 did not prepare medication for two of two sampled residents (Resident 4 and 5) on one tray with intentions of administering them by giving the medications to the residents sequentially (doing things in a set order, one after the other). This deficient practice resulted in LVN 1 attempting to administer Resident 4 and Resident 5's medications literally together had the potential for Resident 4 and 5 to receive the incorrect medication.Findings: a. During a review of Resident 4's admission Record (Face Sheet), the Face Sheet indicated Resident 4 was admitted to the facility on [DATE]. Resident 4 had a diagnosis of osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 4's Minimum Data Set ([MDS] a resident assessment tool) dated 7/23/2026, the MDS indicated Resident 4's cognition was intact and he required substantial/maximal assistance (helper does more than half the effort) from facility staff to complete his activities daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 4's Physician's Order dated 3/16/2026, the Physician's Order indicated Resident 4 was to receive Hydrocodone-Acetaminophen (medication to treat moderate to severe pain) 10-325 milligrams ([mg] metric unit of measurement, used for medication dosage and/or amount) one tablet every 4 hours as needed for severe pain. b. During a review of Resident 5's admission Record (Face Sheet), the Face Sheet indicated Resident 5 was admitted to the facility on [DATE]. Resident 5 had a diagnosis of liver cancer. During a review of Resident 5's MDS dated [DATE], the MDS indicated Resident 5's cognition was intact and he required substantial/maximal assistance from facility staff to complete his ADLs. During a review of Resident 5's Physician's Order dated 7/29/2026, the Physician's Order indicated Resident 5 was to receive Oxycodone Hydrochloride (HCl) 5 mg to every eight hours for pain. During a medication administration observation on 7/30/2026 at 2:26 p.m., with LVN 1, LVN 1 was observed carrying two medication cups with one pill in each cup and two cups of water on one silver tray. LVN 1 proceeded to Resident 4 and 5's room (they were roommates). LVN 1 entered the resident's room and saw that Resident 5 was being transferred from her wheelchair to her bed and stated she would administer Resident 4's medication since Resident 5 was busy. LVN 1 proceeded to administer Resident 4's medication. Resident 5 was still busy being transferred to her bed, LVN 1 stated she would come back to administer the medication when Resident 5 was ready. During an interview on 7/30/2026 at 2:28 pm, LVN 1 stated she knew both residents (Residents 4 and 5) well and had cared for them for some time, so she saw no issue with preparing and administering their medications together. During an interview on 7/31/2026 at 1:28 p.m., the Director of Nursing (DON) stated medications should be prepared and given to just one resident at a time, because preparing medication for multiple residents simultaneously could result in administering the wrong medication to the wrong resident. During a review of the facility's undated Policy and Procedure (P/P) titled Medication Administration the (P/P) indicated medications are administered at the time they are prepared and are not pre-poured. Medications are administered without necessary interruptions.

Based on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse (LVN 1) stored Oxycodone (a Schedule 11 [a drug that has as high risk for abuse and severe physical or psychological dependence) used to treat moderate to severe pain and has a high risk for abuse and dependence) in a secured double locker drawer. This deficient practice had the potential to result in loss, theft, misuse or diversion (the illegal transfer, distribution, or use of a legally prescribed controlled substance for a purpose other than what the prescriber intended) of Resident 5's Oxycodone medication.Findings: During a review of Resident 5's admission Record, (Face Sheet), the Face Sheet indicated Resident 5 was admitted to the facility on [DATE]. Resident 5 had a diagnosis of liver cancer. During a review of Resident 5's Minimum Data Set ([MDS] a resident assessment tool) dated 7/17/2026, the MDS indicated Resident 5's cognition was intact and he required substantial/maximal assistance from facility staff to complete his ADLs. During a review of Resident 5's Physician's Order dated 7/29/2026, the Physician's Order indicated Resident 5 to receive Oxycodone hydrochloride (HCl) oral tablet 5 milligrams ([mg] metric unit of measurement, used for medication dosage and/or amount) every eight hours for pain. During an observation on 7/30/2026 at 2:26 p.m., LVN 1 was seen placing a medication cup with Resident 5's Oxycodone in a single-locked drawer of the medication cart. During an interview on 7/30/2026 at 2:28 p.m., LVN 1 stated Oxycodone should be stored in a double-locked narcotic drawer to prevent unauthorized access. During an interview on 7/31/2026 at 1:28 p.m., the Director of Nursing (DON) stated Scheduled II medications should be secured in a double locked drawer. During a review of the facility's Policy and Procedure (P/P) titled Controlled Drug Storage dated 1/2026, the P/P indicated Schedule II medications shall be kept under double lock drawer.

Based on observation, interview, and record review, the facility failed to ensure two of five sampled thermostats (an automatic device used to control and regulate temperature) were powered on and in working condition. This deficient practice resulted in the inability to regulate the facility's temperatures in certain areas of the facility and had the potential for residents' room temperatures to uncontrolled.Findings: During an interview on 7/30/2026 at 11:38 a.m., Resident 1's Responsible Party (RP) stated it was always hot in Resident 1's room and the facility provided a fan for him because there was no working air conditioning. During an observation on 7/30/2026 at 2:48 p.m., with the Maintenance Supervisor (MS), two thermostats were observed to be off; with black screen and no visible power to the thermostat. During an interview on 7/30/2026 at 2:50 p.m., and a subsequent interview on 7/31/2026 at 9:36 a.m., the MS stated the thermostats should be on and working so temperatures in the residents' rooms were controlled/regulated to prevent residents from being too hot or too cold. He was unsure how often the thermostats should be checked. During a review of the facility's Policy and Procedure (P/P) titled Thermostat and Indoor Temperature Control dated 1/2026, the P/P indicated the facility shall maintain comfortable and safe temperatures levels throughout all resident occupied areas.

Based on observation, interview, and record review, the facility failed to:1. Ensure medications were administered in a timely manner (within one hour before or one hour after scheduled time of administration) for 18 of 30 Station A residents on 4/21/2026 in Station A of the facility, as per facility's policy and procedure (P&P) titled, Medication Timing of Administration Policy, dated 2024.2. Ensure one of six sampled residents (Resident 128's) medications were administered in a timely manner (within one hour before or one hour after scheduled time of administration) on 4/21/2026 in Station A of the facility, as per facility's policy and procedure (P&P) titled, Medication Timing of Administration Policy, dated 2024.3. Ensure one of four inspected medication carts (Station A and C split Medication Cart 4) maintained accurate documentation of Resident 36's Lyrica ([generic name - pregabalin] a controlled medication [medications that the use and possession of are controlled by the federal government] used to treat fibromyalgia [pain in muscles and soft tissues] related pain, neuropathic (nerve related) pain and a subset of seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]) on accountability record or controlled medication count sheet/controlled drug record ([CDR] - a document indicating perpetual inventory and administration of controlled substances) after Lyrica was administered by Licensed Vocational Nurse (LVN) 7.These deficient practices failed to provide medications in a timely manner in accordance with physician's orders or professional standards of practice, failed to maintain accurate documentation of controlled medications, and had the potential to result in medication errors, unintended use and loss of controlled medications and adverse health consequences such as hypertension (HTN - high blood pressure), hyperglycemia (high blood glucose), inadequate pain management, seizures, stroke (loss of blood flow to a part of the brain) and hospitalization for Residents 36, 128, and 17 other facility residents. Findings:1. During the concurrent observation and interview on 4/21/2026 between 9:59 a.m. and 11:22 a.m., with LVN 2, LVN 2 prepared and administered 13 medications to Resident 128. LVN 2 stated he still needed to administer scheduled medications to 13 additional residents who were due at 9 a.m., and one resident whose medication was due at 10 a.m. LVN 2 explained that he had a two hour timeframe to administer medications to 30 residents. LVN 2 stated medications scheduled for 9 a.m. were considered late if administered after 10 a.m. He stated he should have requested assistance from another licensed nurse or a nurse supervisor.During the interview on 4/21/2026 at 12:00 p.m., with Registered Nurse Supervisor (RNS) 3, RNS 3 stated LVN 2 should have reached out for assistance when he was running late with medication administration at Station A Medication Cart 1. RNS 3 stated medications should be administered within one hour before or one hour after the scheduled administration time.During the interview on 4/21/2026 at 12:42 p.m., with the Director of Nursing (DON), the DON stated the LVN may have been nervous. The DON stated if the surveyor began observing LVN 2 at 9:59 a.m., LVN 2 should have completed the 9 a.m. medication administration by 10 a.m., as nurses are allowed one hour before and one hour after the scheduled administration time. The DON stated she would inform RNS 3 to call the physician and initiate a change of condition (COC) for the late administration of medications. The DON stated she could only print a report of late medication administrations after the LVN completed all medications for residents on Station A Medication Cart 1.During a review of Medication Admin Audit Report, dated 4/23/2026 and 4/21/2026, the reports indicated there were 18 residents at Station A Medication Cart 1 who received medications later than 10 a.m. on 4/21/2026.2. During a review of Resident 128's admission Record, the admission Record indicated, Resident 128 was originally admitted to facility on 2/9/2026 and readmitted on [DATE]. The admission Record indicated Resident 128 with diagnoses including but not limited to hemiplegia (total paralysis [loss of muscle function in part of the body] on one side of the body) and hemiparesis (partial muscular weakness on one side of the body) following cerebral infarction (stroke- loss of blood flow to a part of the brain) affecting left dominant side, gastrostomy ([g-tube] a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problem), seizures and cerebral infarction without residual deficits, long term (current) use of anti-thrombotic (medications that reduces formation of blood clots)/antiplatelets (medications that prevents blood cells from sticking together and forming a blood clot) and essential hypertension (high blood pressure).During a review of Resident 128's Minimum Data Set ([MDS], a resident assessment tool) dated 2/16/2026, the MDS indicated Resident 128 was rarely or never understood so there was no cognition (ability to think, understand, learn, and remember) score. The MDS indicated, Resident 128 was dependent on facility's staff for performing activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as eating, oral hygiene, toileting hygiene, showering, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene.During the concurrent observation and interview on 4/21/2026 between 9:59 a.m. and 11:22 a.m., LVN 2 prepared and administered 13 medications and Prostat (a protein supplement), all of which were scheduled to be administered by 10 a.m., to Resident 128 via g tubes. LVN 2 stated he did not have calcium carbonate carbonate (a medication used to relieve acid-reflux) 600 mg available to administer to Resident 128 during the medication pass. LVN 2 checked the resident's blood pressure using a manual blood pressure monitor and reported a reading of 132/76 millimeters of mercury (mmHg - a measurement of pressure) and heart rate was 84.a. One tablet of amlodipine (a medication used to treat HTN) 10 mg with instructions to hold for systolic blood pressure ([SBP] the pressure caused by heart while contracting) of less than 110 mmHg and pulse rate of less than 60.b. One drop of artificial tears eye drops (temporary relief for dry, irritated, or fatigued eyes) in both eyesc. One tablet of aspirin (a medication used to prevent blood clots) 81 mg chewabled. One tablet of vitamin D (a vitamin used to treat low level of vitamin D and to support immune function and muscle strength) 25 micrograms ([mcg] a unit of measurement for mass)e. 10 milliliters ([mL] a unit of measurement for volume) of docusate sodium (a medication used to treat constipation [problem with passing stool]) 50 mg/5 mLf. One-half (1/2) tablet of ezetimibe (a medication used to treat bad cholesterol) 10 mgg. 7.5 mL of ferrous sulfate (an iron supplement used to treat anemia and low level of iron) 220 mg/5 mLh. 30 mL of lactulose (a medication used to treat constipation and brain dysfunction) 10 grams ([gm] a unit of measurement for mass)/15 mLi. Five (5) mL of Keppra ([generic name - levetiracetam] a medication used to treat seizures) 100 mg/mLj. 15 mL of Elder Tonic (a supplement with vitamins B and minerals to support body functions)k. Five (5) mL of vitamin C (a vitamin used to improve immune function and treat low levels of vitamin C) 500 mg/5 mLl. 10 mL of Chlorhexidine (a disinfectant and antiseptic) 0.12% to be administered buccally (in the cheek) for oral carem. One tablet of losartan (a medication used to treat HTN) 50 mg with instructions to hold if SBP of less than 110LVN 2 was not able to swab and cleanse oral cavity with chlorhexidine rinse because Resident 128 did not open her mouth. LVN 2 stated he was supposed to dilute the Prostat with water before administering it via g-tube because the g-tube was clogging during medication administration. LVN 2 stated he needed to change the valve before resuming medication administration. LVN 2 completed administration of 13 medications and Prostat on 4/21/2026 at 11:22 a.m.During a review of Resident 128's Medication Admin Report, dated 4/21/2026, the Medication Admin Report indicated, Resident 128's lactulose solution, amlodipine, ferrous sulfate liquid, ezetimibe, cholecalciferol, artificial tears eye drops, losartan, docusate sodium liquid, aspirin, vitamin C liquid, levetiracetam oral solution and multivitamins liquid were administered on 4/21/2026 between 10:05 a.m. and 10:23 a.m. The Medication Admin Report indicated, the documented date and time for Resident 128's lactulose solution, amlodipine, ferrous sulfate liquid, ezetimibe, cholecalciferol, artificial tears eye drops, losartan, docusate sodium liquid, aspirin, vitamin C liquid, levetiracetam oral solution and multivitamins liquid on 4/21/2026 were at 11:27 a.m. During the interview on 4/21/2026 at 3:39 p.m., with LVN 2, LVN 2 stated Resident 128's medications were administered more than one hour late on 4/21/2026. LVN 2 stated according to facility policy, medications should be administered within one hour before or one hour after the scheduled time. LVN 2 stated administering medications late could reduce their effectiveness and place Resident 128 at risk for hypertension, elevated blood glucose, seizures, and potential hospitalization. He stated he usually completed the medication pass for 30 residents by 10:30 a.m. or 11:00 a.m., but was unsure why it took longer on 4/21/2026. LVN 2 stated administering medications to a g tube resident typically takes 15 to 20 minutes, and administering oral medications takes 10 to 15 minutes. Using an estimate of 15 minutes per resident, the total time needed would be 450 minutes (7.5 hours), which exceeds the required two hour window for a 9 a.m. medication schedule (8 a.m. to 10 a.m.). During the interview on 4/21/2026 at 3:39 p.m., LVN 2 stated he was supposed to dilute the Prostat and stir it well before administering it via g tube to prevent clogging. LVN 2 stated he had to replace the g tube's Lopez valve ( small, three way stopcock device commonly used with g tube) because the previous valve became clogged by the Prostat. LVN 2 stated the delay in medication administration and the clogging of the g tube could have caused discomfort for Resident 128. During the interview on 4/23/2026 at 4:38 p.m., with the Director of Nursing (DON), the DON stated she conducted an in service education for the facility nurses regarding late medication administration. The DON stated there was a risk for adverse effects when residents did not receive their medications on time.3. During a review of Resident 36's admission Record, the admission Record indicated Resident 36 was admitted to the facility on [DATE] with diagnoses that included but were not limited to other hereditary and idiopathic neuropathies (nerve pain) and other chronic pain.During a review of Resident 36's History and Physical (H&P) dated 1/21/2026, the H&P indicated Resident 36 had the capacity to understand and make decisions.During a review of Resident 36's MDS, dated [DATE], the MDS indicated Resident 36's cognition was intact. The MDS indicated Resident 36 needed setup or clean-up assistance from the facility staff for ADLs such as eating and oral hygiene, supervision assistance for upper body dressing and personal hygiene, and moderate assistance for toileting hygiene, showering, lower body dressing and putting on or taking off footwear.During a review of Resident 36's Order Summary Report, dated 4/23/2026, the Order Summary Report indicated but not limited to the following physician order: Lyrica oral capsule 75 mg (Pregabalin), give 75 mg by mouth two times a day for neuropathic pain (nerve pain), hold for lethargy (a state of severe drowsiness, sluggishness, and lack of mental or physical energy) or respiration rate (RR) less than 12, order date 3/3/2026, start date 3/3/2026.During the concurrent observation, interview, and record review on 4/23/2026 at 11:50 a.m. with LVN 7 at Station A C split Medication Cart 4, Resident 36's pregabalin 75 mg bubble packs for morning (a.m.) and evening (p.m.) doses, the facility's controlled medication count sheet (CDR), and the medication administration details in the electronic medical record (eMAR) were reviewed. The a.m., pregabalin bubble pack contained 21 capsules, while the CDR indicated 22 capsules remaining, with the last dose documented as administered on 4/22/2026 at 8:38 a.m. The eMAR showed the last dose of pregabalin 75 mg was documented as administered on 4/23/2026 at 8:39 a.m. The p.m., pregabalin bubble pack contained 21 capsules, while the CDR indicated 20 capsules remaining, with the last dose documented as administered on 4/23/2026 at 8:47 a.m. During the controlled medication count, when the discrepancy in the pregabalin count was identified, LVN 7 stated, I need to check blood sugars for my residents, you (addressing the surveyor) said it was going to be quick, my dear. Now it's taking longer for you to inspect medication cart. Can we do this after blood sugar checks.During an interview on 4/23/2026 at 1:17 p.m. with LVN 7, LVN 7 stated prior to administration of pregabalin, he was supposed to check the controlled medication book to see if the medication count was correct before taking pregabalin out of the bubble pack. LVN 7 stated he took out the pregabalin 75 mg from Resident 36's AM bubble pack but documented on the CDR for PM count sheet. LVN 7 stated he would chart or document when he was taking pregabalin out from medication bubble pack, then he would administer pregabalin, watch the resident take the medication and then he would document in the eMAR once the pregabalin was administered. LVN 7 stated it was important to maintain correct counts of controlled medications because of the associated high risk of diversion and abuse, sedation, allergic reactions and respiratory depression. LVN 7 stated there was a risk for pregabalin to be miscounted, could have led to a double dose for the resident and a medication error could occur. During the interview on 4/23/2026 at 4:58 p.m., with the Director of Nursing (DON), the DON stated for controlled medication administration, the licensed nurse should document the medication as yes in the eMAR but should not save the entry until the medication is fully administered. The DON stated the nurse should document the medication on the controlled medication count sheet as soon as it is removed from the medication card, and after administering the medication, the nurse should then save the eMAR entry as administered. The DON stated accurate documentation of controlled medications was essential to prevent misuse and drug diversion. She stated it would be important to reassess the resident for neuropathic pain or signs of exacerbation due to the pregabalin count discrepancy identified on the controlled drug record (CDR). During a review of the facility's P&P titled, Medication Timing of Administration Policy, dated 2024, the P&P indicated, 1. Standard Administration Time Frames. Routine medications shall be administered within a one-hour window before or after the scheduled time (e.g., 8:00 a.m., dose given between 7:00 a.m., and 9:00 a.m.). Critical medications shall be administered at the exact time ordered or within a more restrictive window as defined below. 2. Medications considered time-critical must be . within 60 minutes before or after the scheduled time, unless otherwise specified by the prescriber. Examples include: Insulin (rapid-acting), anticoagulants (e.g., warfarin, heparin), antibiotics with specific dosing intervals, anti-seizure medications, medications with short half-lives or requiring consistent blood levels. The P&P indicated, 5. Missed or Late Doses. If a medication is not administered within the allowable time frame: The nurse shall assess the situation.if necessary. The dose shall not be automatically .without an order, Documentation must include: Reason for delay or omission.actions taken.notifications made.During a review of the facility's P&P titled, Medication Administration, dated 2024, the P&P indicated, Medications shall be administered safely, accurately, and timely in accordance with physician orders, accepted standards of practice,.outcomes.During a review of the facility's P&P titled, Policy & Procedure: Documentation of Controlled Drugs/Medications, dated 2024, the P&P indicated, All controlled drugs/medications must be documented accurately, completely, and in a timely manner to ensure patient safety, regulatory compliance and prevention of diversion. Documentation must reflect a clear, auditable trail from receipt.disposal. The P&P indicated, 6.3 Administration Documentation. Document administration immediately after giving the medication in the Medication Administration Record (MAR/eMAR). Include: Date and time.signature/initials of administering staff. 6.4 Controlled Drug Register (CDR) Entries. Maintain a separate page.for each medication and strength. Record: running balance after each transaction. Patient details for administered doses. Staff signatures for all entries. Entries must be.(no erasing).

Based on observation, interview, and record review, the facility failed to ensure proper storage and labeling of medications in four of four inspected medication carts (Subacute Medication Cart 1, Station C Medication Cart 3, Station A Medication Cart 1 and Station A-C split Medication Cart 4 and one of two inspected medication rooms (Station A Medication Room Refrigerator) as per manufacturer specifications and facility's policy and procedure (P&P) titled, Medication Storage and Labeling, dated 2024, Medication Labeling, dated 2024, and Medication Storage Temperature Policy, dated 2024, by failing to:1. Ensure gabapentin (a medication used to treat nerve pain and seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]) oral solutions for Residents 131 and 64 were stored in the refrigerator, as per manufacturer requirements, affecting two of four inspected medication carts (Subacute Medication Cart 1 and Station A-C split Medication Cart 4).2. Ensure Resident 74's expired insulin lispro (a type of insulin [a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication] used to treat high blood glucose [simple sugar- the body's primary source of energy from food]) was removed from medication cart, and Lantus Solostar ([generic name - insulin glargine] a long-acting insulin used to treat high blood glucose) prefilled pen was labeled with an open date, according to manufacturer requirements, stored in Station C Medication Cart 3.3. Ensure Resident 30's expired Lantus Solostar prefilled pen was removed from Station C Medication Cart 3.4. Ensure Resident 139's morphine sulfate (a controlled substance or also known as an opioid [medications that the use and possession of are controlled by the federal government] used to treat severe pain) oral solution was stored at room temperature, as per manufacturer requirements, affecting Station A Medication Cart 1 and Station A Medication Room Refrigerator.These deficient practices had the potential to result in Residents 30, 64, 74, 131 and 139 receiving medications that had become expired, ineffective or toxic due to improper storage and labeling possibly leading to adverse effects such as hyperglycemia (high blood glucose), inadequate pain management and hospitalization. Findings:1a. During a review of Resident 131's admission Record, dated 4/22/2026, the admission Record indicated Resident 131 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 131 with diagnoses including but not limited to contracture (condition of shortening or hardening leading to restricted joint mobility) of muscle, multiple sites and generalized muscle weakness.During a review of Resident 131's History and Physical (H&P) dated 8/8/2025, the H&P indicated Resident 131 did not have the capacity to understand and make decisions.During a review of Resident 131's Minimum Data Set ([MDS], a resident assessment tool) dated 3/6/2026, the MDS indicated Resident 131 was dependent on facility's staff for performing activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as oral hygiene, toileting hygiene, showering, upper body dressing, putting on/taking off footwear and personal hygiene, and ADLs of eating and lower body dressing were not attempted due to medical condition or safety concerns.During a review of Resident 131's Order Summary Report (a document containing a summary of all active physician orders) dated 4/22/2026, the Order Summary Report indicated but not limited to the following physician order: Gabapentin oral solution, give 100 milligrams ([mg] - metric unit of measurement, used for medication dosage and/or amount) via gastrostomy tube ([g-tube] a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problem) every eight hours for neuropathic condition resulting in burning, stabbing, or electric shock-like sensations) pain and contractures, order date 3/25/2026, start date 3/25/2026.During a concurrent observation and interview on 4/21/2026 at 3:20 p.m. with Licensed Vocational Nurse (LVN) 5 of Subacute Medication Cart 1, Resident 131's gabapentin oral solution 250 mg per 5 milliliters ([mL] a unit of measurement for volume) was stored in the medication cart instead of medication refrigerator, as required by manufacturer's specifications:a. A one-fourth (1/4th) of volume of gabapentin 250 mg/5 mL remaining in bottle for Resident 131, with an open date of 3/26/2026 and pharmacy label instructions to refrigerate.According to the manufacturer's product labeling, gabapentin oral solution should be stored in refrigerator at 36-degree Fahrenheit [( F) is a unit of temperature] to 46 F or 2 Celsius [( C) is a unit of temperature] to 8 C.LVN 5 stated he took the gabapentin out of the refrigerator around 1 p.m. for a 2 p.m. dose and was going to return to the refrigerator. LVN 5 stated there was a risk that if the gabapentin was not properly stored, it would be less effective to treat nerve pain or seizures for Resident 131.1b. During a review of Resident 64's admission Record, dated 4/23/2026, the admission Record indicated Resident 64 was admitted to the facility on [DATE] with diagnoses including but not limited to other chronic pain and polyneuropathy (nerve pain).During a review of Resident 64's MDS dated [DATE], the MDS indicated Resident 64's cognition was severely impaired. The MDS indicated that Resident 64 was dependent on facility's staff for performing ADLs such as eating, oral hygiene, toileting hygiene, showering, upper body dressing, lower body dressing and personal hygiene, and putting on/taking off footwear was not attempted due to medical condition or safety concerns.During a review of Resident 64's Order Summary Report, dated 4/5/2026, the Order Summary Report indicated but not limited to the following physician order: Gabapentin oral solution 250 mg/5 mL, give 100 mg by mouth two times a day for neuropathic pain, give 2 mL = 100 mg, order date 9/22/2025, start date 9/22/2025.During a concurrent observation and interview on 4/23/2026 at 11:50 a.m. with LVN 7 of Station A-C split Medication Cart 4, Resident 64's gabapentin oral solution 250 mg/5 mL was stored in medication cart instead of medication refrigerator, as required by manufacturer's specifications:a. Less than 1/4th volume of gabapentin 250 mg/5 mL remaining in the bottle for Resident 64 with an open date of 3/28/2026 and pharmacy label instructions to refrigerate.According to the manufacturer's product labeling, gabapentin oral solution should be stored in refrigerator at 36 F to 46 F or 2 C to 8 C.LVN 7 stated he could not remember how long it had been since he (LVN 7) removed gabapentin oral solution from the refrigerator and stored in the medication cart. LVN 7 stated gabapentin oral solution should have been stored in the refrigerator. LVN 7 stated gabapentin had been in the medication cart possibly for three and half hours since it was removed from the refrigerator. LVN 7 due to medication's improper storage, there could be instability, reduced efficacy or could become ineffective. LVN 7 stated gabapentin oral solution might not work for Resident 64 who was using it to treat neuropathic pain and thought the side effects could be drowsiness and possible respiratory depression.2. During a review of Resident 74's admission Record, dated 4/22/2026, the admission Record indicated Resident 74 was admitted to the facility on [DATE] with diagnoses including but not limited to Type 2 Diabetes Mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing) with hyperglycemia (high blood glucose).During a review of Resident 74's MDS dated [DATE], the MDS indicated Resident 74's cognition was intact. The MDS indicated Resident 74 needed supervision assistance from the facility staff for ADLs such as eating, moderate assistance for oral hygiene, upper body dressing and personal hygiene, maximal assistance for showering and lower body dressing, and dependent for toileting hygiene and putting on/taking off footwear.During a review of Resident 74's Order Summary Report, dated 4/22/2026, the Order Summary Report indicated but not limited to following physician orders: Insulin Glargine subcutaneous (under the skin) solution 100 units/mL, inject 20 units subcutaneously at bedtime for DM, hold for blood sugar (BS) less than (<) 100. If BS <70 mg/dL, may give apple juice if BS <70 if able to swallow. Repeat BS check in 15 minutes, and notify MD. Rotate the sites, order date 3/1/2026, start date 3/1/2026. Insulin Lispro injection solution 100 units/mL, inject as per sliding scale: if 70-150 = 0; 151-200 = 2; 201-250 = 4; 251-300 = 6; 301-350 = 8; 351-400 = 10; great than (>) 400, give 12 units and call MD, subcutaneously before meals and at bedtime for DM, may give apple juice if BS <70 if able to swallow. Repeat BS check in 15 minutes and notify MD. Rotate sites, order date 1/28/2026, start date 1/29/2026.During a concurrent observation and interview on 4/22/2026 at 1:14 p.m. with LVN 1 of Station C Medication Cart 3, the following insulins were either found expired and not discarded and/or not labeled, as required by manufacturer's specifications:a. One opened prefilled pen of insulin lispro 100 units/mL for Resident 74 with an open date of 3/22/2026 and an expiration date of 4/20/2026.According to the manufacturer's product labeling, once opened / in-use or once stored at room temperature, below 86 F (30 C), insulin lispro pen must be used within 28 days or be discarded.b. One prefilled pen of Lantus Solostar 100 units/mL for Resident 74 with no open date.According to the manufacturer's product labeling, unopened / not in-use pen if stored at room temperature (a below 86 F [30 C]) and opened / in-use pen must be used within 28 days.LVN 1 stated the expired insulin for Resident 74 should have been removed on 4/20/26. LVN 1 stated the insulin might not be safe and effective for the resident. LVN 1 stated the insulin might not treat high blood glucose levels and Resident 74 could have an adverse reaction to the medication.During a review of Resident 74's Medication Administration Record (MAR), dated 4/20/2026 to 4/22/2026, the MAR indicated Resident 74 potentially received the expired insulin lispro six times.3. During a review of Resident 30's admission Record, dated 4/22/2026, the admission Record indicated Resident 30 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including but not limited to Type 2 Diabetes Mellitus without complications.During a review of Resident 30's MDS dated [DATE], the MDS indicated Resident 30's cognition was moderately impaired. The MDS indicated Resident 30 needed moderate assistance from the facility staff for ADLs such as eating, maximal assistance for oral hygiene, upper body dressing, lower body dressing and personal hygiene, and dependent for toileting hygiene, showering and putting on/taking off footwear.During a review of Resident 30's Order Summary Report, dated 4/22/2026, the Order Summary Report indicated the following physician order: Insulin Glargine subcutaneous solution 100 units/mL, inject five (5) units subcutaneously one time a day for DM. Finger stick blood sugar (FSBS) every morning. Hold if FSBS <100 mg/dL. May give apple juice if BS <70 if able to swallow. Repeat blood sugar (BS) check in 15 min and notify MD. Rotate sites, order date 11/14/2025, start date 11/15/2025.During a concurrent observation and interview on 4/22/2026 at 1:14 p.m. with LVN 1 of Station C Medication Cart 3, the following insulin expired and was not discarded as required by manufacturer's specifications:a. One prefilled pen of Lantus Solostar 100 units/mL for Resident 30 with an open date of 3/22/2026 and an expiration date of 4/20/2026.According to the manufacturer's product labeling, unopened / not in-use pen if stored at room temperature (a below 86 F [30 C]) and opened / in-use pen must be used within 28 days.LVN 1 stated the expired insulin for Resident 30 should have been removed on 4/20/26. LVN 1 stated the insulin might not be safe and effective for the resident. LVN 1 stated the insulin might not treat high blood glucose levels and Resident 30 could have an adverse reaction to the medication.During a review of Resident 30's MAR, dated 4/20/2026 to 4/22/2026, the MAR indicated Resident 30 potentially received the expired Lantus Solostar (generic name - insulin glargine) two times.4. During a concurrent inspection and interview on 4/22/2026 at 3:46 p.m. with LVN 6 of Station A Medication Cart 1 and Station A Medication Room Refrigerator, Resident 139's unopened or sealed bottle of morphine sulfate 100 mg/5 mL oral solution was found in Station A Medication Room Refrigerator, which was not in accordance with manufacturer's specifications.According to the manufacturer's product labeling, morphine sulfate oral solution should be stored at controlled room temperature, 15 C to 30 C (59 F to 86 F).LVN 6 stated, Resident 139's morphine sulfate oral solution was supposed to be stored at room temperature but was found in the refrigerator, which was against the manufacturer's specifications and requirements, even the package indicated to store at room temperature. LVN 6 stated the medication would not be safe or effective to administer to resident.During an interview on 4/23/2026 at 5:11 p.m. with the Director of Nursing (DON), the DON stated there was as risk of affecting gabapentin oral solution's integrity, stability and it could become less potent. The DON stated there was a risk that residents could possibly not be managed well with neuropathic pain and residents could continue to be in pain, which would lead to less participation in activities and would also negatively affect their mood.During an interview on 4/23/2026 at 5:11 p.m. with the DON, the DON stated the insulins should be discarded 28 days after their open date. The DON stated there was a risk that insulins that expired on 4/20/2026 would not be effective if administered to residents and could increase the risk for hyperglycemia and hospitalization.During an interview on 4/23/2026 at 5:16 p.m. with the DON, the DON stated the facility nurse should have verified with the pharmacy if they did not know how to store morphine sulfate oral solution. The DON stated the pharmacy informed her (DON) that morphine could become too thick and might not be a comfortable consistency to administer to the resident when it was stored in refrigerator instead of at room temperature.During a review of the facility's P&P titled, Medication Storage Temperature Policy, dated 2024, the P&P indicated, To ensure all medications are stored under proper temperature conditions to maintain safety, stability, and effectiveness in compliance with regulatory requirements. The P&P indicated, Room Temperature Requirements. Medications labeled for controlled room temperature shall be stored between 68 F-77 F (20 C-25 C). Manufacturer's labeling instructions shall always take precedence over standard ranges. 2. Refrigerator Temperature Requirements. Medications requiring refrigeration shall be stored between 36 F-46 F (2 C-8 C).During a review of the facility's P&P titled, Medication Storage and Labeling, dated 2024, the P&P indicated, All medications shall be.with physician orders, manufacturer instructions and regulatory requirements. Medications must be maintained to ensure integrity, safety.personnel. The P&P indicated, This policy means that medications must be: Properly labeled.Stored under appropriate conditions.Protected from contamination.unauthorized access. The P&P indicated, Staff are expected to: Check for: Expired medications.Ensure multi-dose containers are dated when opened (if applicable). The P&P indicated, To implement this policy.remove and properly dispose of: Expired medications, discontinued medications.During a review of the facility's P&P titled, Medication Labeling, dated 2024, the P&P indicated, Insulin. Multi-dose vials or pens must be dated when opened, Discard per manufacturer guidelines.

Based on observation, interview, and record review, the facility failed to follow and observe infection control measures for five of 30 sampled residents. The facility failed to:a. Ensure padded side rails that were wrapped with porous (having minute spaces or holes through which liquid or air may pass) foams were disinfected properly for Resident 4 and Resident 37. b. Ensure Resident 39's peripheral intravenous catheter (PIV- small flexible tube inserted into a peripheral vein-usually in the hand or arm to deliver fluids or medications) was discontinued when it was no longer needed and intravenous antibiotic (medication to treat an infection is delivered directly into the bloodstream through a vein) was completed. c. Ensure Certified Nursing Assistant (CNA) 7 practiced hand hygiene before entering Resident 148's room and before donning a pair of gloves. d. Ensure Resident 44's urinary catheter drainage bag was not placed on the floor.These failures had the potential to increase the risk of cross-contamination (the transfer of bacteria, viruses, microorganisms or other harmful substances from one surface to another through improper or unsanitary equipment, procedures, or products) and spreading infection among the residents, staff and visitors.Findings: a. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE], and readmitted on [DATE]. The admission Record indicated Resident 4 with diagnoses including chronic respiratory failure (any condition that affects breathing function and result in lungs not functioning properly), dependence on respirator (ventilator- a machine for artificial breathing), and atrial fibrillation (irregular heart rate that can cause poor blood flow). During a review of Resident 4's Minimum Data Set (MDS- a resident assessment tool), dated 2/9/2026, the MDS indicated Resident 4's cognitive (ability to think, understand, learn, and remember) was intact. The MDS indicated Resident 4 was dependent on staff with oral hygiene, toileting hygiene, showering, and personal hygiene. During a review of Resident 37's admission Record, the admission Record indicated Resident 37 was admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 37 with diagnoses including chronic respiratory failure (any condition that affects breathing function and result in lungs not functioning properly), encephalopathy (any damage or disease that affects the brain), and sepsis (life-threatening blood infection). During a review of Resident 37's History and Physical (H&P), dated 1/3/2026, the H&P indicated, Resident 37 did not have the ability to understand and make decisions. During a review of Resident 37's Minimum Data Set (MDS- a resident assessment tool), dated 1/26/2026, the MDS indicated Resident 37's cognitive (ability to think, understand, learn, and remember) skills for daily decision making were severely impaired. The MDS indicated Resident 37 was dependent (helper does all the effort, or the assistance of 2 or more helpers is required for the resident to complete the activity) on staff with oral hygiene, toileting hygiene, showering, personal hygiene, and rolling left and right. During an observation on 4/21/2026 at 10:06 a.m. in Resident 4's room, the resident's side rails were observed padded with foam and secured with electrical tape (a pressure-sensitive and non-conductive tape). During an observation on 4/21/2026 at 10:21 a.m. in Resident 37's room, the resident's side rails were observed padded with foam and secured with electrical tape. During an interview on 4/22/2026 at 11:32 a.m. with Housekeeping Staff (HKS) 1, HKS 1 stated she cleans the side rails wrapped with porous foams using disinfectants identified as 730 solution and Super Sany-Cloth. HKS 1 stated she cleaned all equipment, including the foam-wrapped side rails, using the disinfectants. During a concurrent interview and record review on 4/23/2026 at 11:15 a.m. with the Infection Preventionist Nurse ( IPN), manufacturer's guidelines for Super Sani-Cloth and 730 HP disinfect Cleaner, both undated, were reviewed. The IPN stated both products designed for nonporous surfaces. The IPN stated using the disinfectants on the porous foam was not appropriate because they were porous and could cause the surface not to be cleaned properly and break down the foam. IPN stated, this practice would place vulnerable residents including Resident 4 and 37 at risk for infection. During a review of the facility 's policy and procedure (P&P) titled, Cleaning and Disinfection of Environmental Surfaces, dated 2024, the P&P indicated, staff should ensure a clean, safe, and sanitary environment through standardized housekeeping practices that reduce the risk of infection transmission, for porous materials (foam or exposed surfaces) staff should: 1.Clean per manufacturer instructions for use (IFU) 2.Do not rely on disinfectant wipes for disinfection During a review of the manufacturer's guideline titled, 730 HP Disinfectant Cleaner, undated, the guideline indicated the cleaner is a one-step hospital-use germicidal disinfectant cleaner and deodorant designed for non-porous surfaces. During a review of the manufacturer's guideline titled, Super Sani-Cloth, undated, the guideline indicated the wipe is designed to be compatible with hard non-porous surfaces. b. During a review of Resident 39's admission Record, the admission Record indicated Resident 39 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including pneumonia (infection/inflammation in the lungs), urinary tract infection (UTI- an infection in the bladder/urinary tract) and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 39's Minimum Data Set (MDS- a resident assessment tool) dated 3/10/2026, the MDS indicated Resident 39 had an intact cognition (ability to think, understand, learn, and remember) and required substantial/ maximal assistance (helper does more than half the effort) with bed mobility, transfer to and from a bed to a chair. During a review of Resident 39's Order Summary Report dated 4/9/2026 indicated an order of Ertapenem Sodium (antibiotic- medication to treat infection) 500 milligrams (mgs. - unit of measurement) intravenously (through the vein) one time a day for UTI until 4/16/2027 11:59 p.m. for 7 days. During a review of Resident 39's Order Summary Report dated 4/10/2026 at 9:06 a.m. indicated an order to extend peripheral line (PIV) more than 3 days and one time only until 4/16/2026. During a review of Resident 39's Medication Administration Record (MAR) for the month of April 2026, the MAR indicated Resident 39 received Ertapenem from 4/9/2026, 4/10/2026, 4/11/2026, 4/12/2026, 4/13/2026, 4/14/2026, 4/15/2026 and 4/16/2026. During a concurrent observation and interview on 4/21/2026 at 10:42 a.m. in Resident 39's room, Resident 39 was sitting in her wheelchair. Observed a peripheral catheter on her right hand labeled with a date of 4/9/2026 and initial of a staff. Resident 39 stated she was not receiving any medication or fluids that will need the use of PIV. Resident 39 stated she did not know why she still has the PIV catheter on her right hand. During a subsequent observation and interview on 4/22/2026 at 4:33 p.m. with Resident 39, Resident 39 stated a staff removed the PIV this morning. Observed a small area of redness on the area of the right hand where the PIV was inserted. During a concurrent interview and record review on 4/23/2026 at 11:57 a.m. with Registered Nurse Supervisor (RNS) 3, Resident 39's MAR and Order Summary Report were reviewed. RNS 3 stated Resident 39 's last dose of Ertapenem was 4/16/2026. RNS 3 stated the facility should discontinue the PIV after last dose of antibiotic or intravenous fluids (IVF-sterile liquids injected directly into a vein to treat dehydration or deliver medications). RNS 3 stated she forgot to remove the PIV and it should have been removed on 4/16/2026 after the last dose of Ertapenem. RNS 3 stated not removing PIV when it is no longer necessary can put the resident at risk for infection on the PIV site (area). During an interview on 4/24/2026 at 3:15 p.m. with the Director of Nursing (DON), the DON stated peripheral IV catheter should be removed if it is no longer needed by the resident because Resident 39 can develop infection on the PIV site or at risk for developing phlebitis (inflammation of a vein near the surface of the skin). During a review of facility's policy and procedure (P&P) titled, Peripheral IV Line Care and Removal, dated 2024, the P&P indicated all licensed nursing staff will provide care, maintenance, and removal of peripheral IV lines in accordance with the physician orders with the goal of minimizing complications such as infection, infiltration, and phlebitis. c. During a review of Resident 148's admission Record, the admission Record indicated Resident 148 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including nontraumatic subdural hemorrhage( spontaneous, slow bleeding under the skull that creates a bruise without a fall or hit), gastrostomy(a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems),unspecified dementia(a progressive state of decline in mental abilities), and hyperlipidemia( high level of fats in the blood). During a review of Resident 148's History and Physical (H&P) dated 1/6/2026, the H&P indicated Resident 148 did not have decision making capacity. During a review of Resident 148's MDS dated [DATE], the MDS indicated the resident was dependent (helper does all the effort to complete the activity) on staff with oral hygiene, bathing, toileting hygiene, dressing, and personal hygiene. During a concurrent observation and interview on 4/21/2026 at 9:30 a.m. in Resident 148's room, Certified Nursing Assistant (CNA) 7 entered Resident 148's room then donned (put on) a pair of gloves without practicing hand hygiene. CNA 7 stated he forgot to practice hand hygiene before putting on a pair of gloves. CNA 7 stated practicing hand hygiene before entering a resident's room is a way to keep his hands clean. During an interview on 4/24/2026 at 11:18 a.m. with RNS 4, RNS 4 stated hand hygiene should be performed before entering a resident's room and before putting on a pair of gloves. RNS 4 stated hand hygiene is a standard practice for infection control and can prevent spread of infection. During an interview on 4/24/2026 at 12:56 p.m. with Infection Preventionist Nurse (IPN), IPN stated hand hygiene should be practiced before donning a pair of gloves to prevent spread of infection. During an interview on 4/24/2026 at 3:15 p.m. with the Director of Nursing (DON), the DON stated staff should practice hand hygiene before and after going to a resident's room. The DON agreed using gloves is not a replacement for hand hygiene. The DON stated staff not practicing hand hygiene can spread infection among the residents and staff. During a review of facility's policy and procedure (P&P) titled, Handwashing/ Hand Hygiene, the P&P indicated the use of gloves does not replace handwashing or hand hygiene and staff will perform hand hygiene before applying non-sterile gloves. The P&P indicated hand hygiene is considered the primary means to prevent spread of infection in the facility. d.During a review of Resident 44's admission Record, the admission Record indicated Resident 44 was admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 44 with diagnoses including end stage renal disease (ESRD – permanent kidney function loss)congestive heart failure ( CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), dependence on renal dialysis (a treatment to cleanse the blood of waste and extra fluids artificially through a machine when the kidneys have failed) and diabetes mellitus type 2 (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 44's Care Plan titled Suprapubic Catheter (a thin, flexible tube inserted through a small incision in the lower abdomen into the bladder to drain urine) Indwelling foley catheter with risk of urinary tract infection (UTI -infection in the bladder/urinary tract).dated 7/24/2025, the Care Plan interventions indicated for leg anchor ( device, that holds the catheter tubing firmly to your leg). During a review of Resident 44's Care Plan titled Risk for infection and backflow related to improper positioning of urinary bag due to resident's noncompliance, dated 11/3/2025, the Care plan goal indicated resident will maintain proper urinary drainage bag placement to prevent infection or backflow The Care Plan interventions indicated to document education resident's response and compliance or refusal. During a review of Resident 44's History and Physical (H&P) dated 3/1/2026, the H&P indicated, Resident 44 had the capacity to consent, however with mild cognitive (ability to think, understand, learn, and remember) impairment. During a concurrent observation and interview on 4/22/2026 at 7:50 a.m. with Certified Nurse Assistant (CNA) 8, Resident 44's suprapubic catheter drainage bag was observed on the floor. CNA 8 acknowledged that Resident 44's drainage bag was on the floor and should be secured on the bed frame. CNA 8 stated that all of the nursing staff are responsible for ensuring that infection control was maintained for resident's with indwelling devices such as a suprapubic catheter. CNA 8 stated that Resident 44 could get an infection, and have to be hospitalized if proper infection control practices were not followed. During a concurrent observation and interview on 4/22/2026 at 7:55 a.m. with License Vocational Nurse (LVN) 4, Resident 44's suprapubic drainage bag observed on the floor. LVN 4 acknowledged that the resident's drainage bag was on the floor. LVN 4 stated that she was responsible for ensuring that the resident's drainage bags were covered, and positioned on the bed frame to prevent any infections and protect the resident's privacy. LVN 4 stated that by the drainage bag being on the floor it increases the risk of contamination and infection, including urinary tract infection, and risk of cross-contamination (transfer of harmful germs) from environmental pathogens (germs that live, grow, and survive in the natural environment). During an interview on 4/24/2026 at 3:00 pm with the Director of Nursing (DON), the DON stated the drainage bag should always be kept off the floor and below the bladder to prevent backflow and reduce the risk of infection. The DON stated that the drainage bag should be secured to the bed frame. The DON stated that if there is an order for a leg anchor the catheter tubing should be secured to the resident's leg to prevent pulling, trauma, and movement of the catheter. The DON stated that this also helps to maintain proper positioning of the drainage bag. The DON stated that the drainage bag lying directly on the floor and the catheter not secured with a leg anchor, was not acceptable and was not consistent with the facility's standard of care. The DON stated that this could increase the risk of infection, including urinary tract infections, and could also lead to catheter dislodgement or trauma due to lack of securement. During a review of the facility's policy and procedure (P&P) titled, Suprapubic Catheter Management dated 2024, the P&P indicated The facility ensures safe, sterile, and effective management of suprapubic catheters (SPCs) to reduce the risk of infection, maintain urinary drainage, and promote patient comfort and dignity.

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 10's) Seroquel ([generic name - quetiapine], a medication used to treat schizophrenia (a mental illness that is characterized by disturbances in thought) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) was prescribed and administered in accordance with an appropriate clinical indication and diagnosis.This deficient practice had the potential to expose Resident 10 to unnecessary medication and to significant adverse consequences (unwanted, uncomfortable, or dangerous drug effects) resulting from the prolonged use of Seroquel for mental health condition. Such consequences could lead to impairment or a decline in the resident's mental, physical, functional, or psychosocial status.Findings:During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 10 with diagnoses including but not limited to unspecified dementia (a progressive state of decline in mental abilities), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, generalized anxiety disorder (a condition where someone worries constantly about everyday issues and situations), recurrent major depressive disorder (sadness, low mood).During a review of Resident 10's Psychiatry (branch of medicine focused on diagnosis, treatment and prevention of mental disorders) note, dated 7/1/2025, the Note indicated, Psych consult requested for med/behavior review.On trazodone (a medication used to treat depression) 50 mg.every hour of sleep ( hs-daily at bedtime) for insomnia (difficulty falling and staying asleep). No other psych meds. Following admission.patient was agitated and restless.No other major behavioral issues reported. Sleep good. Dx (diagnoses): Alcohol (ETOH) use disorder, ETOH induced sleep disorder, unspecified insomnia disorder.During a review of Resident 10's Medication Regiment Review (MRR - a monthly evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication) dated 1/29/2026, the review indicated the following note from the consultant pharmacist, Resident 10: MRR date 1/22/2026: Clarify for diagnosis and appropriate behavior. Seroquel oral tablet 25 mg (Quetiapine fumarate), give 25 mg by mouth two times a day for agitation. There was no follow-through notes documented.During a review of Resident 10's MRR dated 2/27/2026, the review indicated the following note from the consultant pharmacist, Resident 10: Seroquel oral tablet 50 mg (Quetiapine fumarate) give one tablet by mouth two times a day for agitation manifested by (m/b) tries to jump out of the bed, *Note to follow up (f/u) with doctor to clarify underlying diagnosis. Please f/u to evaluate monitoring of all indicated behavior(s) and potential side-effect(s) for Quetiapine on the Medication Administration Record. The follow-through indicated, Dementia with behavioral disturbances.During a review of Resident 10's Physician's Note titled, Nursing Home Visit dated 3/23/2026, electronically signed by physician at 4/23/2026 at 10:08 p.m., the document indicated, Subjective: follow up visit in person. Meds reviewed. Staff consulted. Since last visit, Seroquel and prn Ativan ([generic name: lorazepam] a medication used to treat anxiety) added. Patient is still restless manifested by wheeling around facility but less agitated since Seroquel added. Verbalizations are repetitive. No current difficulty with sleep. No side effects reported. Assessment: Improved from last visit. Diagnosis: ETOH (alcohol) use disorder, Unspecified sleep disorder, Unspecified mood disorder. Plan: Change indication for Seroquel to Mood Instability m/b agitated outbursts.During a review of Resident 10's Minimum Data Set (MDS resident assessment tool), dated 3/24/2026, the MDS did not indicate a cognition (ability to think, understand, learn, and remember) score. The MDS indicated Resident 10 needed maximal assistance from facility for Activities of Daily Living (ADLs) such as eating, oral hygiene, upper body dressing and personal hygiene, and was dependent on facility staff for toileting hygiene, showering, lower body dressing and putting on/taking off footwear. The MDS indicated diagnoses for Resident 10 were not-Alzheimer's, dementia, anxiety disorder and depression.During a review of Resident 10's MRR dated 3/29/2026, the review indicated the following note from the consultant pharmacist: Resident 10: Seroquel oral tablet 50 mg (Quetiapine fumarate) give one tablet by mouth two times a day for mood instability m/b agitated outburst, Note to follow up (f/u) with doctor to clarify underlying diagnosis. There were no follow-through notes documented.During a review of Resident 10's Order Summary Report , dated 4/5/2026, the Order Summary Report indicated but not limited to the following physician orders: Seroquel oral tablet 50 milligram ([mg] metric unit of measurement, used for medication dosage and/or amount), give one tablet by mouth two times a day for mood instability manifested by (m/b) agitated outburst, non-pharmacological intervention (NPI): 1 = Re-assurance, 2 = Redirection, 3 = Relaxation technique, 4 = calming environment, 5 = gentle massage, 6 = Meaningful activities, 7 = Other, order date 3/23/2026, start date 3/24/2026.The facility did not provide Resident 10's active orders as of 4/22/2026 and/or 4/23/2026 as per request. During a review of Resident 10's MAR dated 4/1/2026 to 4/22/2026, the MAR indicated Seroquel oral tablet 50 mg was administered 44 times to Resident 10.During a review of Resident 10's MAR dated 3/1/2026 to 3/31/2026, the MAR indicated Seroquel oral tablet 50 mg was administered 48 times to Resident 10.During a review of Resident 10's MAR dated 2/1/2026 to 2/28/2026, the MAR indicated Seroquel oral tablet 25 mg was administered 51 times to Resident 10.During a concurrent interview and record review on 4/23/2026 at 3:29 p.m. with Licensed Vocational Nurse (LVN) 6, Resident 10's electronic medical records and physical chart notes were reviewed. LVN 6 stated Resident 10 was on Seroquel for angry outbursts related to agitation and episodes of wandering (walk around without any clear purpose or direction) at times and screaming. LVN 6 stated Resident 10 should have been evaluated by a psychiatrist for his illnesses. LVN 6 stated she could not find any psychiatrist notes.During the interview on 4/23/2026 at 5:19 p.m., with the Director of Nursing (DON), the DON stated after the consultant pharmacist submitted MRR recommendations, the DON reviewed them as soon as the following day and attempted to address them before the next review date. The DON stated difficulty reviewing the volume of material, noting there were 600 pages and not enough time to review them all. The DON stated residents were routinely seen by a psychiatrist at least quarterly. The DON stated the psychiatric consult had not been uploaded into the facility's electronic health record system, but confirmed that a consult existed and would need to be located. When asked about Resident 10, the DON stated they had requested the psychiatrist to see the resident. The DON added that if a resident's medication list did not contain the correct diagnosis, they would ask the physician to reevaluate.During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Management Policy, dated 2024, the P&P indicated, To ensure the safe, appropriate, and clinically justified use of psychotropic medications while protecting residents from unnecessary drugs, adverse effects, and chemical restraint. Psychotropic medications shall be used only when clinically indicated, prescribed in accordance with accepted standards of practice, and monitored.safety. The P&P indicated, General Requirements: Each psychotropic medication must have: a documented clinical indication/diagnosis .Ongoing evaluation of effectiveness. Medications shall not be used for staff convenience or discipline.During a review of the facility's P&P titled, Medication Regimen Review (MRR) Policy, dated 2024, the P&P indicated, Scope of Review: the MRR shall include, but is not limited to: Medication appropriateness (indication, dose, duration). The P&P indicated, Physician Response: The attending physician must: Review and respond to reported irregularities; Indicate agreement, disagreement or alternative action; Responses must be documented in the medical record.Cross reference F756

Based on observation, interview, and record review, the facility failed to accurately assess the oral and dental status on the Minimum Data Set (MDS) for one of five sampled residents (Resident 26).This failure had the potential to result in Resident 26 not receiving necessary oral care and treatment.Findings:During a review of Resident 26's admission Record, the admission Record indicated Resident 26 was admitted to the facility on [DATE] to with diagnoses including diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), schizoaffective disorder, (a mental illness that can affect thoughts, mood, and behavior) , depression( serious mood disorder characterized by persistent sadness, loss of interest and low energy) and hypertension(HTN-high blood pressure).During a review of Resident 26's Dietary assessment dated [DATE], the Dietary Assessment indicated Resident 26 was edentulous (a person has lost all or some of their natural teeth) and had no difficulty in chewing and swallowing food.During a review of Resident 26's Minimum Data Set (MDS- a resident assessment tool) dated 3/7/2026, the MDS indicated Resident 26 had moderately impaired cognitive (ability to think, understand, learn, and remember) skills. The MDS indicated Resident 26 required setup or clean-up assistance with oral hygiene, dressing and personal hygiene. The MDS indicated Resident 26 had natural teeth.During a review of Resident 26's Care Plan titled, Dental Care, initiated on 4/23/2026, the Care Plan indicated Resident 26 is edentulous and at risk for inadequate nutrition and alteration in comfort. The Care Plan's interventions included notifying the physician about pain issues and monitoring food intake, appetite and weight.During a concurrent observation and interview on 4/21/2026 at 3:28 p.m. with Resident 26, Resident 26 had no natural teeth. Resident 26 stated she did not like dentures because they hurt and would like to have dental implants.During a concurrent interview and record review on 4/23/2026 at 8:46 a.m. with Minimum Data Set Nurse (MDSN) 1, Resident 26's MDS assessment dated [DATE] and Dietary assessment dated [DATE] were reviewed. MDSN 1 stated MDS assessment was not coded correctly regarding Resident 26's oral (mouth) and dental (referring to teeth and oral care) status. MDSN 1 stated accurate assessment of Resident 26's dental status is important because it can affect the care of the resident by not providing the right level of care.During an interview on 4/24/2026 at 3:15 p.m. with the Director of Nursing (DON), the DON stated accurate assessment will ensure appropriate plan of care will be implemented for the resident. The DON stated care plan for the resident will be affected if the MDS assessment is inaccurate.During a review of facility's policy and procedure (P&P) titled, Policy on Accurate Assessment- Minimum Data Set, dated 2024, the P&P indicated MDS assessments should reflect resident's actual condition, supported by clinical documentation in the medical record, completed within time frames and false, misleading and unsupported documentation is strictly prohibited. The P&P indicated MDS Coordinator will review assessments for accuracy and completeness.

Based on interview and record review, facility documentation, and staff interview, the facility failed to ensure timely follow-up and coordination of a require Preadmission Screening and Resident Review (PASRR) Level II evaluation for one of four sampled residents (Resident 14) identified through PASRR Level I screening as needing further evaluation for Serious Mental Illness (SMI).This deficient practice placing the Resident 14 at risk for unmet mental health needs and noncompliance with federal PASRR requirements of competition of level II by the facility.Findings:During a review of Resident 's admission Record, the admission Record indicated, Resident 14 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 14's diagnoses included paranoid schizoaffective (a mental illness that can affect thoughts, mood, and behavior), major depressive disorder (a mood disorder that causes persistent feeling of sadness and loss of interest), and anxiety disorder (excessive, persistent, and uncontrollable fear, worry, or dread that interferes with daily life).During a review of Resident 14's Minimum Data Set ([MDS] - a resident assessment tool), dated 1/26/2026, the MDS indicated, Resident 14 had moderate cognitive (ability to think, understand, learn, and remember) impairment. The MDS indicated, Resident 14 required maximal assistance (helper does more than half the effort) from staff with eating, oral hygiene, and upper body dressing.During a concurrent interview and record review on 4/24/2026 at 12:43 p.m. with Minimum Data Set Nurse 1(MDSN 1), Preadmission Screening and Resident Review (PASRR) level I screening dated 05/02/2025 was reviewed. The form indicated SMI level II Mental Health Evaluation was required. Notice of Evaluation for Level II screening completion dated 05/07/2025 indicate level II assessment was not completed due to facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the Level II screening. As a result of the facility's lack of response, the PASRR Level II case was subsequently closed without completion of the required evaluation.MDSN1 stated the PASRR Level I screening for Resident 14, dated 05/02/2025, showed a positive result for Serious Mental Illness (SMI), which required a PASRR Level II mental health evaluation prior to or upon admission in accordance with federal regulations. MDSN 1 stated the facility failed to follow up on the PASRR Level II because no staff member took ownership of the task; responsibility fell between the nurses and medical records staff, and the process was overlooked. MDSN1 stated that moving forward, the facility will establish a process to prevent this issue from recurring.During an interview, on 4/24/2026 at 2:28 pm with the Director of Nursing (DON), the DON stated residents identified through PASRR Level I screening as requiring Level II evaluation must receive timely follow-up to ensure compliance and appropriate care planning. The DON stated failure to respond to PASRR communications may result in delays or failure to complete required evaluations. The DON stated moving forward, she will have a process of assigning certain staff for PASSR.During a Review of facility's policy and procedure titled Preadmission Screening and Resident Review (PASRR) undated indicated Referral :if the level I screen is positive for SMI or (intellectual Disability) ID referral is made to the State Mental Health or Intellectual Disability Authority.

Based on observation, interview and record review the facility failed to develop and implement comprehensive processing center care plan for Resident 14 identified through PASSR level 1 screening as requiring level II evaluation for residents 14.This deficient practice placed the residents at risk for unmet needs and lack of appropriate coordination of care and services.Findings:During a review of Resident 's admission Record, the admission Record indicated, Resident 14 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 14's diagnoses included paranoid schizoaffective (a mental illness that can affect thoughts, mood, and behavior), major depressive disorder (a mood disorder that causes persistent feeling of sadness and loss of interest), and anxiety disorder (excessive, persistent, and uncontrollable fear, worry, or dread that interferes with daily life).During a review of Resident 14's Minimum Data Set ([MDS] a resident assessment tool), dated 1/26/2026, the MDS indicated, Resident 14 had moderate cognitive (ability to think, understand, learn, and remember) impairment. The MDS indicated, Resident 14 required maximal assistance (helper does more than half the effort) from staff with eating, oral hygiene, and upper body dressing.During a concurrent interview and record review on 04/24/2026 at 1:14 p.m. with Minimum Data Set Nurse 1 (MDSN1), the records showed Resident 14 screened positive on the PASRR Level I, indicating the need for a PASRR Level II evaluation due to mental illness. Resident 14's review of electronic health record (EHR)contained no evidence of an individualized, interdisciplinary care plan addressing Resident 14's identified mental health or specialized service needs as required. MDSN 1 stated she believed the care plan had been completed; however, upon reviewing Resident 14's EHR no care plan could be found. MDSN 1 stated the facility had not developed or implemented a comprehensive care plan at this time.During an interview on 4/24/2026 at 2:28 p.m. with the Director of Nursing (DON), the DON stated the care plan was missing because the facility failed to complete the PASRR Level II. The DON stated the process lacked clear staff assignment, which led to the follow up being missed. The DON stated that moving forward, she will implement a process to assign responsibility and ensure all required care plans are completed in a timely manner.During a review of facility's policy and procedure (P&P) titled Preadmission Screening and Resident Review (PASRR) undated indicated Referral: if the Level II evaluation recommends Specialized Services, these must be integrated into the resident's comprehensive care plan within 14 days of admission.Cross reference F644

Based on observation, interview, and record review, the facility failed to ensure that one of one sampled resident (Resident 37) received safe and adequate assistance with activities of daily living by failing to provide the required two person assistance during incontinent care.This failure had the potential to result in injury, accidents, compromised safety, and inadequate personal care.Findings:During a review of Resident 37's admission Record, the admission Record indicated Resident 37 was admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 37 with diagnoses including chronic respiratory failure (any condition that affects breathing function and result in lungs not functioning properly), encephalopathy (any damage or disease that affects the brain), and sepsis (life-threatening blood infection).During a review of Resident 37's History and Physical (H&P), dated 1/3/2026, the H&P indicated, Resident 37 did not have the ability to understand and make decisions. The H&P indicated the resident had a tracheostomy (a tube placed into a surgically created hole through the front of the neck and into the windpipe-trachea), a gastrostomy tube (G-tube, a tube placed directly into the stomach for long-term feeding), and a foley catheter ( a flexible, thin tube inserted through the urethra into the bladder to drain urine into a collection bag).During a review of Resident 37's Minimum Data Set (MDS- a resident assessment tool), dated 1/26/2026, the MDS indicated Resident 37's cognitive (ability to think, understand, learn, and remember) skills for daily decision making were severely impaired. The MDS indicated Resident 37 was dependent (helper does all the effort, or the assistance of 2 or more helpers is required for the resident to complete the activity) on staff with oral hygiene, toileting hygiene, showering, personal hygiene, and rolling left and right.During a review of Resident 37's Task List Report, dated 4/21/2026, the Task List Report indicated Resident 37 required two- to three-person assist as needed during turning to maintain spine alignment.During a concurrent observation and interview on 4/21/2026 at 10:21 a.m. with Certified Nursing Assistant (CNA) 1 in Resident 37's room, CNA 1 was observed providing incontinent care to the resident alone, on the left side of the bed. During the care, CNA 1 supported the resident's left side and buttock with one hand while using the other hand to clean him, change the incontinent brief, and replace linens underneath him for approximately 10 minutes. Resident 37 was observed coughing intermittently throughout the resident personal care. CNA 1 stated Resident 37 was typically provided incontinent care by two staff members; however, because the other staff member was busy, she performed the care alone.During a concurrent interview and record review on 4/23/2026 at 10: 15 a.m. with Registered Nurse Supervisor (RNS) 1, Resident 37's Task List Report, dated 4/23/26, was reviewed. RNS 1 stated turning and providing incontinent care to the residents who had tracheostomy, G-tube, and foley catheter were weight bearing tasks. RNS 1 stated Resident 37 was totally dependent and required at least two-person assistance for turning and incontinent care to prevent falls, any accidents or any injury for both the resident and the staff.During an interview on 4/24/2026 at 3: 38 p.m. with the Director of Nursing (DON), the DON stated staff should provide incontinent care with at least two to three staff members for Resident 37, as indicated in the Task List Report, to prevent injury or accident. The DON stated if staff were unsure of the required assistance level, they should ask the resisted nurse for instructions.During a review of the facility's policy and procedure (P&P) titled, Safe Resident Handling, Turning, and Repositioning Residents, dated 2024, the P&P indicated staff shall use sufficient staff assistances as reflected in the president's plan of care.During a review of the facility's P&P titled, Activities of Daily Living (ADL) Performance and Assistance, dated 2024, the P&P indicated staff should assist residents according to their assessed level (independent, supervision, limited assist, expensive assist, total assist) provide care in a safe and timely manner.

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 184) received oral hygiene care who was dependent on staff for oral care.This deficient practice had the potential to place Resident 184 at risk for diseases of the mouth, gums, and teeth.Findings:During a review of Resident 184's admission Record, the admission Record indicated Resident 184's was admitted to the facility on [DATE] with diagnoses including, dysphagia (difficulty swallowing) emphysema unspecified ( a chronic, progressive lung disease where air sacs (alveoli) are damaged, causing shortness of breath and decreased lung function. ), muscle wasting and atrophy (refers to the loss or thinning of muscle tissue). During a review of Resident 184's Minimum Data Set (MDS a resident assessment tool) dated 04/22/2026 indicated Resident 184 with severe cognitive (ability to think, understand, learn, and remember) impairment in decision making. The MDS indicated Resident 184 was dependent (helper does all the effort) in oral hygiene, toileting, shower/bath and substantial /maximal assistance (helper does more than half the effort) for upper/lower body dressing.During a concurrent observation and interview on 04/21/2026 at 10:50 a.m. with Resident 184 and Registered Nurse Supervisor (RNS 3), observed Resident 184 lying in bed with her mouth full of a brown, sticky substance coating the roof of her mouth, tongue, teeth, and lips. Resident 184 stated that her mouth had not been cleaned for a while and she did not know what was inside her mouth. Resident 184 opened her mouth to inspect it more closely. While in the room, RNS 3 came in to assess the substance in the resident's mouth. RNS 3 stated it appeared to be brown crust, not chocolate. RNS 3 gathered supplies and immediately began providing mouth care while waiting for the assigned Certified Nursing Assistance (CNA). RNS 3 used a mouth swab to remove the dry, sticky brown substance and stated she would request the assigned CNA to complete the remaining oral care because it would take additional time and the resident needed to rest, as Resident 184 had requested.During an interview on 04/21/2026 at 11:00 a.m., with CNA 4, CNA 4 stated it was her responsibility to perform mouth care on her residents because it reflects dignity and respect. CNA 4 stated she had Resident 184 on her assignment on 04/20/2026 and again on the day of the observation. CNA 4 stated she did not perform oral care because the resident had a mouth sore, and she was unsure whether the CNA or a licensed nurse should clean the resident's mouth. CNA 4 stated she should have verified with a licensed nurse any concerns instead of ignoring the situation. CNA 4 stated the resident should have still receive oral care and she would provide it immediately.During an interview on 04/23/2026 at 9:51 a.m. with Registered Nurse Supervisor 3 (RNS 3), RNS 3 stated CNAs were required to perform oral care on all residents because providing daily oral hygiene was an essential part of maintaining dignity and respect. RNS 3 stated she immediately assisted in cleaning the resident's mouth to remove the crusted brown substance and improve the resident's comfort. RNS 3 stated staff must ensure residents receive proper care and comfort to prevent further complications.During an interview on 04/24/2026 at 2:27 p.m. with the Director of Nursing (DON), the DON stated CNAs were expected to understand the importance of oral care through constant huddles and in-service training. The DON stated she was surprised oral care had not been completed, as providing oral hygiene reflects dignity and respect. The DON stated CNAs should seek clarification whenever they were unsure whether a resident requires oral care.During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADLs) Supporting undated, the P&P indicated Residents who are unable to carry out activities of daily living independently will receive the service necessary to maintain good nutrition, grooming and personal and oral hygiene.

Based on observation, interview and record review, the facility failed to ensure an environment free from accident hazards for two of four sampled residents (Resident 163 and 188).The facility failed to:1.Ensure Certified Nursing Assistant (CNA) 2 was informed of Resident 163's (who was assessed as high risk for fall and had a history of fall) of interventions for fall prevention.2.Ensure Resident 163's bed pad alarm (a pad with sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff) was functioning and operational when Resident 163 was found on the floor on 4/21/2026.These failures resulted in Resident 163 scooting himself on the floor unnoticed and unassisted by the staff near the doorway of resident's room which can put the resident at risk for serious bodily injury.3. Ensure one of four sampled residents (Resident 188) was repositioned to an upright position prior to meal consumption, as required under standard feeding and aspiration (food or liquid enters the airway/lungs) precaution protocols.These failures resulted in Resident 163 scooting himself on the floor unnoticed and unassisted by the staff near the doorway of resident's room which can put the resident at risk for serious bodily injury.This deficient practice placed Resident 188 at risk for choking and aspiration.Findings: 1.During a review of Resident 163's admission Record, the admission Record indicated Resident 163 was admitted to the facility on [DATE] and was readmitted on [DATE]. The admission Record indicated Resident 163 with diagnoses including acquired absence of right leg below knee (right lower leg was surgically removed), cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), difficulty in walking, metabolic encephalopathy(sudden or gradual decline in brain function), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 163's History and Physical (H&P) dated 11/1/2025, the H&P indicated Resident 163 had fluctuating capacity to understand and make decisions. During a review of Resident 163's Minimum Data Set (MDS- a resident assessment tool) dated 2/6/2026, the MDS indicated Resident 163 had moderately impaired cognitive (ability to think, understand, learn, and remember) skills. The MDS indicated Resident 163 required partial/ moderate assistance ( helper does less than half the effort to complete an activity) with transferring to and from a bed to a chair or wheelchair, and moving from sitting on the side of the bed to lying flat on the bed. The MDS indicated Resident 163 required substantial/ maximal assistance (helper does more than half the effort) with toileting hygiene, bathing and had a fall since admission in the facility. During a review of Order Summary Report dated 11/3/2025, the Order Summary Report indicated an order to apply bed alarm and to monitor placement and function. During a review of Order Summary Report dated 11/16/2025, the Order Summary Report indicated an order to monitor resident for intentionally getting out of bed unassisted and crawling on the floor. During a review of Resident 163's Care Plan titled, Actual Fall, initiated 11/6/2025, the Care Plan indicated Resident 163 had poor safety awareness (not paying attention to risks or dangers, resulting in a failure to take precautions to prevent accidents), was not compliant with safety precautions and attempted to get out of bed unassisted. The Care Plan indicated interventions included implementing bilateral landing pads, bed alarm, wheelchair alarm (pressure sensitive device designed to alert caregivers immediately when a resident attempts to stand up, helping prevent falls), encouraging patient to use call light and providing assistance as needed. During a review of Resident 163's Fall Risk assessment dated [DATE], the Fall Risk Assessment indicated Resident 63 was a high risk for fall. During a review of Resident 163's Change in Condition (COC- a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional status which without immediate intervention, may result in complications or death) dated 4/21/2026 at 10:20 a.m. , the COC indicated Resident 163 was found sitting on the floor in his room and the nature of the incident was unknown. The COC indicated Resident 163 had no signs and symptoms of injury upon assessment, the physician and family were notified. During a review of Resident 163's Care Plan titled, Resident 163 was found sitting on the floor, initiated 4/21/2026, the Care Plan indicated Resident 163 had poor safety awareness, had behavior of attempting to get out of bed unassisted , had episode of crawling out of bed, was a high risk for fall and had a right below knee amputation (BKA- surgical removal of the portion of the leg below the knee). The Care Plan indicated interventions included continuing to implement bilateral landing pads, maintaining a low bed (a specialized, height-adjustable bed that can lower significantly closer to the floor to prevent injuries from falls), encouraging the resident to use the call light, helping the resident as needed, replacing failed sensor alarm, monitoring for any worsening behavior. During an observation on 4/21/2026 at 10:19 a.m. in Resident 163's room, room was dim and Resident 163 was not on the bed but sitting on the right side of the bed. During a subsequent observation on 4/21/2026 at 10:21 a.m. in Resident 163's room, Resident 163 was wearing a shirt and an adult brief (highly absorbent disposable undergarment designed for people with bladder or bowel control issues) and was scooting himself toward the doorway. No audible sound was heard coming from the room. Two unknown staff members walked past the room and did not notice Resident 163 on the floor. Certified Nursing Assistant (CNA) 3 was walking in the hallway, wheeling another resident, when she pointed out Resident 163 on the floor to an unknown staff member. This prompted several staff to enter Resident 163's room. 2.During a concurrent observation and interview on 4/21/2026 at 10:30 a.m. with the Quality Assurance Nurse (QAN) in Resident 163's room, a landing pad (a floor pad designed to help prevent injury should a person fall) was observed on the right side of the bed, a bed pad alarm was present on the bed, and no chair was located on either side of the bed. The QAN stated the bed alarm pad was not functioning and explained that the bed pad alarm activates through pressure. The QAN further stated Resident 163 had a bed pad alarm in place because the resident attempts to get out of bed unassisted. During an interview on 4/21/2026 at 10:37 a.m. with the Central Supply Manager (CSM), the CSM stated the bed pad alarm was not working and would be replaced with a new one. The CSM stated CNAs and licensed nurses notify him when a bed pad alarm is not functioning and needs replacement. The CSM further stated that he does not perform routine checks to ensure bed pad alarm devices are functioning properly During an interview on 4/23/2026 at 10:52 a.m. with CNA 2, CNA 2 stated she did not know that Resident 163 was at high risk for falls and was not familiar with the resident. CNA 2 stated residents identified as high fall risk wear a yellow wristband, and she did not see a yellow wristband on Resident 163. She stated she saw Resident 163 on 4/21/2026 at approximately 8:40 a.m. while she was picking up breakfast trays, before the resident was later observed on the floor at 10:21 a.m. CNA 2 stated staff are informed during morning huddle if a resident is identified as a high fall risk. She stated that at the time Resident 163 was found on the floor, she was busy assisting other residents. CNA 2 stated she would have checked on the resident hourly and ensured the bed pad alarm was functioning if she had known the resident was at risk for falls. She stated that charge nurses, CNAs, and the maintenance department share responsibility for ensuring bed pad alarms are working. CNA 2 stated she did not check Resident 163's bed pad alarm because the resident was asleep. She stated Resident 163 could be at risk for falls, which could lead to injury if the bed pad alarm was not working, and the alarm is intended to alert staff if the resident moves or falls from the bed. During an interview on 4/23/2026 at 12:13 p.m. with RN Supervisor (RNS) 3, RNS 3 stated Resident 163 could not walk independently and was at high risk for falls due to having an amputated leg and behavioral issues. RNS 3 stated CNAs and licensed nurses are responsible for ensuring bed pad alarm are functioning properly. RNS 3 stated the facility did not hold a morning huddle (a brief daily stand-up meeting of the staff to improve communication, enhance safety and foster teamwork) on 4/21/2026 because of the recertification survey (an unannounced, mandatory, annual inspection conducted by state health department to ensure facilities are following federal safety and quality standards). RNS 3 stated Resident 163 could sustain a fall or injury if staff failed to recognize him as a high fall risk. RNS 3 further stated non working bed pad alarms can contribute to a resident falling. During an interview on 4/23/2026 at 2:11 p.m. with the Quality Assurance Nurse (QAN), the QAN stated residents identified as high risk for falls can be recognized by a green wristband, a star placed next to the resident's name at the entrance of the room, and a pink slip located at the end of the bed. The QAN stated when staff are unable to identify a resident as a high fall risk, it can lead to residents sustaining injuries or accidents During an interview on 4/24/2026 at 10:40 a.m. with CNA 3, CNA 3 stated she saw Resident 163 on the floor while she was wheeling another resident down the hallway. CNA 3 stated residents at high risk for falls are identified by a green wristband, landing pads, bed and wheelchair pad alarms, and a green star placed by the resident's name at the door. CNA 3 stated she checks residents frequently while they are in bed and responds immediately when a bed pad alarm activates. During an interview on 4/24/2026 at 3:15 p.m. with the Director of Nursing (DON), the DON stated fall prevention measures cannot be implemented effectively if staff are unable to identify residents who are at high risk for falls. The DON stated residents at high risk for falls may sustain a fall when appropriate fall prevention interventions are not provided. During a review of facility's policy and procedure (P&P) titled, Fall Prevention Program, dated 2/2025, the P&P indicated the facility will identify interventions and resident specific risks and causes to prevent the resident from falling and minimize complications. The P&P indicated a fall is considered to have occurred when a resident is found on the floor and a fall without an injury is still a fall. 3.During a review of Resident 188's admission Record, the admission Record indicated Resident 188's was admitted to the facility on [DATE] with diagnoses of generalized muscle weakness (a loss of strength across multiple muscle groups), gout unspecified, ( form of inflammatory arthritis[inflammation of one or more joints], type 2 diabetes mellitus (DM-disorder characterized by difficulty in blood sugar control and poor wound healing) with hyperglycemia (high blood sugar)). During a review of Resident 188's Minimum Data Set ([MDS] – a resident assessment tool), dated 02/23/2026, the MDS indicated, Resident 188's cognitive (ability to think, understand, learn, and remember) skills for daily decision making was intact. The MDS indicated Resident 188 required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds truck or limbs and provides more than half the effort) from staff with sit to lying, lying to sitting on the side of bed. Resident 188 needs supervision or touching assistance with eating and oral hygiene. During a concurrent observation and interview on 04/21/2026 at 12:27 p.m. with Resident 188, Resident 188 was observed in bed during lunchtime in a slouched position, sliding downward and unable to safely access her meal tray. Resident 188 stated Certified Nursing Assistant (CNA) 6 delivered her meal tray without repositioning her into an upright position. Resident 188 stated I don't want to report this, but I need to be repositioned. During an interview on 04/21/2026 at 3:19 p.m. with CNA 6, CNA 6 stated she did not intentionally fail to reposition Resident 188. CNA 6 stated Resident 188 requires a two person assist to be repositioned and pulled up in bed because of the resident's size. CNA 6 stated she had stepped out to find help to reposition Resident 188 for her meal but became busy passing meal trays and forgot to return. CNA 6 stated failing to reposition the resident could cause choking and aspiration. She stated that in the future she will obtain assistance before moving on to the next resident, so she does not forget or become distracted again. During an interview on 04/23/2026 at 10:27 a.m. with Registered Nurse Supervisor 3 (RNS 3), RNS3 stated residents were required to be properly positioned upright at approximately 35 to 45 degrees during mealtimes to prevent choking and aspiration. RNS 3 stated CNAs must ensure residents were comfortable and correctly positioned when delivering meal trays and must reposition residents before leaving the room. During an interview on 04/24/2026 at 2:28 p.m., with the Director of Nursing (DON), the DON stated staff must properly position all residents during mealtimes to reduce the risk of aspiration and choking. During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADLs) Supporting undated, the P&P indicated Appropriate care and service will be provided for residents who are unable to carry out activities of daily living independently, will receive the service necessary to maintain good nutrition, grooming and personal and oral hygiene. Including dining (meals and snacks).

Based on observation, interview, and record review, the facility failed to ensure proper urinary catheter care by maintaining the Foley catheter drainage bag below the bladder level during care for one of two sampled residents (Resident 37).This failure had the potential to cause urine backflow into the resident's bladder, increasing the risk for urinary tract infection (UTI- an infection in the bladder/urinary tract) and indwelling catheter-related complications.Findings:During a review of Resident 37's admission Record, the admission Record indicated Resident 37 was admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 37 with diagnoses including chronic respiratory failure (any condition that affects breathing function and result in lungs not functioning properly), benign prostatic hyperplasia (BPH, age-associated prostate gland enlargement that can cause urination difficulty) and retention of urine (difficulty emptying the bladder).During a review of Resident 37's History and Physical (H&P), dated 1/3/2026, the H&P indicated, the resident did not have the ability to understand and make decisions. The H&P also indicated Resident 37 had a foley catheter (a flexible, thin tube inserted through the urethra into the bladder to drain urine into a collection bag).During a review of Resident 37's Minimum Data Set (MDS- a resident assessment tool), dated 1/26/2026, the MDS indicated Resident 37's cognitive (ability to think, understand, learn, and remember) skills for daily decision making were severely impaired. The MDS indicated Resident 37 was dependent (helper does all the effort, or the assistance of 2 or more helpers is required for the resident to complete the activity) on staff with oral hygiene, toileting hygiene, showering, personal hygiene, and rolling left and right.During a review of Resident 37's care plan, titled Indwelling foley catheter with risk of urinary tract infection (UTI- an infection in the bladder/urinary tract ), created 1/12/2026, the care plan's interventions included staff should keep drainage bag below bladder level and change bag as needed.During a concurrent observation and interview on 4/21/2026 at 10:21 a.m. with Certified Nursing Assistant (CNA) 1 in Resident 37's room, a foley drainage bag was observed remaining on top of the bed while CNA 1 was providing personal care to the resident approximately for 10 minutes, and the drainage bag was filled with urine. CNA 1 stated she placed the foley drainage bag on top of the bed during personal care to prevent accidental pulling of the catheter/ drainage bag.During an interview on 4/24/2026 at 3:38 p.m. with the Director of Nursing (DON), the DON stated the foley catheter drainage bag should be maintained below the level of the bladder to prevent backflow of urine into the resident's bladder and reduce the risk of urinary tract infection.During a review of the facility's policy and procedure (P&P) titled, Indwelling Urinary Catheter Care, dated 2024, the P&P indicated staff must always keep drainage bag below bladder level.

Based on observation, interview, and record review, the facility failed to ensure adequate hydration for one of three sampled residents (Resident 13), who was visually impaired (unable to see) and required assistance with fluid intake.This deficient practice resulted in Resident 13 becoming dehydrated placing the resident at risk for worsening urinary tract infection (UTI - an infection in the bladder/urinary tract), electrolyte imbalance (when the levels the blood become too high or too low), and potential hospitalization.Findings:During a review of Resident 13's admission Record, the admission Record indicated Resident 13 was admitted to the facility on [DATE] with diagnoses including dysphagia (difficulty swallowing), glaucoma (a group of eye conditions that can cause vision loss or blindness), visual loss both eyed, and diabetes mellitus type 2 ( DM- a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 13's urine culture (a test that checks and identifies germs in a urine sample to check for a urinary tract infection) dated 2/22/2026, the Urine Culture indicated, multi-drug resistant Escherichia coli (E-Coli a type of germ resistant to at least one agent in three or more antibiotics) colony count > 100,000 (normal urine culture result is no growth less than 100,000).During a review of Resident 13's Care Plan Report titled Urinary tract infection dated 3/7/2026, the care plan goal and intervention indicated Resident 13 will maintain adequate hydration (getting enough water and fluids to keep the body working properly).During a review of Resident 13's Minimum Data Set (MDS a resident assessment tool) dated 3/16/2026, the MDS indicated Resident 13 required substantial/maximal assistance (helper does more than half) for eating, and oral hygiene.During a review of Resident 13's Basic Metabolic Panel (BMP laboratory test measures kidney health and fluid balance) dated 3/16/2026, the Basic Metabolic Panel indicated the following:Blood Urea Nitrogen (BUN a test that measures the amount of nitrogen from waste in your blood) BUN 46 milligram per deciliter (mg/d-unit of measurement) Reference Range 9-23 mg/dLCreatinine (a waste product produced by the body from normal muscle breakdown) Creatinine- 1.64 mg/dL (Reference Range 0.73- 1.30 mg/dL).During an observation on 4/21/ 2026, at 9:02 a.m. in Resident 13's room, Resident 13 was lying in bed with signage posted above the head of the bed stating, I'm blind please give me water. The bedside table was positioned at the foot of the bed, and the resident's water pitcher was empty. No alternate fluids were available, and the resident had no means to independently access fluids.During an interview on 4/22/2026 at 9:54 am with Resident 13's Resident Representative (RR an individual chosen by the resident to act on behalf of the resident in order to support the resident in decision-making), the RR stated Resident 13 had vision loss due to glaucoma. The RR stated the facility does not provide the Resident 13 with water throughout the day. The RR stated that during her visits, the Resident 13, bedside table was not within reach, the water pitcher is empty, and no cup available at the bedside. RR stated that she raised these concerns to the staff during the Interdisciplinary Team ([IDT] team members from different departments working together with a common purpose to set goals and make decisions that ensure residents receive the best care) meetings, but the issue has persisted. RR stated that Resident 13 was treated with intravenous fluid ( fluids administered directly into a resident vein) due to dehydration approximately two weeks prior. RR stated that when she came to visit Resident 13 two weeks ago ( unknown date) he was sitting in his wheelchair and informed her that he was severely dizzy. RR stated that she informed the staff and instructed them to call the physician. RR stated that the staff obtained Resident 13's vital signs but does not know what they were. RR stated that the next day the facility called her to inform her that Resident 13 would be started on intravenous fluid for hydration.During an observation on 4/22/2026 at 2:47 p.m. Resident 13 was lying in bed, Resident 13's bedside table was not within reach and the water pitcher was empty. During an observation on 4/22/2026 at 4:24 p.m. Resident 13's bedside table was not within reach and the water pitcher was empty. During an interview on 4/23/2026 at 11:46 am with Certified Nurse Assistant (CNA) 9, CNA 9 stated Resident 13's bedside table should be within his reach at all times and should instruct Resident 13 where the items were placed due to his visual impairment. CNA 9 stated if a resident is not drinking adequate fluids, it should be reported to the charge nurse immediately. CNA 9 stated Resident 13 requires additional assistance compared to other residents due to his visual loss. CNA 9 stated if a resident has no fluids within reach, this indicates the resident was not receiving adequate hydration and could become dehydrated or pass out. CNA 9 stated that it was the staff responsibility to ensure Resident 13 receive adequate fluids in order to maintain their hydrational status.During a concurrent interview and record review on 4/23/2026 at 11:57 a.m. with License Vocational Nurse (LVN) 2, Resident 13's Physician Orders, Summary dated 3/17/2026 and 4/8/2026 was reviewed. The Physician Orders indicated on 3/17/2026 NS to administer Normal Saline ( NS intravenous fluid) IV at 60 cubic centimeter (cc-unit of measurement) per hour for three days. Resident 13's Physician Orders, dated 4/8/2026 was reviewed. The Orders indicated, NS at 60 cc per hour for 2 liters, diagnosis of chronic kidney disease (CKD-a long-term condition where the kidneys are damaged) , and dehydration. LVN 2 acknowledged that Resident 13 had received the NS IV due to dehydration. LVN 2 stated the potential complications of inadequate hydration include dehydration, abnormal laboratory values, abnormal vital signs, and possible hospitalization if adequate hydration was not maintained. LVN 2 stated Resident 13's fluids and bedside table should be kept within reach and that staff should ensure that the resident was made aware of the location water pitcher due to his visual impairment.During an interview on 4/24/2026 at 3:15 p.m. with the Director of Nursing (DON), the DON stated residents identified at risk for dehydration should have fluids offered routinely throughout the day, with intake monitored and documented, and staff should intervene when intake was low. The DON stated residents' who are dependent on staff, including those with visual impairments, require active assistance and prompting to ensure adequate hydration. The DON stated residents who do not receive adequate hydration were at risk for dehydration, urinary tract infection, electrolyte imbalances, and increased confusion. The DON stated that inadequate hydration could lead to more serious complications, including acute kidney injury, worsening infection and potential hospitalization. During a review of the facility's policy and procedure (P&P) titled, Hydration and Nutrition Policy, dated 2024, the P&P indicated, To ensure that all residents receive adequate nutrition and hydration to maintain the highest practicable level of health, prevent malnutrition and dehydration, and support overall will-being.During a review of the facility's P&P titled, Hydration Management Policy, dated 2024, the P&P indicated, The facility shall assess, monitor, and manage each resident's fluid needs to maintain adequate hydration, while accommodating medical conditions, physician orders, and individual preferences.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services for one of two sampled residents (Resident 3) who are receiving enteral feeding (delivers liquid nutrition through a flexible tube that goes directly into the stomach or small intestine). The facility failed to:1.Ensure the tube feeding formula (liquid, specialized nutrition delivered directly to the stomach or small intestine to support health when eating by mouth is not possible or sufficient) was not administered more than 24 hours to Resident 3.This failure had the potential to cause Resident 3 to have intolerance to the tube feeding formula leading to diarrhea (loose stool), nausea, vomiting and inadequate nutrition. Findings:During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. The admission Record indicated Resident 3 with diagnoses including anoxic brain damage(brain oxygen supply is cut off which can cause long-lasting issues with memory, movement, thinking and personality), dysphagia(difficulty in swallowing), gastrostomy(a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problem),and cerebral aneurysm(a bulge in a blood vessel in the brain).During a review of Resident 3's History and Physical (H&P) dated [DATE], the H&P indicated Resident 3 did not have the capacity to understand and make decisions.During a review of Resident 3's Order Summary Report dated [DATE], the Order Summary Report indicated an order for Isosource 1.5 ( liquid nutrition) at 75 milliliter (ml- unit of measurement) per hour for 10 hours to provide 750 ml via gastrostomy tube (GT- a soft tube surgically inserted directly into the stomach to administer medication, fluids and nutrition) enteral pump and to be turned on at 8:00 p.m. and be turned off at 6:00 a.m.During a review of Resident 3's Minimum Data Set (MDS- a resident assessment tool) dated [DATE], the MDS indicated the resident had moderately impaired cognitive (ability to think, understand, learn, and remember) skills. The MDS indicated Resident 3 was dependent( helper does all the effort) on staff with bathing, toileting hygiene, dressing and transferring to and from a bed to chair.During an observation on [DATE] at 10:44 a.m. in Resident 3's room, Resident 3 was lying in bed and an enteral feeding pump (medical device designed to deliver liquid nutrition through a tube directly into a person's stomach or small intestine) was next to the resident's bed with a tube feeding bag labeled and dated [DATE] at 9:00 p.m. Observed the tube feeding pump was off but still connected to the resident.During a concurrent interview and record review on [DATE] at 9:59 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 3's Order Summary Report and a picture of the tube feeding bag taken on [DATE] were reviewed. LVN 1 stated Resident 3 was receiving Isosource tube feeding at 75 ml per hour for 10 hours. LVN 1 stated Resident 3's tube feeding administration starts at 8:00 p.m. and turns off at 6:00 a.m. LVN1 stated the tube feeding bag was already expired because it was hung on [DATE] at 9:00 p.m. LVN 1 stated tube feeding formula is only good for 24 hours once the tube feeding bag is open and spiked to ensure the integrity of contents are not spoiled or expired. LVN 1 stated she should have discarded the tube feeding bag and the next bag will be hung at 8:00 p.m. LVN 1 stated the charge nurses each shift should check the tube feeding bag for expiration and ensure that it is still good to be administered to the resident. LVN 1 stated Resident 3 can have stomach problems due to the expired tube feeding formula.During an interview on [DATE] at 1:21 p.m. with Registered Nurse Supervisor (RNS) 3, RNS 3 stated tube feeding formula is usable for only 24 hours after opening, and after 24 hours it is no longer safe for the resident to consume. RNS 3 stated that if expired formula is given, Resident 3 could develop nausea, vomiting, and diarrhea.During an interview on [DATE] at 10:40 a.m. with the Director of Nursing (DON), the DON stated Resident 3 would be at risk for developing nausea, vomiting, stomach upset, and inadequate nutrition if expired tube feeding formula were administered.During a review of facility's policy and procedure (P&P) titled, Enteral Nutrition, dated 2024, the P&P indicated staff caring for residents with enteral feedings must ensure accuracy of labeling and dating of each feeding bag or formula container. The P&P indicated label should contain expiration date/ time per manufacturer or facility protocol.

Based on observation, interview and record, review, the facility failed to ensure one of one sampled residents (Resident 8) received appropriate monitoring and labeling of an intravenous (IV- giving medicine, fluids, or nutrition directly into a person's vein using a small tube, allowing it to enter the bloodstream instantly) site who was on IV antibiotic (a medicine that fights infections caused by harmful bacteria) therapy.This failure had the potential to result in IV infiltration( when the IV catheter slips out of the vein, causing fluids or medication to leak into surrounding tissue), leading to pain, tissue injury, and increased risk of infection.Findings:During a review of Resident 8's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 8 with diagnoses including multiple sclerosis (a disease in which the immune system attacks the protective covering of the nerves causing nerve damage), respiratory failure (any condition that affects breathing function and results in lungs not functioning properly) and sepsis (a life threatening blood infection).During a review of Resident 8's Minimum Data Set (MDS- a resident assessment tool), dated 1/4/6/2026, the MDS indicated Resident 8's cognitive (ability to think, understand, learn, and remember) was severely impaired. The MDS indicated Resident 8 was dependent (helper does all the effort) on staff with oral hygiene, toileting hygiene, showering, and personal hygiene.During a review of Resident 8's Order Summary Report, dated 4/21/2006, the Order Summary Report indicateda. Starting 4/18/2026, administer Vancomycin HCl Solution (antibiotic medication used to treat sever bacterial infections) one gram intravenously every 12 hours for ventilator-associated pneumonia (a lung infection that develops in a person who is on a ventilator) until 4/24/2026.b. Starting 4/18/2026, monitor peripheral IV site for any signs and symptoms of infection and infiltration: None; Redness; Swelling; Pain; Warm to touch; Infiltration every day and night.During a review of Resident 8's Medication Administration Record (MAR), dated 4/21/2026, the MAR indicated Registered Nurse Supervisor (RNS) 2 started Vancomycin one gram via back of right hand IV access on 4/21/2026 at 8:51 a.m.During an observation on 4/21/2026 at 9:25 a.m. in Resident 8's room, observed Vancomycin 1 gram in a 250 milliliter IV antibiotic infusion through Resident 8's left hand IV access at 125 milliliters per hour (ml/hr-how much liquid flows in one hour). The IV site dressing does not have label for insertion date, time, and staff initialsDuring an interview on 4/21/2026 at 9:45 a.m. with Registered Nurse Supervisor (RNS) 2 in Resident 8's room, RNS 2 stated the resident's IV site dressing lacked the required labeling. RNS 2 stated she had initiated the IV antibiotic infusion at 125 ml/hr approximately one hour before the observation and, upon reassessment, noted that the IV site had infiltrated, with redness and swelling present. RNS 2 acknowledged responsibility for managing the IV.During an interview on 4/24/2026 at 3:38 p.m. with the Director of Nursing (DON), the DON stated staff must label the IV site dressing with the insertion date, time, and their initials to ensure proper rotation. The DON stated staff should monitor the IV site after initiating IV medication, including reassessment approximately 15 minutes after starting the infusion, as part of standard practice. The DON stated Vancomycin may cause phlebitis ( inflamed, swollen, and painful vein) as well as discomfort, infiltration, and vein damage, and therefore requires close monitoringDuring a review of the facility's policy and procedure (P&P) titled, Peripheral IV Catheter Insertion, dated 2001, the P&P indicated Staff should label on dressing of the IV insertion site including date and time of dressing placement, initials, gauge size, and length of catheter.During a review of the facility's P&P titled, Intravenous (IV) Medication Administration Policy, dated 2024, the P&P indicated Staff must assess IV site for signs of infiltration, phlebitis, or infection and monitor IV site throughout administration.During a review of the facility's P&P titled, Peripheral IV-line care and Removal, dated 2024, the P&P indicated Staff should assess IV site after medication administration to evaluate for redness, swelling, pain or tenderness, warmth or coolness, leakage, and signs of infiltration or phlebitis.

Based on observation, interview, and record review, the facility failed to ensure respiratory care was provided according to physician's order and nasal cannula (NC-plastic tube to deliver supplemental oxygen) was dated according to the facility policy and procedure (P&P) for one of one sampled resident (Resident 150).This failure had the potential to result in residents receiving too much oxygen, delayed identification of tubing replacement, and increased the risk of infection. Findings:During a review of Resident 150's admission Record, the admission Record indicated Resident 150 was admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 150 with diagnoses including hydrocephalus (a condition where too much fluid builds up in the brain's fluid spaces), chronic respiratory failure (any condition that affects breathing function and result in lungs not functioning properly) and intracranial hemorrhage (a serious medical emergency where a blood vessel brakes and causes bleeding inside the skull or brain).During a review of Resident 150's History and Physical (H&P), dated 5/28/25, the H&P indicated, Resident 150 did not have the ability to understand and make decisions.During a review of Resident 150's Minimum Data Set (MDS- a resident assessment tool), dated 4/14/2026, the MDS indicated Resident 150's cognitive (ability to think, understand, learn, and remember) was severely impaired. The MDS indicated Resident 150 was dependent (helper does all the effort) for oral hygiene, toileting hygiene, showering and personal hygiene.During a review of Resident 150's Order Summary Report, physician orders as of 4/21/2026, the Order Summary Report indicateda. Starting 11/2/2024, administer oxygen at 2 liters per minute (L/min-a measurement used to define the flow rate of a gas) via NC to keep oxygen saturation (the percentage of hemoglobin in your red cells carrying oxygen compared to the total amount of hemoglobin available) above 92% (normal range 95%-100%) as needed.b. Starting 11/2/2024, change NC every Saturday night shift. During a concurrent observation and interview on 4/21/2026 at 11:05 a.m. with Resisted Nurse Supervisor (RNS) 3, in Resident 150's room, Resident 150 was observed receiving oxygen through a NC. The NC tubing was observed without a date label indicating when the tubing was last changed. RNS 3 confirmed the oxygen flow rate was set at 3 L/min and the NC tubing lacked the required date label. RNS 3 stated staff are responsible for dating NC tubing upon replacement and changing tubing per facility protocol to promote infection control and ensure timely replacement.During an interview on 4/24/2026 at 3:38 p.m. with the Director of Nursing (DON), the DON stated staff were expected to date NC tubing to promote infection prevention and ensure oxygen was administered in accordance with the physician's order for accurate oxygen delivery.During a review of the facility's policy and procedure (P&P), titled Oxygen Equipment and Tubing Change Policy, dated 2024, the P&P indicated staff should ensure oxygen flow rate matches physician order.During a review of the facility's P&P titled Oxygen Set-Up, dated 2024, the P&P indicated all oxygen tubing must be dated when initiated and when replaced to ensure timely changes and infection prevention compliance. The P&P indicated oxygen tubing shall be dated when initiated or changed near oxygen source end of tubing or another visible location that does not obstruct function.

Based on interviews and record reviews, the facility failed to ensure a safe discharge for one of three sampled residents (Resident 1), who was a Regional Center client (a person with a developmental disability receiving care in a state-sponsored facility), with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) bipolar type (mood swings that range from the lows of depression [persistent feeling of sadness] to elevated periods of emotional highs), unspecified psychosis (mental health condition characterized by a loss of contact with reality), anxiety disorder (intense and persistent worry that is difficult to control and interferes with daily life) and seizures (sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). The facility failed to: 1.Notify Resident 1's conservator (a court-ordered arrangement that appoints a responsible individual to manage the financial affairs, personal care, or both, of an adult who is unable to do so due to incapacity or severe disability) of Resident 1's discharge plan. 2. Ensure the conservator was actively involved in selecting the facility and consenting prior to discharging Resident 1 to a recuperative care home ([RCC] a temporary safe place for people to heal after discharge from the hospital) on 1/28/2026. 3. Ensure an Interdisciplinary (IDT group of health care professionals who work together on the same plan of care) meeting was held to assess Resident 1's cognitive (ability to think, understand, learn, and remember), medical, physical, and psychosocial (emotional wellbeing) needs prior to discharging the residents to a lower level of care. 4. Ensure the RCC was notified by Licensed Vocational Nurse (LVN) 1 of Resident 1's medical condition including the resident's diagnoses, medications, history of wandering (walk around without any clear purpose or direction), and risk for falls/seizures prior to discharging the resident. These deficient practices resulted in Resident 1 being transferred to a RCC without proper discharge planning by the facility and without input or permission from Resident 1's Conservator to transfer Resident 1 to the RCC on 1/28/2026. On 1/30/2026 at 3:39 a.m., Resident 1 was found wandering approximately 9.1 miles from the RCC without any shoes on. Resident 1 was transported via the fire department to a General Acute Care Hospital (GACH). This placed Resident 1 at risk for experiencing uncontrolled seizures, falls, hallucinations (sights, sounds, smells, tastes, or touches that a person believes to be real but are not real), harsh weather conditions, environmental dangers including motor vehicle accidents, and assault. There was a likelihood Resident 1, did not receive any medication after she was discharged to the RCC. As of 2/20/2026 Resident 1 remains in the GACH. On 2/5/2026 at 2:44 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called in the presence of the facility's Administrator (ADM) , Assistant ADM, Administrator in Training (A.I.T.), Director of Staff Development (DSD), and the Quality Assurance Nurse, due to the facility's failure provide appropriate discharge planning and the subsequent discharge of Resident 1 to a lower level of care without the permission of Resident 's Conservator and where Resident 1's needs could not be met. On 2/6/2025, the facility submitted an acceptable IJ Removal Plan ([IJRP] interventions to immediately correct the deficient practices). After onsite verification of the IJRP's implementation through observation, interview, and record review, the IJ was removed on 2/6/2026 at 3:40 p.m., in the presence of the facility's DON and Social Services Director (SSD). Non-compliance of F-627 remained at the scope and severity of D no actual harm with potential for more than minimal harm that is not immediate jeopardy The facility's IJRP included the following immediate actions:Resident-Specific Interventions On February 2/5/2026, Director of Nursing (DON), Designee in collaboration with the DON, conducted an immediate clinical review of Resident 1's status in collaboration with the general acute care hospital (GACH) including medication reconciliation and continuity of care. Current Resident 1 status on 2/5/2026 at acute hospital based on records did not appear to meet inpatient admission criteria and does not appear to require psychiatric hospitalization (medical facility providing 24/7 inpatient care for patient with severe mental health disorders) or to be an immediate danger to self and others at this time. The IDT including Social Service, Director of Rehabilitation (DOR), DON, Assistant Director of Nursing (ADON)/Quality Assurance (QA) Nurse, Director of Staff Development (DSD) and Minimum Data Set Nurse (MDSN) met on 2/6/2026 and review root cause ( process to identify the causes of problems or adverse events) and analysis to ensure a safe discharge planning were compliant and meet the criteria of the discharge protocol. Facility-Wide Resident Safety SweepOn 2/5/2026, the Interdisciplinary Team (Social Services Director, Director of Nursing, and Assistant Director of Nursing) conducted a review of 85 resident discharges occurring between 1/1/2026 and 1/31/2026. Of these, 15 residents were identified as having been discharged to a lower level of care, including home, Independent Living Facilities (ILF), Assisted Living Facilities (ALF), Residential Care Facilities for the Elderly (RCFE), and Recuperative Care Center. The review includes but not limited to the following: 1.Appropriate level of care determination2.Interdisciplinary Team (Social Service Director (SSD), Nursing, Therapy, Dietary) involvement 3.Legal representative notification/consent 4.Safe discharge destination 5.Medication Reconciliation and Continuity A review of 15 residents discharged to a lower level of care revealed one discrepancy involving Resident 1. No discrepancies were found for the other residents, who were all discharged safely to the community. Licensed nursing staff will notify the Social Services Director (SSD) of all resident discharges. Beginning 2/5/2026, discharge information is communicated to the SSD and reviewed during the weekly discharge planning meeting. The review includes assessment of cognitive impairment, elopement (a situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision) risk, behavioral symptoms, conservatorship or legal representative involvement, and discharge planning. Any identified variances are corrected immediately. Compliance with the discharge review process is sustained through interdisciplinary oversight, routine monitoring, and leadership accountability. Licensed nursing staff notify the Social Services Director (SSD) of all planned and unplanned discharges. Discharges are reviewed during the weekly interdisciplinary discharge planning meeting to ensure appropriate level of care, resident safety, legal representative involvement, and continuity of care. The Director of Nursing (DON) or designee provides final authorization prior to discharge. During weekends or when the SSD and DON are not physically present in the building, the Nursing Supervisor reviews discharge documentation, confirms completion of required steps, and notifies the SSD and DON for follow-up review. Discharge audits are completed routinely and reviewed through the Quality Assurance and Performance Improvement (QAPI- proactive approach to quality improvement) program. Any identified variances are corrected immediately. Systemic Corrections ImplementedHard Stop Discharge Protocol (Effective Immediately)The Hard Stop Discharge Protocol was implemented effective immediately and initiated as a standardized checklist by the Interdisciplinary Team (IDT), including the Social Services Director (SSD), Director of Rehabilitation (DOR), Director of Nursing (DON), Dietary Services Supervisor (DSS), and Quality Assurance (QA). On 2/5/2026, the IDT reviewed and implemented this process. The IDT is responsible for completing and verifying all required elements of the discharge checklist, including interdisciplinary discharge planning, clinical readiness and safety, receiving provider or facility coordination, guardian or responsible party involvement, regulatory and program-specific requirements, notice and documentation, final review and authorization, handoff report to the receiving facility, and post-discharge follow-up as a best practice for risk mitigation. No resident may be discharged until all checklist steps are completed. All planned discharges, including those to Residential Care Facilities for the Elderly (RCFE), Assisted Living Facilities (ALF), Independent Living Facilities (ILF), and Recuperative Care, require final approval by the Administrator or Director of Nursing. Discharge planning begins at baseline admission and is reviewed at least 30 days prior to the projected discharge, again seven days prior to discharge, and prior to the day of discharge. During weekends or when IDT leadership is not physically present, the Nursing Supervisor or Administrator designee ensures checklist completion and communicates any outstanding items to the SSD and DON for follow-up. Compliance with the Hard Stop Discharge Protocol is reviewed during the weekly discharge planning meeting. Medical Records conducts ongoing audits of discharge documentation and reports findings to the DON. Any discrepancies identified are corrected timely. The checklist is as follows: 1. QA Nurse will be responsible for Resident Assessment & Participation 2. Interdisciplinary Team (IDT) Social Services Director (SSD), Director of Rehabilitation (DOR), Director of Nursing (DON), Dietary Services Supervisor (DSS), and Quality Assurance (QA). Will be responsible for reviewing discharge planning 3. DON/QA/DON Designee will be responsible for reviewing Clinical Readiness and Safety 4. Licensed nursing staff are responsible for communicating and providing a complete handoff to the receiving provider or facility at the time of discharge. This includes reviewing the resident's clinical status, medications, care needs, and any follow-up requirements to ensure a safe transition of care. Documentation of the handoff is maintained in the resident's medical record. 5. As part of the Hard Stop Discharge Protocol, the Social Services Director (SSD) and licensed nursing staff are responsible for notifying the resident's guardian or responsible party regarding discharge planning. They provide information on the resident's options for discharge destinations, including home, Residential Care Facilities for the Elderly (RCFE), Assisted Living Facilities (ALF), Independent Living Facilities (ILF), and Recuperative Care, and ensure the responsible party's preferences and consent are documented in the medical record. 6. The Social Services Director (SSD) is responsible for all resident discharge notices and documentation. This includes notifying the resident and/or guardian or responsible party, documenting the discharge plan, recording the resident's or guardian's choice of discharge destination (home, RCFE, ALF, ILF, or Recuperative Care), maintaining all related forms and communications in the medical record, and ensuring timely completion in compliance with regulatory requirements. 7. The Nursing Supervisor or licensed nursing staff are responsible for providing a complete handoff report to the receiving facility at the time of discharge. This report includes the residents' clinical status, medications, care needs, behavioral considerations, and any follow-up requirements to ensure a safe and seamless transition. Documentation of the handoff is maintained in the resident's medical record. 8. The SSD is responsible for post-discharge follow-up as the best practice and risk mitigation measure. This includes contacting the resident and/or guardian or responsible party after discharge to ensure the resident has safely arrived at the receiving setting, confirming that care needs and medications are being appropriately managed, identifying any emerging concerns, and documenting all follow-up actions in the medical record. A wellness check follow-up call is completed within 72 hours of discharge to verify the resident's safety, address any questions or issues, and provide additional support as needed. All planned discharges are subject to the approval of the Administrator or DON upon completion of the steps above. Staff EducationThe governing body provided in-service training on the Policy of Safe Discharge Planning to the Director of Nursing (DON) and Administrator on 2/6/2026. This training included review of the Hard Stop Discharge Protocol, interdisciplinary responsibilities, resident safety considerations, and compliance monitoring to ensure safe and regulated discharge practices. The governing body conducted a 1:1 in-service and competency validation with the Social Services Director (SSD) to review the Policy of Safe Discharge Planning, including the Hard Stop Discharge Protocol, interdisciplinary responsibilities, resident safety requirements, and documentation expectations. All licensed nurses, Social Services staff, and Interdisciplinary Team (IDT) members were educated on CMS discharge requirements, resident rights, safe transitions of care, documentation expectations, legal representative notification, and high-risk discharge criteria. Training is provided by the Director of Nursing and Social Services Director, and attendance is documented in maintained logs. New hires receive this training during orientation from the DON to ensure ongoing compliance.Monitoring to Ensure Ongoing ComplianceAll resident discharges are audited by Medical Records using the Hard Stop Discharge Checklist. Audits are conducted daily for the first 2 weeks, weekly for the following 4 weeks, and monthly thereafter through the QAPI program to ensure ongoing compliance. The audit tool includes: a. Interdisciplinary Team (IDT) participation b. Level of care validationconsent documentation d. Medication reconciliation e. Safe destination confirmation On the day of discharge, the Licensed Nurse provides a complete report and handoff to the receiving facility prior to resident transfer. Medical Records reviews audit findings and reports results to the DON, ADON, and Quality Assurance (QA) team. Any identified discrepancies are corrected in a timely manner. Results reported to QAPI Committee by Director of Nursing and Social Service Director. 4. Quality Assurance & Performance Improvement (QAPI)The discharge process has been incorporated into the facility's QAPI program.An emergency QAPI meeting was held on 2/6/2026 to address the Immediate Jeopardy situation, with a follow-up scheduled for the next QAPI meeting on 2/10/82026Key actions include:Tracking and trending discharge variancesIdentifying root causesImplementing corrective actionsReporting findings to leadership Performance Goal: Achieve 100% compliance with discharge procedures.Findings: Resident 1's admission Record (Face Sheet) indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included schizoaffective disorder bipolar type, unspecified psychosis seizures, anemia (a condition where the body does not have enough healthy red blood cells), and anxiety disorder. The Face Sheet indicated Resident 1's Conservator was her Responsible Party (RP). During a review of Resident 1's Elopement Risk assessment dated [DATE], the Elopement Risk Assessment indicated Resident 1 was a high risk for elopement. During a review of Resident 1's Fall Risk assessment dated [DATE], the Fall Risk Assessment indicated Resident 1 had a balance problem while standing, walking and a decreased muscular coordination. During a review of Resident 1's Social Services Discharge Plan dated 11/10/2025 and timed at 2:46 p.m., the Social Services Discharge Plan indicated Resident 1 came from a homeless environment and might need additional help once discharged home with the support of her Conservator. During a review of Resident 1's IDT Conference notes dated 11/14/25, the IDT Conference notes indicated Resident 1's Conservator attended the IDT meeting via telephone and there was no discharge planning discussed during the meeting. The IDT Conference Notes indicated the bed hold policy and discharge plan would be reviewed with Resident 1's Responsible Party (RP)/Conservator. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 11/19/2025, the MDS indicated Resident 1 had severely impaired cognitive skills (ability to think, understand, learn, and remember) for daily decision making. The MDS indicated Resident 1 was dependent (helper does all the effort and the resident makes none of effort to complete the activity) on staff to complete her activities of daily living ([ADL] activities such as bathing, dressing and toileting a person performs daily) Resident 1 did not have the ability to ambulate. The MDS indicated had no functional limitation in range of motion (ROM- is the extent of movement of a joint, measured in degrees of a circle) for upper and lower extremity. During a review of Resident 1's Physician's Order dated 1/28/2026 the Physician's Order indicated to discharge Resident 1 to RCC. During a review of Resident 1's Progress Note dated 1/28/2026 and timed at 1:20 p.m., the Progress Note indicated Resident 1 was discharged from the facility and picked up by an emergency transport team (EMT) personnel. The Progress Note indicated prior to Resident 1's departure, all standard safety checks were completed, including identity verification, confirmation of transfer destination, ensuring all necessary documents were attached to the transfer packet and securing the resident safely on a gurney (hospital bed with wheels) with straps. It also indicated Resident 1 was transferred to the RCC and a voice mail was sent to Resident 1's conservator notifying them of Resident 1's transfer. During a telephone interview on 2/3/2026 at 8:18 a.m., the Lead Coordinator at the GACH stated Resident 1 was found wandering in the streets on 1/30/2026, at 3:39 a.m. (approximately 9.1 miles from the RCC) with no shoes on, by the Fire Department and transferred to the GACH. During a review of Resident 1's Emergency Medical Service (EMS) Report dated 1/30/2026, the EMS report indicated Resident 1 was found wandering around the street, not alert or oriented, wearing a helmet with insect eggs all over her clothes and hands. The report indicated Resident 1 was transported to a GACH. During a review of the GACH's admission Record (Emergency Documentation), dated 1/30/2026, the Emergency Documentation indicated Resident 1 was admitted to the GACH on 1/30/2026 with active diagnoses of acute psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) and altered mental status ([AMS] a changed level of awareness or mental state that falls short of unconsciousness). During an interview on 2/3/2026 at 9:37 a.m., Social Services Staff (SSS) 1 stated Resident 1 was conserved under a Public Guardian and was discharged from the facility to a RCC on 1/28/2026. SSS 1 stated the facility did not discuss the discharge planning and Resident 1's transfer to the RCC, with Resident 1's Conservator. SSS 1 stated the facility should have discussed Resident 1's discharge plan and subsequent discharge prior to Resident 1's discharge on [DATE]. SSS 1 stated no IDT meeting was held related to Resident 1's discharge plan prior to Resident 1's discharge. SSS 1 stated this was the first time she used this RCC. During an interview on 2/3/2026 at 10:47 a.m., the Director of Nursing (DON) stated Resident 1 was [AGE] years old, impulsive (the tendency to act or react quickly without planning, forethought, or consideration of potential consequences), had a one to one (a safety intervention where a dedicated staff member is assigned to monitor a single patient at all times), due to her fall risk, from the time of her admission [DATE]) until she was discharged (1/28/2026), she had no rehabilitation potential and did not meet the skill criteria needed to remain at the facility. The DON stated Resident 1 required a lower level of care where her medications would be managed, so she (DON) met with SSS 1, and the decision was made to transfer Resident 1 to the RCC. The DON stated Resident 1's physician was notified and an order obtained to discharge Resident 1 to the RCC for 24-hour care. The DON stated Resident 1's Conservator was not involved in Resident 1's discharge planning or discharge and there was no IDT meeting conducted related to Resident 1's discharge plan/discharge. The DON stated the facility should have waited for authorization from Resident 1's public guardian before discharging the resident to another level of care. During an interview on 2/3/2026 at 12:41 p.m., Resident 1's Conservator stated she visited Resident 1 in the facility (date unknown) and discussed transferring Resident 1 to a locked facility with SSS 1, but SSS1 never followed up with her regarding Resident 1's transfer. The Conservator stated she was responsible for making decisions for Resident 1 and the facility should not have transferred Resident 1 to another facility without her knowledge, involvement and approval, or the approval of someone else in the Public Guardian's office if she was not available. The Conservator stated Resident 1 was a Regional center client who had a mental disability and was developmentally delayed (a child not reaching developmental milestone compared to others of the same age). The Conservator stated transferring Resident 1 to an inappropriate facility placed the resident at risk for neglect and harm. During an interview on 2/3/2026 at 1:52p.m., Certified Nurse Assistant (CNA) 1 stated Resident 1 was alert to person only, could follow instructions, had a one to one sitter, required assistance getting dressed, and could not be left alone because she (Resident 1) was a high risk for falls and a wanderer (when a person with cognitive challenges leaves a safe place and walk away where they can be endangered and cannot trace back). During an interview on 2/4/2026, at 3:38 p.m., with Licensed Vocational Nurse, (LVN) 1 stated to discharge a resident out of the facility, the licensed nurse was to obtain a physician's discharge order, perform a skin assessment, notify the resident's family or conservator, prepare discharge paperwork, print the face sheet and medication summary, and contact the receiving facility. LVN 1 stated these steps were not fully completed during Resident 1's discharge to the RCC. LVN 1 stated he was unable to communicate with the conservator or the receiving facility. LVN 1 stated the conservator should have been informed and provided consent prior to Resident 1's discharge to ensure Resident 1's safety. Resident 1 was oriented only to self and lacked awareness of environment, place, and person, making the discharge unsafe without the conservator's consent. LVN 1 stated he did not communicate with the receiving nurse, did not perform medication reconciliation, and did not endorse Resident 1's medical history to the receiving facility. He stated paperwork was handed to the EMT personnel at the time of discharge. LVN 1 stated he failed to verify the type of setting at the RCC to ensure it could meet Resident 1's needs. LVN 1 stated these failures placed Resident 1 at risk for illness, hospitalization, and life-threatening complications. During a review of facility's undated Policy and Procedure (P&P) titled, Discharge Planning the P&P indicated the Social Service Director, or Designee shall be involved in discharge planning to ensure a safe discharge and successful transition to the next level of care or return to home. The Social Service Director or Designee will work with the IDT, physician, resident, and the resident's representative on the following: a. Discharge planning services (e.g. helping to place a resident on a waiting list for community congregate living, arranging intake for home care services for residents returning home, assisting with transfer arrangements to other facilities), and document in the resident's medical record efforts to involve the resident in discharge planning and efforts to create a successful transition of care. b. Changes to the discharge plan will be discussed with the resident and, if indicated, the resident's representative and documented in the resident's medical record.

Based on interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, Diabetic Management and Insulin Administration, which indicated the facility will ensure safe, timely, and effective monitoring of blood sugar (BS) and administration of insulin in accordance with physician orders and regulatory standards, for one of 3 sampled residents (Resident 1), who was diagnosed with diabetes mellitus type 2 ([DM], a disorder characterized by difficulty in BS control and poor wound healing). The facility failed to:1. Ensure Resident 1's primary care provider (PCP) was aware Resident 1 did not have orders for monitoring BS levels, and insulin coverage. 2. Ensure Resident 1 had orders for BS monitoring and insulin coverage as indicated. 3. Ensure the licensed staff assigned to Resident 1 were aware of Resident 1's diagnosis of DM and monitored the resident's BS for signs and symptoms of hyperglycemia ([high BS] such as blurred vision, fatigue, increased thirst, fruity-scented breath, confusion and loss of consciousness) and hypoglycemia ([low BS] such as sweating, dizziness, hunger, anxiety, difficulty concentrating, and slurred speech). 4. Implement Resident 1's Plan of Care, titled Diabetes Mellitus, Uncontrolled High Blood Sugar Results initiated 9/27/2025 which indicated to monitor Resident 1's BS through finger sticks (a simple procedure where a small amount of blood is collected from the fingertip for testing), and signs and symptoms of hyperglycemia As a result of these deficient practices, on 10/21/2025 Resident 1 was admitted to a general acute care hospital (GACH), diagnosed with hyperglycemia and Diabetic ketoacidosis ([DKA], a life-threatening complication of diabetes that occurs when the body does not have enough insulin and is left untreated for a prolonged length of time), which had the potential to cause Resident 1 to fall into a diabetic coma (a condition when the body is overwhelmed with the amount of BS levels, and the resident cannot wake up or respond purposefully to the environment) and possibly death.Findings A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included DM with DKA without coma, chronic kidney disease (a condition where the kidneys gradually lose their ability to filter waste products from the blood, leading to a buildup of toxins and other harmful substances in the body), and quadriplegia (cannot move or feel their arms and legs due to injury).A review of Resident 1's Care Plan titled, Diabetes Mellitus, Uncontrolled High Blood Sugar Results, indicated to monitor Resident 1 for signs and symptoms of hyperglycemia, monitor BS through finger sticks, and notify the PCP of signs and symptoms of uncontrolled BS A review of Resident 1's Order Summary Report dated 9/27/2025 indicated:-Empagliflozin oral (medication used to treat DM by removing excess sugar from the blood and lowering BS) tablet 10 milligrams ([mg] unit of measurement), give 1 tablet via g-tube (plastic tube surgically inserted into the stomach to provide medications and nutrition) one time a day for DM, -Insulin Regular Human Injection Solution ( a short-acting insulin solution [starts to work after about 30 to 60 minutes and usually lasts up to 8 hours] used to manage high BS levels in individuals with diabetes) 100 units/milliliter (ml unit of measure of volume) inject per sliding scale (insulin amount administered based on the level of the BS and the PCP's order for that level of BS) A review of Resident 1's History and Physical (H&P) dated 9/28/2025, indicated Resident 1 could make his needs known but could not make medical decisions.A review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool), dated 10/7/2025, indicated Resident 1 was rarely/never understood. The MDS indicated Resident 1 was dependent (helper does all the effort to complete the task) for activities of daily living (ADL: hygiene, bathing and getting dressed and mobility functions such as transfers, rolling and sitting up in bed.A review of Resident 1's Order Summary Report, dated 10/13/2025, indicated Lantus, a long-acting insulin which provides a slow, steady release of insulin into the bloodstream to help maintain stable BS levels throughout the day and overnight] to regulate BS) Subcutaneous (injection applied under the skin) solution 100 units/mL (a unit of measurement, used for medication dosage and/or amount) Inject 10 units subcutaneously at bedtime for DM. The Order Summary Report did not include any other orders to monitor or treat Resident 1's diagnosis of DM such as orders for insulin (short-acting) diabetes and BS monitoring for Resident 1.A review of an online article from the American Diabetic Association (a nonprofit organization that funds research to prevent, cure and manage diabetes) website titled Diabetes and DKA (Ketoacidosis) 11/12/2025, DKA was a life-threatening condition that could lead to diabetic coma and death. The article indicated treatment for DKA took place in the GACH but could be prevented by learning the warning signs and checking BS regularly. (https://diabetes.org)A review of Resident 1's Medication Administration Record (MAR) dated 10/1/2025 through 10/31/2025, indicated facility staff administered Lantus Subcutaneous solution 10 units daily to Resident 1 from 10/1/2025 to 10/7/2025 (7 doses of 10 units each) and again daily from 10/14/2025 until 10/20/2025 (7 doses of 10 units each). A review of the facility's blood glucose monitoring machine user instruction manual, revised 10/2024, indicated if a resident's BS level was above 600 mg/dl, the reading will appear as HI on the screen. The user manual indicated the test should be repeated, and if it indicated HI again, the healthcare professional should be contacted immediately. A review of Resident 1's Change in Condition (CIC), dated 10/21/2025 and timed at 12:50 a.m., indicated Resident 1 had high BS that could not register on the glucometer. The CIC indicated Resident 1 had an altered level of consciousness (ALOC not able to respond normally), tachypnea (abnormal rapid, shallow breathing) and oxygen desaturation (an unhealthy decrease in the blood's oxygen levels). The CIC indicated Resident 1 was hypotensive, (low blood pressure),systolic blood pressure (the pressure of blood when the heart pushes blood out to the rest of the body] was 87 millimeters of mercury (mm Hg, unit of measure), (reference range is 90 -120mm Hg), and the diastolic (the measurement between pressure when the heart is filling with blood) was 46 mm Hg, (reference range 60-80 mm Hg). The CIC indicated the facility staff notified Resident 1's DNP who ordered Resident 1 to be transferred to the GACH via emergency transportation services. A review of Resident 1's Order Summary Report, dated 10/21/2025, indicated transfer to ED via emergency transportation services due to high BS, ALOC, tachypnea, and shaking. A review of Resident 1's GACH Emergency Department (ED) Note, dated 10/21/2025 and timed at 1:33 a.m., indicated Resident 1 was sent to the GACH due to ALOC, hypotension and hyperglycemia. The Note indicated 10/21/2025 at 2:01 a.m., Resident 1's blood glucose level was 1824 mg/dl. The Note indicated Resident 1 was admitted with a diagnosis of DKA with coma and was intubated (a tube inserted into an individual's windpipe to help them breathe, usually in an emergency or for surgery to protect the airway). The Note indicated Resident 1 was started on an insulin drip (a medical treatment used in hospital critical care settings to rapidly and precisely manage severe high BS).During a concurrent interview and record review on 10/28/2025 at 3:26 p.m., with Registered Nurse Supervisor (RNS) 1, Resident 1's Order Summary Report dated 10/2025, the MAR dated 10/1/2025 to 10/31/2025, and the Progress Note dated 10/21/2025 were reviewed. RNS 1 stated Resident 1 was admitted to the facility with a diagnosis of DM and should have had his BS monitored daily. RNS 1 stated there should have been orders for BS monitoring and insulin administration as needed. RNS 1 stated there was no order to check Resident 1's BS but there should have been an order to check the BS and give insulin coverage as needed if the BS was high. RNS 1 stated if BS checks were not done, and the BS level was not controlled Resident 1, could go into hyperglycemic shock. During a telephone interview on 10/29/2025 at 10:37 a.m., with Resident 1's PCP, the PCP stated he was aware Resident 1 was a diabetic with a history of DKA. The PCP stated he was not aware Resident 1 did not have orders for BS monitoring. The PCP stated he was not aware Resident 1's BS was not checked from 10/13/2025 until 10/21/2025 when Resident 1 had to be transferred out to GACH due to hyperglycemia. During an interview on 10/29/2025 at 3:07 p.m., with the Director of Nursing (DON), the DON stated it was her responsibility to review all newly admitted residents' clinical documents including Resident 1, to ensure residents received the appropriate care and treatments. The DON stated facility staff should have checked Resident 1's BS at least four times a day with orders to administer insulin as indicated, when he was readmitted on [DATE]. The DON stated she should have clarified the orders with Resident 1's PCP to ensure Resident 1's DM was properly monitored for complications of hyperglycemia. The DON stated since BS checks and insulin were not administered when Resident 1's BS level was high, Resident 1 experienced ALOC, and was at risk for DKA, unconsciousness, and non-responsiveness. The DON stated it was the facility's responsibility to make sure residents with diagnosis of DM had BS checks and insulin orders in place. During a concurrent interview and record review on 10/30/2025 at 2:57 p.m., with RNS 2, Resident 1's care plan, titled Diabetes Mellitus Uncontrolled High BS Results dated 9/27/2025, was reviewed. RNS 2 stated Resident 1 had a diagnosis of DM, and the interventions on the care plan included to monitor Resident 1 for signs and symptoms of hyperglycemia, and to monitor the resident's BS. RNS 2 stated the facility did not implement Resident 1's care plan for DM. RNS 2 stated the staff did not check the resident's BS four times a day (before meals and at bedtime) and did not administer insulin to Resident 1 as needed per the sliding scale. RNS 2 stated any resident admitted with a diagnosis of DM should have orders for BS monitoring. RNS 2 stated a care plan was a plan on how to take care of residents. RNS 2 stated the care plan should be initiated and implemented according to each resident's diagnoses. RNS 2 stated a care plan outlined how staff should care for the residents, and If the care plan was not followed, it may lead to a negative outcome (hyperglycemia, DKA, coma) in the residents' condition. A review of the facility's undated policy and procedures (P&P) titled Diabetic Management and Insulin Administration, indicated to ensure safe, timely, and effective monitoring of blood glucose and administration of insulin in accordance with the physician orders and regulatory standards.A review of the facility's undated P&P titled, Comprehensive Plan of Care, indicated the facility will develop a comprehensive plan of care for each resident including goals, measurable objectives and timetables to meet their medical, nursing, mental, psychosocial needs as identified during each resident's comprehensive assessment. The P&P indicated the care plan must describe services provided to the resident including interventions to attempt to manage risk factors; periodically reviewed and revised by the interdisciplinary team as changes in the resident's care and treatment occurred,.re-evaluate and modify care plans as necessary to reflect changes in care, service and treatment, quarterly, and with significant change in status assessment.A review of the facility's undated Job Description titled, RN Supervisor, indicated the RN supervisor will provide direct nursing care to the residents, and supervise the day-to-day nursing activities performed by the Licensed Vocational Nurse (LVN) and certified nursing assistants (CNA). The job description indicated nursing care functions included consulting with the resident's physician in providing the resident's care, treatment, rehabilitation, as necessary, review the resident's chart for specific treatments, medication orders, diets, as necessary, implement and maintain established nursing objectives and standards, make periodic checks to ensure that prescribed treatments are being properly administered by certified nursing assistants and to evaluate the resident's physical and emotional status, ensure that direct nursing care be provided by a licensed nurse and/or a certified nursing assistant, ensure that personnel providing direct care to residents are providing such care in accordance with the residents' care plan and wishes, review care plans daily to ensure that appropriate care is being rendered, inform the nurse supervisor of any changes that need to be made on the care plan, ensure that your nurses' notes reflect that the care plan is being followed when administering nursing care or treatment. review resident care plans for appropriate resident goals, problems, approaches, and revisions based on nursing needs, ensure that your assigned LVNs and CNAs are aware of the resident care plans.A review of the facility's undated job description titled, Director of Nursing Service/Vice President of Nursing Service, indicated the purpose of this position is to provide nursing management, set resident care standards for all direct care providers and provide complete supervision and management for the nursing department. assess resident needs and interview, set resident care standards in accordance with accepted current standards of care to provide high quality care to residents, develop and implement policies and procedures for nursing care of residents, supervise and manage all aspects of the nursing department, assess, direct and supervise residents' care needs.direct, evaluate and supervise all resident care and initiate corrective action as necessary.assess resident care needs and assist in the development of individualized plans of resident care. assess resident pre-admission and/or admission information and determine appropriate level of care.assess resident responses to medication and treatments and make appropriate recommendations for nursing action to be implemented.consistently make accurate level of care determinations, based on the physician's recommendations and the resident's plan of care.

Based on interview, and record review, the facility failed to ensure the resident, who had a diagnosis of paraplegia (loss of movement and/or sensation, to some degree, of the legs), did not fall and sustain an injury during transfer from bed to a shower chair for one of three sampled residents (Resident 2). The facility failed to: 1. Ensure Certified Nursing Assistant (CNA 4) and Restorative Nursing Assistant (RNA) 1 used a mechanical lift (a device used to safely move and transfer individuals who have limited mobility, especially those who cannot bear weight independently) to transfer Resident 2 from a bed to a shower chair as recommended by the Physical Therapy (PT) department. 2. Develop a care plan for Resident 2's mode of transfer between surfaces with an intervention to prevent the resident's injury. 3. Ensure staff followed the facility's policy and procedure (P/P) titled, Total Mechanical Lift dated 9/29/2016, which indicated a mechanical lift is used to appropriately facilitate transfers of residents. 4. Ensure staff followed facility's P/P titled, Falls Prevention Program revised 2/2025, which indicated staff from all departments will be expected to contribute to the efforts of fall prevention for their residents. As a result of this deficient practice, Resident 2 sustained an acute (severe and sudden in onset) minimally displaced impacted (a fracture [broken bone] where the broken bone fragments are compressed together but the degree they are out of alignment is small) distal (sites located away from a specific area, most often the center of the body) fracture of the left femur (thigh bone) when she had an assisted fall (a fall in which a staff member was with the resident and attempted to minimize theimpact of a fall by slowing by slowing the resident's descent) while being transferred from a bed to a shower chair by CNA 4 and RNA 1 without using a mechanical lift. Findings: During a review of Resident 2's Admission Record (Face Sheet), the Face Sheet indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of paraplegia. During a review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool), dated 4/22/2025, the MDS indicated Resident 2 had no cognitive (thought process) impairment. The MDS indicated Resident 2's functional abilities to both her lower extremities (legs) were impaired, and she was dependent (helper does all of the effort, resident does none of the effort to complete the activity or, the assistance of two or more helpers is required for the resident to complete the activity) for toileting hygiene, shower/bathe and chair/bed to chair transfers. During a review of Resident 2's History and Physical (H&P), dated 4/15/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Physical Therapy (PT) Evaluation and Plan of Treatment, dated 4/16/2025, the PT Evaluation and Plan of Treatment indicated Resident 2 presented with balance deficits, decreased dynamic balance (the ability to maintain a stable posture and control movements while the body is in motion), decreased static balance (the ability to maintain an upright posture and keep the center of gravity within the limits of the base of support while standing or sitting still), gross motor (physical abilities involving large muscle groups and body movements, such as walking, running, jumping, and climbing) coordination deficits, pain, strength impairment, deficits in judgment and limitations in range of motion ([ROM] the direction a joint can move to its full potential). The PT Evaluation and Plan of Treatment indicated Resident 2 was totally dependent on transfers and with bed mobility. The PT Evaluation and Plan of Treatment indicated a recommendation for Resident 2 to use a mechanical lift during transfers. During a review of Resident 2's Occupational Therapy (OT) Evaluation and Plan of Treatment, dated 4/16/2025, the OT Evaluation and Plan of Treatment indicated Resident 2 presented with a decrease in activity tolerance affecting her ability to safely perform and complete self-care activities safely with her activities of daily living ([ADLs] (activities such as bathing, dressing and toileting a person performs daily) due to decreased activity tolerance, decrease strength, and decrease sitting tolerance. During a review of Resident 2's Change of Condition (COC) form, dated 4/19/2025, the COC indicated Resident 2 was observed sitting on the floor following an assisted fall. The COC indicated Resident 2 complained of pain to her left breast rated six out of 10 on a pain scale (an 11 eleven point scale where pain is rated from zero to 10; 0=no pain, 1-3=mild pain, 4-6=moderate pain, and 7-10=severe pain, and 10=worst imaginable pain). The COC indicated Resident 2 was medicated with Acetaminophen Extra Strength 500 milligram ([mg] metric unit of measurement, used for medication dosage and/or amount)for moderate pain. During a review of Resident 2's Skin assessment dated [DATE], the Skin Assessment indicated Resident 2 had slight swelling to her left knee and her left knee was warm to touch. During a review of Resident 2's COC dated 4/24/2025, the COC form, indicated Resident 2 complained of a five out of 10 pain level to her left knee. The COC indicated Resident 2's physician was notified and an order for an X-Ray (a procedure that takes pictures of the inside of the body to diagnose broken bones and other injuries) to Resident 2's left knee was given. During a review of Resident 2's Physician's Order dated 4/24/2025, the Physician's Order indicated to obtain an X-ray of Resident 2's left knee due to pain and swelling. During a review of Resident 2's Radiology (the branch of medicine that uses imaging technology to diagnose and treat disease) Report dated 4/24/2025, the Radiology Report indicated Resident 2 sustained an acute minimally displaced impacted fracture to her distal left femur. During an interview on 4/30/2025 at 10:36 a.m., Registered Nurse Supervisor (RNS) 2 stated, CNA 4 reported that Resident 2 had an assisted fall on 4/19/2025. RNS 2 stated on 4/19/2025, when she (RNS 2) entered Resident 2's room she found Resident 2 sitting on the floor. RNS 2 stated CNA 4 reported that she (CNA 4) and RNA 1 attempted to transfer Resident 2 from her bed to a shower chair without using a mechanical lift. RNS 2 stated she was not aware that Resident 2 refused to be transferred using the mechanical lift. RNS 2 stated CNA 4 and RNA 1 should have used a mechanical lift to transfer Resident 2. During a telephone interview on 4/30/2025 at 10:57 a.m., CNA 4 stated on 4/19/2025, Resident 2 requested to be transferred from her bed to a shower chair using a mechanical lift. CNA 4 stated she had to look for a mechanical lift and sling (a flexible strap or belt used in the form of a loop to support or raise a weight), but Resident 2 did not want to wait and insisted on being transferred without using a mechanical lift. CNA 4 stated she asked RNA 1 to assist with Resident 2's transfer. CNA 4 stated when they attempted to transfer Resident 2, they realized she was too heavy, and they assisted her to the floor. CNA 4 stated for safety Resident 2 should have been transferred using a mechanical lift. During an interview on 4/30/2025 at 11:59 a.m., Resident 2 stated staff would usually transfer her by using a mechanical lift but on 4/19/2025 she insisted that CNA 4 transfer her from her bed to a shower chair without it because the sling hurts her back and she did not want to use the mechanical lift. Resident 2 stated during the transfer RNA 1 placed his (RNA 1) hand under her (Resident 2) left arm and at the same time put pressure on her left breast causing her pain. Resident 2 stated she screamed put me down, put me down! and she was assisted to the floor by CNA 4 and RNA 1. Resident 2 stated when she was on the floor, she noticed her left leg was twisted backwards and asked CNA 4 to place her leg forward. During an interview on 4/30/2025 at 12:48 p.m., RNA 1 stated on 4/19/2024 CNA 4 asked him to assist her with Resident 2's transfer from her bed to a shower chair. RNA 1 stated, during the transfer Resident 2 started leaning forward and they (CNA 4 and RNA 1) could not hold her up, so they sat her on the floor and requested help. RNA 1 stated he knew Resident 2 used a mechanical lift for transfers, but Resident 2 was in a hurry and insisted they not use the mechanical lift. RNA 1 stated if given the opportunity to redo the transfer he would have used the mechanical lift for the safety of the resident. During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 3 on 4/30/2025 at 1:16 p.m., LVN 3 stated on 4/19/2025 CNA 4 called her and RNS 2 to Resident 2's room and they (LVN 3 and RNS 2) both found Resident 2 sitting on the floor. LVN 3 stated Resident 2 should have been transferred using a mechanical lift and if Resident 2 refused to be transferred using the mechanical lift, CNA 4 and RNA 1 should have notified her (LVN 3) and/or RNS 2. During an interview on 5/1/2025 at 9:25 a.m., the Director of Nursing (DON) stated because of Resident 2's diagnosis of paraplegia, a Care Plan did not have to be created with an intervention to use a mechanical lift when transferring Resident 2. The DON stated the recommendation from the Rehabilitation Department to use a mechanical lift when transferring Resident 2 should have been enough for the staff and the nurses should have followed PT's recommendation to use the mechanical lift to prevent Resident 2 from falling and sustaining an injury. During a concurrent interview and record review with the Director of Rehabilitation (DOR) on 5/1/2025 at 12:10 p.m., Resident 2's OT/PT Evaluation and a Plan of Treatment dated 4/16/2025 was reviewed. The OT/PT Evaluation and Plan of Treatment indicated Resident 2 was placed on the high risk for falls list and based on the evaluation and plan of treatment Resident 2 was required to be transferred using a mechanical lift. The DOR stated the nursing staff should have followed the recommendation from the OT/PT to use a mechanical lift when transferring Resident 2 to prevent Resident 2 from falling. The DOR stated the rehabilitation department communicates the residents' needs verbally and via their OT/PT evaluation to the nursing staff and they should have been aware of the recommendation to transfer Resident 2 using a mechanical lift. During a review of the facility's Policy and Procedure (P/P), titled, Falls Prevention Program revised 2/2025, the P/P indicated staff from all departments will be expected to contribute to the efforts of fall prevention for their residents. During a review of the facility's P/P, titled, Total Mechanical Lift dated 9/29/2016, the P/P indicated that a mechanical lift is used to appropriately facilitate transfers of residents.

Based on observation, interview and record review, the facility failed to ensure the resident did not develop a deep tissue skin injury ([DTI] (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure) on the right lateral (side) foot and the right buttock for one of four reviewed residents (Resident 154). The facility failed to: 1.Ensure Resident 154 was turned and repositioned every two hours per physician order and a care plan titled, Risk for Skin breakdown dated 1/27/25 2. Ensure Resident 154 skin assessment was done during shower days and/or bed bath (a wash that you give to someone who cannot leave their bed). 3. Ensure Certified Nursing Assistant (CNA- in general) inspected Resident 154's skin daily and the licensed nurses assessed the resident 's skin weekly as indicated in the resident's care plan titled, Risk for Skin Breakdown dated 1/2025. These failures resulted in Resident 154 in developing a DTI on 2/25/25 measured 2.5 centimeter ([cm] a unit of measurement) in length by 2.0 cm in width, on the right lateral foot and on 3/11/25 developing DTI on a right buttock measured 3.5 cm in length by 1.5 cm in width and with undetermined depth. Findings: a. During a review of Resident 154's Admission Record, the Admission Record indicated Resident 154 was admitted to the facility on [DATE], with diagnoses of cerebral infarction (damage to the brain from interruption of its blood supply), chronic respiratory failure (a long-term condition where there is not enough oxygen in your body), and functional quadriplegia (complete immobility due to severe disability requiring total assistance with daily activities). During a review of Resident 154's History and Physical (H&P), dated 1/28/25, the H&P indicated, Resident 154 did not have the capacity to understand and make decisions. During a review of Resident 154's Minimum Data Set ([MDS], resident assessment tool), dated 2/1/25, the MDS indicated, Resident 154 was dependent (helper does all the effort. Resident does none of the effort to complete the activity) on staff for toileting hygiene, shower/bath self, and personal hygiene. The MDS indicated Resident 154 was always incontinent of bowel (no episodes of continent bowel movements) The MDS indicated Resident 154 was at risk of developing pressure injuries. During a review of Resident 154's Braden Scale (tool used to assess a patient's risk of developing pressure injury) dated 1/25, the Braden Scale indicated, Resident 154's total score of 10 (High Risk: Total Score 10-12) which indicated Resident 154 was a high risk for developing a pressure injury. During a review of Resident 154's care plan titled, Risk for Skin breakdown, dated 1/27/25 the care plan indicated the goal for Resident 154's was to have an intact skin as evidence by no redness over bony prominences (areas where bones are close to the skin's surface) and other pressure area. The care plan interventions included to turn and reposition resident at least every two hours, reassess skin daily by CNA and weekly by licensed nurses/treatment nurse and notify a physician and resident or resident representative for significant change in skin condition. During a review of Resident 154's Physician Order Summary, dated 1/27/25, the Physician Order Summary indicated to elevate the resident's left and right lower extremity with a pillow when in bed daily for 14 days. During a review of Resident 154's Interdisciplinary Team ([IDT] team members from different departments working together with a common purpose to set goals and make decisions that ensure residents receive the best care) Conference, dated 1/29/25, the IDT Conference indicated interventions for skin breakdown included repositioning the resident as often as needed. During a review of Resident 154's undated IDT Notes for Pressure Ulcer and Other Wounds Recommendations/Comments, the IDT notes indicated, Resident at risk for further skin breakdown from multiple medical contributing factors; severely contracted, generalized edema (swelling), limited positioning, total dependent with two persons assist in bed mobility and positioning. During a review of Resident 154's Skin Inspection dated 2/7/25 Resident 154's right buttock and right lateral foot had intact skin. During a review of Resident 154's Physician Order Summary dated 2/25/25, the Physician Order Summary indicated to apply Prevalon Boots (help reduce the risk of pressure injury by keeping the heel floated) to bilateral feet while in bed to reduce/prevent further pressure damage every day and night shift. During a review of Resident 154's Skin Integrity Report, dated 2/25/25, the Skin Integrity Report indicated the resident had a DTI to a right buttock measured 3.5 cm in length, 1.5 cm in width, with undetermined depth and DTI to a right lateral foot measured l 2.5 cm in length, 2.0 cm in width with undetermined depth. During a review of Resident 154's Treatment administration Record (TAR) dated 2/25/25, the TAR indicated a physician's order to apply Prevalon Boots, to relieve pressure to bilateral feet while in bed to reduce/prevent further damaged due to pressure, on day shift (7a.m. to 7 p.m.) and on night shift (7 p.m. to 7 a.m.). During a review of Resident 154's undated shower record, titled Subacute Shower, the record indicated, Resident 154's shower days were Tuesday and Friday. During an observation on 3/12/25 at 8:39 a.m. in Resident 154's room, Resident 154 was observed in bed lying on a left side with eyes open, non-verbal (unable to communicate using spoken words), and non-responsive to verbal and tactile stimuli (any form of touch or physical contact that is perceived by the skin). During a concurrent observation and interview on 3/12/25 at 1:21 p.m. with Treatment Nurse (TN ) 1, in Resident 154's room, Resident 154 was observed in bed lying on a left side with open eyes and non-verbal. Resident 154 was observed lying on a low loss air mattress ([LAL] a type of medical mattress designed to prevent and treat pressure injury by constantly circulating air through tiny holes, keeping the skin cool and dry and reducing moisture buildup) with a sheet under the resident. During the observation Resident 154's was observed to have a pressure injury located on her right lateral foot which appeared with intact skin and black discolored area without a drainage. Also, Resident 154 was observed to have an open skin on the right buttock, red in color and without a drainage. TN 1 stated the Registered Nurse (RN) and TN were responsible for performing skin assessments upon admission, weekly, and as needed. TN 1 stated CNA's will inform TN of any changes in residents skin condition. TN 1 stated during shower and resident bed bath, CNAs would do a residents ( in general) skin inspections and document on the Skin Inspection sheet of any changes to a residents' skin. TN 1 stated any changes to a residents' skin will be reported immediately to the charge nurses and TN. TN 1 stated residents were showered twice weekly and received bed baths on remaining days of the week. TN 1 stated CNA 3 reported to TN 1 Resident 154's newly developed pressure injury to the right buttock on 3/11/25 (documented 2/25/25). TN 1 stated it started as a blister that progressed to a DTI. TN 1 stated Resident 154 also developed a DTI to her right lateral (side) foot that was observed on 2/25/25 during TN 1 weekly wound assessment. TN 1 stated Resident 154 should be turned and repositioned every two hours and as needed in order to prevent pressure injuries and to prevent Resident 154 pressure injuries on her sacrococcyx, left and right ear from getting worse. TN 1 stated turning and repositioning residents helps with blood circulation (the movement of blood throughout the body) and helps to decrease the chances of developing a pressure injury. TN 1 stated Resident 154's pressure injury to the right lateral foot and right buttock could have been avoided if the resident was turned every two hours and if Prevalon boots were applied on admission on 1/25/25. TN 1 stated he did not order Prevalon boots to Resident 154, instead he used pillows to help relieve the pressure from Resident 154's heels. During a concurrent interview and record review on 3/12/25 at 1:30 p.m. with TN 1, Resident 154's Turn and Reposition Turning Schedule for the month of 2/2025, was reviewed. The Turn and Reposition Turning Schedule indicated Resident 154 had not been turned and repositioned every two hours per Resident 154's care plan. TN 1 stated that Resident 154 had not been turned and repositioned every 2 hours for several days (from 2/11/25 through 2/28/25). During an observation on 3/12/25 at 3:30 pm in Resident 154's room, Resident 154 remains in bed lying on her left side. During a concurrent interview and record review on 3/13/25 at 9:20 a.m. CNA 3 stated that he was responsible for assisting residents with their activities of daily living and turning and repositioning the residents in bed. Resident 154's Skin Inspection Sheets dated 2/7/25 and 2/11/25 were reviewed with CNA 3. CNA 3 stated Resident 154 right buttock and right heel skin were intact. CNA 3 stated Resident 154 did not have Skin Inspection sheets for the month of 1/25 and 3/25. CNA 3 stated missing Resident 154's Skin Inspection sheets indicated Resident 154 did not receive a shower on her scheduled shower days (Tuesdays and Fridays) and the resident's skin was not inspected. CNA 3 stated that he was responsible for doing skin inspection when Resident 154 received a shower or a bed bath. CNA 3 stated he must report any observed skin changes to the charge nurse or treatment nurse immediately. CNA 3 stated on the days that residents (in general) were not scheduled for shower; residents should receive a bed bath. CNA 3 stated skin changes would be considered open areas, redness, blisters, discoloration, and swelling of the skin. CNA 3 stated after resident shower or bed bath he documents on the Skin Inspection Sheets and the treatment nurse reviews the Skin Inspection Sheets and signs the sheet after it was reviewed. CNA 3 stated residents should be turned and repositioned every two hours and as needed. CNA 3 stated when the residents were turned and repositioned it should be documented on the residents Turn and Reposition Turning Schedule form. CNA 3 stated if there was no documentation on the Turn and Reposition Turning Schedule form it means that Resident 154 was not turned and repositioned. CNA 3 stated if residents were not turned and repositioned every two hours it had the potential to result in pressure injury. During a concurrent interview and record review on 3/13/25 at 9:44 a.m. with the Director of Staff Development (DSD), Resident 154's Skin Inspection Sheets for the month of 1/25, 2/25, and 3/25 were reviewed. The Skin Inspection Sheets indicated Resident 154 did not receive a shower and her skin was not inspected on the following days: On 1/28/2025 (Tuesday) On 1/31/2025 (Friday) On 2/7/2025 (Friday) On 2/14/2025(Friday) On 2/25/2025 (Tuesday) On 2/28/2025 (Friday) On 3/4/2025 (Tuesday) On 3/7/2025 (Friday) The DSD stated that CNAs were responsible for checking the residents' skin on the residents' shower days and to document it on the Skin Inspection Sheet. The DSD stated the purpose of the Skin Inspection Sheet was to document any skin changes including open areas, redness, blisters, discoloration, and swelling and inform the charge nurse and treatment nurse, so that charge nurse and or TN could intervene in a timely manner and implement the necessary interventions. The DSD stated that according to the reviewed Skin Inspection Sheets , Resident 154 was only showered on 2/7/2025 and 2/11/2025 since her admission on 1/25/2025. The DSD stated residents (in general) should be showered according to their shower schedule and if the residents do not receive a shower they should receive a bed bath. The DSD stated showering residents that have pressure injuries helps maintain healthy skin by keeping the area clean and dry, and removing potential irritants (is a substance that directly damages the skin's surface when it comes into contact) like stool and urine which could cause pressure injuries. During a concurrent interview and record review on 3/13/25 at 10:30 a.m. with CNA 3, Resident 154's Turn and Reposition Turning Schedule, dated February 2025 was reviewed. The Turn and Reposition Turning Schedule indicated Resident 154 should be turned and repositioned every two hours. CNA 3 stated there was no documentation that indicated Resident 154 was turned every two hours as ordered by Resident 154 physician. The Turn and Reposition Schedule for the following dates and times were documented as follows: On 2/11/2025 6:02 a.m.,14:20 p.m., and 9:23 p.m. On 2/12/2025 6:00 a.m.,12:24 p.m.,1:01 p.m., and 8:38 p.m. On 2/13/2025 6:59 a.m., 12:10 p.m.,1:15 p.m.,3:51 p.m., and 9:54 p.m. On 2/14/2025 1:05 a.m.,6:36 a.m.,1:50 p.m.,3:54 p.m., and10:11 p.m. On 2/15/2025 3:11 a.m., and 6:57 a.m. On 2/16/2025 2:30 a.m.,6:50 a.m.,2:50 p.m.,4:20 p.m., and 9:37 p.m. On 2/17/2025 2:31 a.m.,6:37 a.m.,12:34 p.m.,1:56 p.m., 4:20 p.m., and 10:06 p.m. On 2/18/2025 6:00 a.m.,12:51 p.m.,1:44 p.m.,6:20 p.m., and 9:13 p.m. On 2/19/2025 6:00 a.m.1:26 p.m.6:34 p.m., and 9:25 p.m. On 2/20/2025 6:00 a.m.,12:42 p.m.,1:57 p.m.,4:15 p.m., and 10:18 p.m. On 2/21/2025 6:00 a.m., 2:40 p.m.,5:40 p.m., and 10:00 p.m. On 2/22/2025 6:00 a.m., 1:46 p.m., 3:57 p.m., and 10:35 p.m. On 2/23/2025 1:16 p.m.4:21 p.m.9:48 p.m. On 2/24/2025 3:26 a.m.6:09 a.m.2:44 p.m. 6:43 p.m.10:16 p.m. On 2/25/2025 6:44 a.m.,11:40 a.m.,2:04 p.m.10:10 p.m. On 2/26/2025 2:00 p.m.7:52 p.m. On 2/27/2025 5:32 a.m.10:39 a.m.11:38 a.m.1:48 p.m., and 7:57 p.m. On 2/28/2025 6:00 a.m.,2:37 p.m., and 8:53 p.m. CNA 3 stated, Resident 154 should have been turned and repositioned every two hours and as needed to prevent pressure injuries from developing and prevent Resident 154 pressure injuries on her sacrococcyx and right and left ear from getting worse. CNA 3 stated Resident 154 could have developed the pressure injuries on her right lateral foot and right buttocks from not being turned every two hours. CNA 3 stated that he discovered Resident 154's right buttock pressure injury on 3/11/2025 and informed the License Vocational Nurse (LVN ) 2 and the TN (unknown) about Resident 154's pressure injury on right buttock. CNA 3 stated Resident 154 had not been turned and repositioned every two hours on several days as ordered (from 2/11/25 through 2/28/25). During a concurrent interview and record review on 3/13/25 at 11:39 a.m. LVN 2 stated CNAs were responsible to provide residents a shower and bed baths. LVN 2 stated CNAs were responsible for doing skin inspections when giving a shower and bed baths and to report any skin changes to the charge nurse and treatment nurse. LVN 2 stated the RN ( in general) and the TN (in general) were responsible for assessing the residents' skin upon admission and weekly. LVN 2 stated skin changes would be considered open wounds, redness, bruising, blisters, and drainage. LVN 2 stated all residents should receive a shower twice weekly by the CNA's depending on their shower schedule. LVN 2 stated providing a shower was part of the residents' hygiene and a way to assess the residents skin integrity. LVN 2 stated residents should be turned and repositioned every two hours and as needed, especially for residents that are dependent for care and have pressure injuries, to prevent developing pressure injuries and aid in healing their current pressure injuries. LVN 2 stated Prevalon boots were important intervention for residents that were high risk for developing pressure injuries because they decrease the pressure under residents' feet. LVN 2 reviewed Resident 154's Skin Inspection sheet dated 2/7/2025 and 2/11/2025 and validated that Resident 154 did not have any other Skin Inspection sheets. LVN 2 stated the lack of Skin Inspection sheets confirms that Resident 154 did not have skin inspections and was not showered on Tuesday and Fridays as per her showering schedule. During an interview on 3/14/25 at 4:17 p.m. with the Director of Nursing (DON), the DON stated the RN Supervisor (RNS) and TN were responsible for doing skin assessments upon a resident admission, weekly and as needed. The DON stated CNAs were responsible for doing skin inspections when providing a shower and bed baths and report any findings to the charge nurse and TN. The DON stated residents were showered twice weekly and the CNA's use Skin Inspection Sheets to document resident skin condition once the resident received a shower or bed bath. The DON stated if a resident does not have a Skin Inspection Sheet completed, it would be an indication that the resident did not receive a shower and did not have a skin inspection done by the CNA's. The DON stated it was imperative that residents receive showers and bed baths as this their right, and good hygiene practices, can help prevent or reduce the risk of pressure injury infection. The DON stated residents that are total dependent need to be repositioned and turned every two hours, because it helps to maintain their skin integrity, improves circulation, and relieves pressure which could cause pressure injury. During a review of the Certified Nursing Assistant (CNA) Job Description, [undated], the CNA Job Description indicated, Special Nursing Care Functions .Turn bedfast residents at least every two (2) hours. During a review of facility's P&P titled Wound and Ulcer Protocol undated, the P&P indicated, CNA's will complete body checks on resident shower days and report findings to the charge nurses. The P&P indicated the treatment nurse will ensure if the treatment plan is appropriate for the current status and if changes are needed , the treatment nurse will obtain needed treatment from the physician. 45269

Based on interview and record review, the facility failed to ensure the resident, who was a high risk for falls and injuries, did not fall and sustain injury for one of three sampled residents (Resident 4). The facility failed to: 1. Ensure staff implemented the fall risk prevention program for Resident 4, which included landing pads (a rectangular floor pads with inner surface made of foam or other cushiony materials used to provide a softer place for the resident to land when falling especially if the residents are falling from the bed), bed in low position, bed and chair alarm (devices that are attached to a resident's bed/wheelchair and sound an alarm when the resident gets up). 2. Ensure Resident 4 had landing pads, and bed alarm in place, and had the bed in the lowest position to prevent from falls per care plan titled, Resident is High Risk For Injury/Accidents And Repeat Falls. 3. Ensure Certified Nursing Assistant (CNA) 4 and CNA 5 were informed of Resident 4's high risk for falls to ensure implementation of interventions to prevent the resident from falling. 4. Ensure staff followed the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, revised 7/2017, which indicated The care team will target interventions that will reduce individual risks related to hazards in the environment including adequate supervision and assistive devices (equipment that can help you perform tasks and activities). These failures resulted in Resident 4 falling from the bed on 1/26/2025 and sustaining a right femoral neck fracture (a break in the upper part of the thigh bone, just below the hip joint), right humerus fracture (a break in the upper arm bone on the right side of the body). Resident 4 was transferred to a General Acute Care Hospital (GACH) on 1/27/2025 and underwent a right hip cephalomedullary nail (nail inserted to the bone to help restore its shape and alignment) surgery. Findings: During a review of Resident 4's Admission Record, the Admission Record indicated Resident 4 was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including fracture (broken bone) of unspecified right femoral neck, right humerus fracture, history of falling, muscle weakness and bilateral (both) primary osteoarthritis (a condition that occurs when the cartilage [flexible tissue] that lines your joints is worn down ) of both hips. During a review of Resident 4's Minimum Data Set (MDS-resident assessment tool) dated 11/20/2024, the MDS indicated Resident 4 had moderately impaired cognitive skills (ability to think, understand, learn, and remember) for daily decision making and required a substantial/ maximal assistance (helper does more than half the effort) with toileting hygiene, showering or bathing. The MDS indicated Resident 4 required partial or moderate assistance (helper does less than half the effort) with upper and lower body dressing, personal hygiene, bed mobility, toilet transfer and transfer to and from a bed to a chair. The MDS did not indicate any resident's history of falls since admission on 4/14/2016 or prior MDS assessment (2/23/2024,5/23/2024 and 11/20/2024). During a review of Resident 4's Nurses Progress Notes dated 1/4/2024, and timed at 4:30 p.m., the Nurses Progress Notes indicated a change in condition (COC - a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional condition) due to Resident 4 was found lying on the floor on 1/4/2024. The Nurses Progress Notes indicated Resident 4 tried to transfer herself back to her wheelchair without calling for help. During a review of Resident 4's Fall Risk Evaluation dated 11/20/2024, the Fall Risk Evaluation indicated Resident 4 score was 14 (indicates a person's level of risk for falling, with higher scores signifying a greater risk; a score of 10 and above represents high risk for fall). During a review of Resident 4's COC dated 1/27/2025 and timed at 12:05 a.m., the COC indicated Resident 4 had a fall on 1/26/2025 at 11:15 p.m. and was complaining of body pain on a right side (shoulder and knee) with a pain scale of 7 out of 10 (pain screening tool using numerical value to assess the level of pain; 7 to 9-severe pain). The COC indicated Resident 4's physician was notified and placed an order to transfer Resident 4 to GACH via 911 (a phone number used to contact for emergency services) was received and carried out. During a review of Resident 4's Care Plan titled, Resident is High Risk For Injury /Accidents And Repeat Falls related to poor safety awareness, unsteady gait/balance, functioning beyond capabilities dated 11/24/2023, the Care plan indicated the goal for Resident 4 was not to have injury/accident or falls and to minimize the risk for falls through the review date on 12/8/2023. The Care Plan interventions included frequent visual checks (regularly assessing residents), monitoring and to implement fall precautions (not specified). During a review of Resident 4's Care Plan titled, Resident is High Risk For Injury/Accidents And Repeat Falls revised on 1/27/2025, the Care Plan indicated Resident 4 had poor safety awareness, was not using a call light for assistance, was functioning beyond capabilities, and getting out of bed without calling for assistance. The Care Plan indicated the goal for Resident 4 was not to have injuries /accidents or falls and to minimize the risk of falls through the review date. The Care Plan interventions included to continue frequent (not specified) visual checks, implement fall precautions, bilateral (both) landing pads, wheelchair alarm, bed alarm and to assess and educate the resident about using a call light for assistance. During a review of Resident 4's right femur (thigh bone) X-ray (a photographic image of the internal composition of something, especially a part of the body) dated 1/27/2025, the X-ray indicated a right femoral neck fracture. During a review of Resident 4's right humerus (long bone in the upper arm extending from the shoulder to the elbow) X-ray dated 1/27/2025, the X-ray of the right humerus indicated a proximal (near the center of the body) humerus fracture (broken bone in the upper part of the right arm). During a review of Resident 4's GACH Records titled Operative Report, dated 1/27/2025, the Operative Report indicated Resident 4 had right hip cephalomedullary nail surgery. During a review of Resident 4's Physical Therapy (PT- licensed professional aimed in the restoration, maintenance, and promotion of optimal physical function)) Evaluation and Plan of Treatment dated 1/30/2025, PT Evaluation indicated Resident 4 showed significant declined in her functional mobility with decreased muscle strength on bilateral lower extremities, decreased balance and inability to ambulate (walk) at this time. During an interview on 2/4/2025, at 9:42 a.m. with Certified Nursing Assistant (CNA 1), CNA 1 stated there were no landing pads or bed alarm on Resident 4's bed, and her bed was not in a low position before the resident's fall on 1/26/2025 at around 11:15 p.m. CNA 1 stated for residents, who are at high risk for fall, The facility keeps the bed low, places a pad alarm on the bed and wheelchair and have staff to do frequent visual checks ( not specified). During an interview on 2/4/2025, at 10:45 a.m. Licensed Vocational Nurse (LVN) 5 stated Resident 4 slid off the bed while trying to remove her pants and fell off the bed on 1/26/2025 at 11:15 p.m. LVN 5 stated Resident 4 required assistance with transferring between surfaces, walking, dressing and toileting. LVN 5 stated Resident 4 did not have a landing pad, the resident's bed was not in a low position, and there was no bed alarm present on a bed prior to Resident 4's fall on 1/26/2025. During a telephone interview on 2/4/2025, at 1:38 p.m. CNA 4 stated on 1/26/2025, at around 11:15 p.m. Resident 4 was on the floor near Resident 4's wheelchair and was asking for help. CNA 4 stated Resident 4's bed was not in the low position and there was no bed alarm present on Resident 4's bed. CNA 4 stated no one informed her during the huddle (short meeting where healthcare professionals share information about residents and discuss patient safety and care plans) that Resident 4 was a high risk for fall. CNA 4 stated residents, who had unstable gait (manner of walking) or were getting out of bed without using the call light for assistance, were a high risk for falls. CNA 4 stated it was important to identify residents who were at risk for falls so staff were performing frequent visual checks on the residents (in general) to prevent occurrence of falls and to provide needed help in a timely manner. During a telephone interview on 2/4/2025, at 2:31 p.m. CNA 5 stated on 1/26/2025 at 9:00 p.m. she made her last round and Resident 4 was sleeping in bed. CNA 5 stated she did not know Resident 4 was a high risk for fall. During an interview on 2/4/2025, at 3:41 p.m. Licensed Vocational Nurse (LVN 1) stated Resident 4 was in bed sleeping on 1/26/2025, at 11:05 p.m. LVN 1 stated Resident 4 was found on the floor lying on her right side and was complaining of right shoulder pain on 1/26/2025 at 11:15 p.m. LVN 1 stated Resident 4 wanted to remove her pants and thought she could do it by herself when the fall happened. LVN 1 stated Resident 4 liked to do things on her own. During a concurrent interview and record review on 2/4/2025, at 12:17 p.m. with RN Supervisor (RNS 1), Resident 4's Fall Risk assessment dated [DATE], was reviewed. RNS 1 stated a resident (in general) fall risk assessment was being done upon admission, after 72 hours of admission, quarterly, and as needed if there was incident of fall. RNS 1 stated the last Resident 4's Fall Risk Assessment was completed on 11/20/2024 with a score of 14. RN 1 stated a score of 14 meant Resident 4 was a high risk for falls (a person has a significantly increased likelihood of experiencing a fall due to factors like poor balance, muscle weakness, certain medications, or environmental hazards). RNS 1 stated landing pads, bed and wheelchair alarms were ordered on 1/29/2025 after Resident 4's fall on 1/26/2025. RNS 1 stated when a resident (in general) identified as high risk for fall staff should initiate interventions including application of landing pads on the floor, bed, and wheelchair alarms, place the bed in a low position, declutter a resident's environment and place a call light within reach. RNS 1 stated not properly identifying a resident who was a high risk for fall could lead to injury and occurrence of falls. During a concurrent interview and record review on 2/4/2025, at 11:14 a.m. with PT 1, reviewed PT Treatment Encounter (week of 1/20 to 1/24/2025). PT 1 stated Resident 4 could get out of bed and transfer from bed to chair with stand by assistance (when someone is nearby to help prevent injury or provide physical assistance if needed) and close supervision prior to Resident 4 fall on 1/26/2025. PT 1 stated Resident 4 required contact guard assist (physical contact from the helper to prevent fall) for lower body dressing. PT 1 stated Resident 4 could do lower body dressing, but staff had to be there for safety. During a concurrent interview and record review on 2/4/2025, at 12:52 p.m. with Minimum Data Set Coordinator (MDSC1), Resident 4's Fall Risk assessment dated [DATE] and Interdisciplinary Team (IDT- team members from different departments working together with a common purpose to set goals and make decisions that ensure residents receive the best care) Notes dated 11/20/2024 were reviewed. MDSC 1 stated a resident (in general) Fall Risk Assessment should be done upon admission and during quarterly assessment. MDSC 1 stated Resident 4's Fall Risk assessment dated [DATE] score was 14 which indicated Resident 4 was a high risk for falls. MDSC 1 stated the IDT meeting conducted on 11/20/2024 did not address Resident 4's high risk for falls. MDSC 1 stated if a resident scored 14, the facility would develop a plan of care for high risk for fall and would conduct an IDT review to address falls prevention. MDSC 1 stated Resident 4's high risk for fall should have been communicated with the other team members of the IDT and staff members to ensure implementation of interventions including frequent visual checks, placement of landing pads, bed in a low position, and alarm pads on bed and wheelchair. During a telephone interview on 2/4/2025, at 2:38 p.m. RNS 2 stated she saw Resident 4's in her room at 10:55 p.m. on 1/26/2025. RNS 2 stated Resident 4 was sleeping in her bed at that time. RNS 2 stated on 1/26/2024, at 11:15 p.m., Resident 4 was found on the floor crying, grimacing (distort one's face in an expression usually of pain) and guarding (involuntary reaction to protect an area of pain) her right shoulder. RNS 2 stated Resident 4 was complaining of a lot of pain in her right shoulder. RNS 2 stated when she interviewed Resident 4, Resident 4 stated she was trying to remove her pants off when she had a fall. RNS 2 stated Resident 4 was transferred out to GACH on 1/27/2025 and returned to the facility on [DATE]. RNS 2 stated it was important to identify residents who were a high risk for fall to implement fall risk prevention program to have landings pads, bed in low position, bed, and wheelchair alarm in order to prevent falls and injury. During an interview on 2/4/2025, at 8:10 a.m. and subsequent interview on 2/5/2025, at 11:39 a.m. the Director of Nursing (DON) stated Resident 4 liked to be independent and would not call the staff for help. The DON stated Resident 4 informed the DON that she tried to remove her pants by herself when she fell . The DON stated MDS Coordinator should have communicated Resident 4's fall risk assessment score of 14 (score of 10 and above represents high risk for fall) to the staff and to MDSC 1 to ensure fall risk prevention program were implemented. The DON stated Resident 4 had a history of fall on 1/4/2024 and the resident required Resident 4's bed in a low position. The DON stated although Resident 4's assessment indicated the resident was a high risk for falls, the facility staff was not able to identify Resident 4 as high risk for fall and did not implement fall risk prevention program to prevent fall and injury. During a review of facility's P &P titled Safety and Supervision of Residents revised 7/2017, the P&P indicated the interdisciplinary care team will analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The P&P indicated the care team will target interventions that will reduce individual risks related to hazards in the environment including adequate supervision and assistive devices.

Based on interview and record review the facility failed to ensure the resident, who had a history of urinary tract infection (UTI an infection in the urinary system) and had an indwelling (inserted and left in place) urinary catheter (a flexible tube inserted into the urinary bladder [organ that holds urine to empty the urine and collect it in a drainage bag) in place, did not develop a sepsis (a potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs) due to UTI for one of 25 sampled residents (Resident 39). The facility failed to: 1. Ensure nursing staff carried out a physician's order for Resident 39's urinalysis (urine test) with urine culture and sensitivity (a test to determine a responsible organism causing an infection and the right medication to treat an infection) ordered on 2/15/2024 and 2/21/2024 due to Resident 39's complaint of dysuria (pain or a burning sensation upon urination). 2. Ensure nursing staff repeated a collection of Resident 39's urine specimen for urinalysis with urine culture and sensitivity when the original urine sample was mislabeled on 2/15/2024 and not processed by the laboratory. 3. Ensure Resident 39's abnormal laboratory tests results of urinalysis with urine culture received on 2/25/2024 and again on 2/26/2024 were reported to Resident 39's physician to ensure timely initiation of Resident 39's medical treatment for UTI to prevent development of sepsis. 4. Ensure the licensed nurses completed Resident 39's Change of Condition ([COC] a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) form to alert the resident's physician and interdisciplinary (a group of healthcare professionals with various areas of expertise who work together toward the goals of the residents) team of Resident 39's significant change in condition and the need to alter the resident's medical treatment significantly in accordance with the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status revised 2/2014. These deficient practices resulted in Resident 39 experiencing a low blood pressure, lethargy (a general state of fatigue that involves a lack of energy and motivation for physical and mental tasks) and 88 percent ([%)] a unit of measurement) of oxygen saturation (concentration of oxygen in a person's blood) on room air on 2/28/2024. Resident 39 was transferred to a general acute care hospital (GACH) on 2/28/2024, where the resident was diagnosed with severe sepsis due to catheter-associated-urinary tract infection ([CAUTI] a urinary tract infection associated with the use of urinary catheter) and pyelonephritis (a urinary tract infection that results from bacteria or a virus that moves to one or both kidneys). Findings: During a review of Resident 39's Admission Record, the Admission Record indicated Resident 39 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including sepsis due to urinary source of chronic indwelling urinary catheter, hypotension (low blood pressure), neuromuscular dysfunction of the bladder (a bladder malfunction caused by an injury or brain disorder of the brain, spinal cord, or nerves), and quadriplegia (paralysis of both arms and legs due to spinal cord injury, stroke {damage to the brain from interruption of its blood supply}, and cerebral palsy [a condition that affects movement and posture]). Resident 39 has a history of UTIs and chronic precense of an indwelling urinary catheter. During a review of Resident 39's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 1/17/2024, the MDS indicated, Resident 39 had the ability to understand others and was able to make self-understood. The MDS indicated Resident 39 was dependent on staff for toileting, eating, showering, oral hygiene, personal hygiene, dressing, transferring, and repositioning. The MDS indicated Resident 39 had an indwelling urinary catheter. During a review of Resident 39's Care Plan, titled Urinary Incontinence (loss of bladder control), dated 7/25/2023, the care plan indicated one of the interventions was to notify the resident's physician of abnormal laboratory tests results. During a review of Resident 39's Care Plan titled Indwelling foley (urinary) catheter with risk of UTI related to neurogenic bladder (lacks bladder control due to brain, spinal cord problem) and urinary incontinence dated 7/26/2023 indicated the resident was identified to be at risk of UTI. During a review of Resident 39's Care Plan, titled Urinary Tract Infection Recurrence, dated 12/28/2023, the care plan indicated one of the interventions was to draw laboratory test as ordered and to report to the medical doctor abnormal laboratory results. During a review of Resident 39's Care Plan, titled Potential for possible side effects from antibiotic (medication used to treat and prevent infections) therapy for treatment of urinary tract infection, dated 1/23/2024, the care plan indicated one of the interventions was to draw laboratory test as ordered and to report to the medical doctor abnormal laboratory results. During a review of Resident 39's general acute care hospital (GACH) History and Physical (H&P) records dated 1/18/2024 indicated Resident 39 was admitted with diagnoses including septic shock (widespread infection causing organ failure and dangerously low blood pressure) secondary to urinary source, and hematuria (blood in the urine). During an interview on 3/5/2024 at 1:42 p.m. Resident 39 stated he just returned from the hospital on 3/1/2024 due to acute kidney failure (kidneys suddenly cannot filter waste from the blood) and UTI. Resident 39 stated he has been on oral antibiotic for 12 days. During a review of Resident 39's Physician's Orders Summary dated 2/15/2024, the Orders Summary indicated a physician's order to collect urine for the urinalysis with cultures (a test that can detect bacteria in the urine and diagnose urinary tract infections) and sensitivity for dysuria (painful or uncomfortable urination). During an interview on 3/08/2024 at 10:40 a.m. the Licensed Vocational Nurse (LVN 6) stated Resident 39 was hospitalized on [DATE] for weakness, lethargy, and a low blood pressure. LVN 6 stated Resident 39's lethargy was related to a urinary infection. LVN 6 stated on 2/28/2024 Resident 39 called the nursing staff and told them to call 911(number to call for emergency services) because he was lethargic. LVN 6 stated Resident 39 had a urinalysis and urine culture ordered on 2/15/2024. LVN 6 stated the urinalysis specimen was mislabeled and the urinalysis was reordered on 2/21/2024. LVN 6 stated Resident 39's urine for a urinalysis with urine culture and sensitivity was not collected until 2/23/24 and came back with the positive results for Escherichia coli ([E. coli] a bacteria that can cause infection) in the urine. LVN 6 stated the urinalysis test results were received on 2/25/2024 and again on 2/26/2024. LVN 6 stated COC was not done and Resident 39's physician was not notified of the urinalysis with urine culture results on 2/25/2024 or on 2/26/2024. LVN 6 stated COC should have been documented and the resident physician should have been notified of the abnormal urine culture test results. LVN 6 stated Resident 39 was transferred to a GACH on 2/28/2024 for altered level of consciousness (a person's state of reduced alertness or inability to arouse due to low awareness of the environment) and was admitted to the GACH where the resident was diagnosed with sepsis due to UTI. During a concurrent interview and record review on 3/8/2024 at 12:21 p.m., the Registered Nurse Supervisor (RNS 4), stated Resident 39 was hospitalized on [DATE] due to lethargy, low blood pressure, and oxygen saturation of 88 % on room air (the reference range is 95% to 100% on room air). RNS 4 stated Resident 39 returned from the hospital on 3/1/24 with a diagnosis of UTI. RNS 4 stated Resident 39's physician ordered to collect urine for urinalysis with urine culture and sensitivity on 2/15/2024. RNS 4 confirmed, after reviewing Resident 39's medical record, there was no documentation to indicate the urine was collected for urinalysis with urine culture test as ordered on 2/15/2024. RNS 4 stated on 2/21/2024 Resident 39's physician reordered a urinalysis, and a urine culture. However, she (RN 4) did not see any documentation in Resident 39's medical record that urine was collected for testing as ordered. RNS 4 stated Resident 39 urine for cultures was collected on 2/23/2024 and the results were received on 2/25/2024 and again on 2/26/2024. RNS 4 stated the results were positive for E. coli. RNS 4 stated when a physician orders a laboratory test the order should be carried out right away and a physician should be informed of results in a timely manner. RNS 4 stated the COC should be done to alert everybody (the physicians and licensed staff) to monitor the resident for condition improvement or decline and was not done. During an interview on 3/8/2024 at 2:37 p.m., the Director of Nursing (DON), stated Resident 39 had a history of UTI. The DON stated Resident 39 was admitted to the GACH on multiple occasions for lethargy, elevated temperature, or UTI. The DON stated on 2/15/2024 Resident 39's physician ordered a urinalysis test with urine culture due to Resident 39 complained of dysuria. The DON stated on 2/15/2024 the urine specimen was collected, but a collected urine sample was mislabeled. The DON stated Resident 39's urine for a urinalysis with urine culture was reordered on 2/21/2024. The DON stated the urine for urinalysis with urine culture was not collected until 2/23/2024 and on 2/25/2024 and 2/26/2024 the results revealed Resident 39 had E. Coli. The DON stated Resident 39's physician was not informed of the urinalysis with urine culture laboratory test results received on 2/25/2024 and again on 2/26/3024. The DON stated the physician should be notified of Resident 39's change of condition and if the licensed nurse cannot get a hold of the physician, facility's medical director should have been notified of Resident 39's positive for E. Coli results of urinalysis with urine culture. During an interview on 3/8/2024 at 3:13 p.m. with the Infection Preventionist Nurse (IPN) stated Resident 39 was admitted back to the facility from the hospital on 3/1/2024 with diagnosis of sepsis secondary to UTI. The IPN stated Resident 39 was prescribed Bactrim (medication used to treat bacterial infections). The IPN stated at the GACH Resident 39 was treated with Meropenem (medication to treat infection) 1000 milligram (mg-unit of measurement) intravenously ([IV] directly into the veins] IV piggyback ([IVPB] a small bag of solution attached to a primary infusion line) antibiotic and Vancomycin (medication to treat infection) 1000 mg IVPB for an acute kidney injury (a condition in which the kidneys suddenly cannot filter waste from the blood ) at GACH. IPN stated urinalysis and urine culture ordered on 2/15/2024 were not done. During a review of Resident 39's Physician's Order Summary Report (from the facility) dated 3/1/2024, the Order Summary indicated a physical's order for Bactrim (Sulfamethoxazole-Trimethoprim) 800-160 mg one tablet two times a day for sepsis/UTI for 12 days. During a review of Resident 39's GACH's MAR, the MAR dated 2/28/2024 indicated Meropenem 1000 mg IV piggyback and Vancomycin 1000 mg IVPB were administered to Resident 39. During an interview on 3/8/2024 at 5:44 p.m. the IPN stated on 2/15/2024 Resident 39's urine was collected for a urinalysis with urine culture as ordered on 2/15/2024. The IPN stated the urine specimen was not tested because it was mislabeled. IPN stated no repeat urine collection for urinalysis with urine culture was done after the original specimen was mislabeled. The IPN stated Resident 39's physician was not notified that on 2/15/2024 the urinalysis and urine culture test was not done due to mislabeled urine specimen. IPN stated on 2/21/2024 the urinalysis and urine culture were reordered but a urine specimen was not collected until 2/23/2024. IPN stated the licensed nurses did not receive a call back from Resident 39's physician to inform of the positive urine culture results received on 2/25/2024 and on 2/26/2024. IPN stated licensed nurse should have called the medical director if no call back from Resident 39's physician. During a review of Resident 39's Nurses Progress Notes dated 2/26/2024 and timed at 6:47 p.m. indicated urine culture and sensitivity result was relayed to the physician and nurses were waiting for a physician to call back. During a interview on 3/8/2024 at 8:20 p.m. LVN 7 stated Resident 39's physician ordered to repeat urinalysis with urine culture on 2/15/2024 because urine sample was not collected as ordered on 1/18/2024. LVN 7 stated the repeat test for urinalysis with urine culture was not done as order on 2/15/2024 because the specimen was mislabeled. LVN 7 stated a urine specimen for urinalysis with culture ordered on 2/21/2024 at 2 a.m. was not collected until 2/23/2024. LVN 7 stated the licensed nurses should have informed Resident 39's physician of positive E. Coli results urine culture test received on 2/25/2024 and 2/26/2024, and if the physician did not call back, the licensed nurses should have called the medical director. LVN 7 stated it was important to notify Resident 39's physician of test results of the urine culture to prevent the resident's decline and to provide the resident with treatment in a timely manner. LVN 7 stated on 2/28/2024 at 6:30 a.m. Resident 39 was lethargic and was transferred to the GACH due to UTI. During an interview on 3/8/24 at 9:46 p.m. the DON stated it was important to notify the physician of any abnormal laboratory tests results to prevent decline in the residents' medical condition. During a review of Resident 39's Laboratory Results Report, dated 2/15/2024, indicated, Resident 39's urinalysis test with culture and sensitivity was not done due to received specimen in the laboratory was mislabeled. During a review of Resident 39's Laboratory Results Report, dated 2/20/2024, indicated Resident 39's urinalysis test with culture and sensitivity was not done because no specimen was received. During a review of Resident 39's Physician's Orders Summary, dated 2/21/2024, the Order Summary indicated to repeat collection of urine for the urinalysis with culture and sensitivity one time only. During a review of Resident 39's Laboratory Results Report dated 2/23/2024 indicated Resident 39's urinalysis test with culture and sensitivity was positive for E. coli. The Laboratory Result Report indicated the test results were reported to the facility on [DATE] and again on 2/26/2024. During a review of Resident 39's Nurses Progress Notes dated 2/28/2024 the Nurses Progress Notes indicated Resident 39 had a low blood pressure and oxygen saturation from 86% to 88 % on room air. The Nurses Progress Notes indicated Resident 39 called for help and asked staff to call 911. The Nurses Progress Notes indicated Resident 39 was lethargic, 911 was called and Resident 39 left the facility with paramedics (person trained to give emergency medical care). During a review of Resident 39's GACH record dated 3/1/2024, the GACH record indicated Resident 39 was diagnosed with severe sepsis related to CAUTI and pyelonephritis. The GACH record indicated Resident 39's indwelling urinary catheter was changed in the emergency room and Vancomycin IVPB and Meropenem IVPB were started. The GACH's record indicated previous urine culture on previous hospitalization [DATE] were reviewed for the presence of E. coli and Methicillin-resistant Staphylococcus aureus (MRSA-a bacteria that causes infections in different parts of the body type that is resistant to some antibiotics). During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, revised 4/2013, the P&P indicated, All incidents, accidents, or changes in the resident's condition must be recorded, documentation of procedures and treatments shall include care-specific details and shall include at a minimum, the date and time the procedure/treatment was provided . A physician should respond within one hour regarding a laboratory test result requiring immediate notification, and no later than the end of the next office day to a non emergency message regarding non-immediate laboratory test notification with a request for response (for example, by Wednesday afternoon for a call made on Tuesday), if the attending or covering physician does not respond in the required time frame, the nursing staff should contact the medical director for assistance. If the resident/patient has signs and symptoms of acute illness or condition change and he/she is not stable or improving, or there are no previous results for comparison, then the nurse will notify the physician promptly to discuss the situation, including a description of relevant clinical findings as well as the test results. Facility staff should document information about when, how, and to whom the information was provided and the response. During a review of the facility's P&P titled, Lab and Diagnostic Test Results: Physician Role and Follow-Up Documentation, revised 4/2013, the P&P indicated, A nurse will review all results. If staff who first receive or review laboratory and diagnostic test results cannot follow the remainder of this procedure for reporting and documenting the results and their implications, another nurse in the facility (supervisor, charge nurse, etc.) should follow or coordinate the procedure. During a review of the facility's P&P titled, Change in a Resident's Condition or Status, revised 2/2014, the P&P indicated, The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been. A significant change in the resident's physical/emotional/mental condition. A need to alter the resident's medical treatment significantly. Cross reference F-637

Based on observation, interview, and record review the facility failed to ensure the resident, who was a high risk for falls, did not fall and sustained a rib fracture (broken) for one of two sampled residents (Resident 1). The facility failed to: 1. Ensure the registered nurse supervisor (RNS) 3 correctly assessed and completed Resident 1's Fall Risk Assessment to reflect the resident's cognitive (the process of thinking, learning, and reasoning), functional mobility (ability of a person to move around in their environment, in order to participate in the activities of daily living) status, medications, and current diagnoses to indicate Resident 1's correct score for falls. 2. Ensure Resident 1's fall prevention measures including landing pads (a rectangular floor pads with inner surface made of foam or other cushiony materials used to provide a softer place for the resident to land when falling especially if the residents are falling from the bed), and bed alarm (devices that are attached to a resident's bed and sound an alarm when the resident gets up) were implemented upon Resident 1's admission to the facility. 3. Ensure the licensed nurses developed a care plan to include interventions for Resident 1's high risk for falls with the measures to prevent falls and minimize injury. These failures resulted in Resident 1's fall on 1/18/2024 and sustaining a skin tear (layers of skin peel back) on his both arms and left 10th rib fracture. On 1/18/2024 Resident 1 was transferred to a general acute care hospital (GACH) for evaluation and treatment and returned to the facility on the same day. Findings: During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses including history of falling, difficulty walking, heart failure (impairment of the heart blood pumping action), obstructive sleep apnea (a sleep disorder in which breathing repeatedly stops and starts during sleep) and anemia (not enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues). During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 1/23/2024, indicated Resident 1 had a moderately impaired cognitive (ability to learn, understand, and make decisions) skills for daily decision making. The MDS indicated Resident 1 required maximal assistance from staff with walking, transferring to the toilet, transferring to the chair or bed, sitting, lying, standing, and rolling from left to right in bed, toileting, showering, and lower body dressing. The MDS indicated Resident 1 required partial to moderate assistance from staff with oral hygiene (brushing teeth), upper body dressing, and personal hygiene. During a review of Resident 1's History and Physical (H&P), dated 1/17/2024, the H&P indicated Resident 1 had a fall on 1/12/2024. The H&P indicated Resident 1 was alert with periods of confusion but able to make his needs known. The H&P indicated Resident 1's responsible party should be involved with making complex medical decisions. During an observation on 1/29/2024 at 10:50 a.m., in Resident 1's room, Resident 1 was observed in bed asleep. On both side of Resident 1's bed was landing pads, a bed alarm in place and the call light within reach. In Resident 1's room, there was Sitter 1. During an interview on 1/29/2024 at 11:00 a.m., Resident 1 stated on 1/18/2024 he fell on the floor and hit his head on the bed. Resident 1 stated he was trying to get out of bed and did not call for help. Resident 1 stated he was lying on the floor for an hour before facility staff came to help him. Resident 1 stated he injured both arms and went to the hospital. Resident 1 stated chest x ray was done that showed bruising on the right rib and a fractured rib. During an interview on 1/29/2024 at 11:10 a.m. Sitter 1 stated she was assigned to Resident 2 (Resident 1's roommate) but assisted with Resident 1's care and fall prevention. Sitter 1 stated Resident 1 and Resident 2 have bed alarms and landing pads as fall preventative measures. Sitter 1 stated she was watching after both residents to make sure they do not fall. During an interview on 1/29/2024 at 11:51 a.m., Certified Nursing Assistant (CNA) 1 stated he took care of Resident 1 on 1/17/2024 from 11 p.m. to 7 a.m. shift. CNA 1 stated when he made rounds at 12:45 a.m. on 1/18/2024 he found Resident 1 on the floor. CNA 1 stated he informed the Licensed Vocational Nurse (LVN) 1. CNA 1 stated LVN 1 and the Registered Nurse Supervisor (RNS) assisted Resident 1 back to bed. CNA 1 stated 911 (a phone number used to contact emergency services) was called and transfer Resident 1 to GACH. During an interview on 1/29/2024 at 6:22 a.m. LVN 1 stated Resident 1 was admitted to the facility on [DATE] with a history of fall at home on 1/12/2024. LVN 1 stated upon admission of Resident 1 to the facility, fall risk factors were assessed and documented in the nurse's progress notes. LVN 1 stated Resident 1 sustained skin tear to both arms and complained of pain on his left side of the abdomen. LVN 1 stated on 1/18/2024 at the time of Resident 1 fall, he did not have landing pads or a bed alarm in place. LVN 1 stated residents, who are at high risk for fall, should have a landing pad next to a bed, a bed alarm, wheelchair alarm, and a brighter lighting in room for safety to prevent potential fall and injuries. LVN 1 stated Resident 1 should have had landing pads and a bed alarm in place because he had a history of fall and was a high fall risk. During an interview on 1/30/2024 at 6:54 a.m., RNS 1 stated Resident 1 required assistance with his care, was confused and disoriented after the fall on 1/18/2024. RNS 1 stated Resident 1 had a skin tear to both arms and complained of pain on his left side of the abdomen (belly). RNS 1 stated Resident 1 said he got out of bed and fell on the floor on 1/18/2024. RNS 1 stated Resident 1 was transferred to a GACH for evaluation after the fall. RNS 1 stated if a resident was a high risk for falls, the bed should be placed in the lowest position with landing pads in placed on both sides of the bed, a bed alarm, and staff's frequent observation of the resident to ensure safety. Resident 1 did not have fall preventive measures like a landing pad on each side of the bed or a bed alarm prior to his fall on 1/18/2024. RNS 1 stated Resident 1 should have had landing pads and a bed alarm in place to prevent any injury because Resident 1 was receiving an anticoagulant (blood thinner) and could bleed to death from a fall. During an interview on 1/30/2024 at 11:40 a.m., CNA 2 stated Resident 1 required assistance with oral care, dressing, changing, showering, and feeding. CNA 2 stated Resident 1 was not independent with his activities of daily living ([ADL]-activities related to personal care which includes bathing, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) and should have had a bed alarm in place to alert staff of his attempt to get out of bed unassisted. CNA 2 stated residents who had history of fall and were at high risk for fall should be checked every 30 minutes, have a bed alarm and a landing pad for safety. During an interview on 1/30/2024 at 11:55 a.m., RNS 2 stated Resident 1 was admitted to the facility for physical therapy after falling at home on 1/12/2024. RNS 2 stated the registered nurses do the initial fall risk assessment and document within 24 hours after admission to the facility. RNS 2 stated Resident 1 had multiple falls at home, upon admission to the facility Resident 1 should have landing pads and a bed alarm in place. RNS 2 stated the landing pads on both sides of the bed help prevent any injury when Resident 1 fell and the bed alarm help to alert staff if Resident 1 was trying to get out of bed. RNS 2 stated Resident 1's fall was avoidable if fall preventative measures were in place upon Resident 1 admission to the facility. During a concurrent interview and record review on 1/30/2024 at 3:19 p.m. with RNS 3, Resident 1's Fall Risk assessment dated [DATE] was reviewed. RNS 3 stated she scored Resident 1's Fall Risk Assessment incorrectly. RNS 3 stated Resident 1 was admitted to the facility for physical therapy (PT-care provided by a physical therapist who promotes, maintains, or restores health through rehabilitation), with a history of falls and difficulty walking. RNS 3 stated she documented Resident 1 as ambulatory (resident able to walk around) even though he came to the facility with a history of falling, difficulty walking and needed two-person assistance to walk from the stretcher to bed during admission. RNS 3 stated the areas she assessed incorrectly were with Resident 3's current diagnoses. RNS 3 stated Resident 1 should have scored 11 instead of initial score of nine (score of 10 and above represents a high risk for falls). On 1/30/2024 at 4:40 p.m., during a concurrent interview and record review with the Director of Nursing (DON) Resident 1's Fall Risk assessment dated [DATE] was reviewed. The DON stated Resident 1 was admitted to the facility on [DATE] and fell at the facility on 1/18/2024. The DON stated Resident 1 was admitted to the facility for PT and Occupational Therapy (OT- health care provider who helps people learn or regain skills of daily living) and had a history of falls at home. The DON stated Resident 1 was confused and RNS 3 should have scored Resident 1's Fall Risk Assessment higher (initial fall risk assessment score of nine) based on Resident 1's history of fall, gait (manner of walking)/balance, medications, and his current diagnoses. The DON stated RNS 3 did not assess and document Resident 1's Fall Risk Assessment correctly. Resident 1 was a high risk for fall and fall prevention measures (bed in low position, landing pads, bed alarm) should have been implemented upon admission to the facility. During a concurrent interview and record review on 1/31/24 at 2:50 p.m. with PT 1, Resident 1's PT Evaluation & Plan of Treatment, dated 1/16/2024 was reviewed. PT 1 stated on initial assessment done on 1/16/2024 Resident 1 required 75 percent assistance from staff for bed mobility and transferring between surfaces. PT 1 stated Resident 1 had to stand up with staff maximum assistance and was not ambulating. PT 1 stated landing pads were used in case a resident fall from a bed to lessen possible injury. On 1/31/2024 at 3:37 p.m. during a concurrent interview and record review with the DON, Administrator (ADM) and Minimum Data Set Coordinator (MDSC), Resident 1's Care Plan, titled Falls, dated 1/17/2024 was reviewed. The CP goals were to minimize fall, injury from fall and accident in the next three months. The interventions were to answer call light promptly and keep within reach, adequate lighting in resident room, keep bed in low position, and provide assistance with transfer and ambulation. The DON stated landings pads, a bed alarm, and a sitter (a person who looks after the resident) were not implemented until 1/18/2024 after Resident 1's fall. During a review of Resident 1's Fall Assessment, dated 1/16/2024, the Fall Assessment indicated Resident 1 was taking one to two medications that caused lethargy (lack of energy and mental alertness) or confusion (inability to think clearly). During a review of Resident 1's Physician's Orders, dated 1/16/2024, the Physician's Orders indicated Resident 1 had an order for Carvedilol 6.25 milligrams ([mg-unit of measurement]a medication used to treat congestive heart failure) one tablet by mouth two times a day for heart failure, Eliquis 2.5 mg (an anticoagulant [blood thinner] medication used to lower the risk of a heart rhythm called atrial fibrillation (abnormal heart rhythm) one tablet by mouth two times a day, Isosorbide Mononitrate 30 mg (medication used to prevent chest pain) extended release one tablet by mouth once a day for angina (chest pain), Lasix 20 mg (medication used to treat congestive heart failure) one tablet by mouth once a day for congestive heart failure, Nitroglycerin 0.4 mg (medication used to treat heart conditions) one tablet sublingually (under the tongue) as needed for chest pain, and Remeron 30 mg ([antidepressant ] medication to improve mood or emotion,) one tablet by mouth at bedtime. During a review of Resident 1' Physician Order dated 1/18/2024 timed at 2:57 a.m., indicated to transfer Resident 1 to GACH for evaluation. During a review of Resident 1's GACH Record dated 1/18/2024, the GACH Record indicated Resident 1 was admitted to GACH for a fall on 1/18/2024. Resident 1's GACH records indicated a Computed Tomography ([CT] is a medical imaging technique used to obtain detailed internal images of the body) scan dated 1/18/2024 indicated Resident 1 had a left 10th rib fracture. During a review of the facility's policy and procedure (P&P) titled, Fall/Accident Management System, undated, the P&P indicated the facility will provide each resident with appropriate assessment and interventions to prevent falls/accidents and to minimize complications if a fall or accident occurs. Falls Risk Assessment score of 10 or above represents a high risk for fall and will require the development of a care plan with interventions implemented designed to prevent falls. During a review of the facility's P&P titled Fall Prevention Program (undated), the P&P indicated The focus of this program is to reduce the number of falls within the facility through a carefully devised prevention program. Any resident with a fall risk assessment score of 10 and greater will be identified by the following: A pink paper/sign will be placed at the foot of the resident bed to indicate resident has a safety device (bed alarm, chair alarm and/or landing pad). During a review of the facility's P&P titled, Anticoagulation-Clinical Protocol, dated 4/2013, the P&P indicated, the facility's staff and physician will identify and address potential complications in individuals with a fall risk receiving anticoagulant medication.

Based on observation, interview and record review, the facility failed to ensure the resident, who was smoking on the patio, was provided with environment free of accidental hazards for one of two sampled residents (Resident 1). The facility failed to: 1. Ensure Resident 1 was provided with fire retardant (having the ability or tendency to slow up or halt the spread of fire by providing insulation) smoking apron. 2. Ensure Resident 1 was supervised and assisted on 11/9/2022, during smoking as care planned and in accordance with the facility ' s policy and procedure titled ' Smoking Policy-Residents. ' These failures resulted in Resident 1 setting his clothing on fire on 11/9/2022 with a lit cigarette, sustaining a third-degree skin burn (type of burn destroys the outer layer of skin (epidermis) and the entire layer beneath (the dermis). [full thickness]) to the left chest, left arm, and left neck area. Resident 1 was transferred on 11/9/2022 to a general acute care hospital (GACH) and admitted to the Intensive Care (ICU) Burn Unit where Resident 1 received two surgical skin grafts (surgical procedure in which a piece of skin is transplanted from one area to another). Findings: During a review of Resident 1 ' s Admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE], with the diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body), cerebrovascular disease (a range of conditions that affect the flow of blood through the brain) affecting the left dominant side, muscle weakness, epilepsy (a neurological disorder that causes seizures or unusual sensations and behaviors), speech and language deficits. During a review of Resident 1 ' s Minimum Data Set [(MDS), a standardized assessment and screening tool], dated 9/12/2022, the MDS indicated Resident 1 required extensive with one-person physical assistance with bed mobility, transferring, dressing, toilet use and personal hygiene. During a review of Resident 1 ' s Physician ' s Progress Notes (PPN) dated 11/9/2022, the PPN indicated, Resident 1 had generalized weakness and left hemiparesis, Resident 1 needed assistance of another person due to physical debility and cognitive (ability to learn, remember, understand, and make decision) impairment, forgetfulness and had an unspecified psychosis (mental disorder characterized by a disconnection from reality). During a review of Resident 1 ' s Smoking Assessment (SA), dated 2/23/2022, the SA indicated, Resident 1 was a dependent smoker and needed staff assistance and supervision while smoking, smoke only at designated times and in designated places with staff supervision and/or assistance, and may need to wear a protective smoking vest or apron as determined by the Interdisciplinary Team ( [IDT] team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) The SA indicated Resident 1 needed assistance with smoking and had a loss of sensation to touch and pain in the left arm and leg. During a review of Resident 1 ' s Nursing Assessment (NA) dated 11/9/2022, the NA indicated, Resident 1 had a left neck skin burn measured 8.0 centimeters ([cm] unit of measurement) by 8.0 cm, the left chest had a skin burn measured 30 cm by 25 cm, the left arm had a skin burn measured 17 cm by 12 cm, and on the back the head there were partially burned hair. The NA indicated Resident 1 had left sided weakness and the left arm was contracted. During a review of Resident 1 ' s care plan (CP), undated and untitled, the CP indicated Resident 1 was a dependent smoker, was at risk for injury and did not demonstrate a safe technique for putting out lighter and disposing ash. The CP indicated Resident 1 needed supervision during smoking and was at risk for injury due to the following: 1. Smoking during not a scheduled smoking time. 2. Not following smoke breaking time. 3. Having numbness and tingling in the upper extremities. 4. Uncontrollable muscle movements. 5. Impaired mobility due to hemiparesis and hemiplegia. During a review of Resident 1 ' s GACH Registration Record (RR), the RR indicated, Resident 1 arrived at the hospital on 11/09/2022 at 9:55 p.m. and was admitted to the emergency roiagnom on [DATE] at 12:05 a.m., with third degree skin burns to the chest wall and neck. The RR indicated Resident 1 ' s skin to the left upper chest and left neck was blistered and the skin area around the chest burn was singed (scorched`). The RR indicated Resident 1 was admitted to the Burn ICU for further evaluation and treatment. During a review of Resident 1 ' s GACH Progress Notes (PN), dated 11/15/2022, the PN indicated Resident 1 had an excision (removal of tissue from the body using a scalpel (a sharp knife) with xenograft (skin grafting [ surgical procedure in which a piece of skin is transplanted from one area to another] using skin from other species, such as pigs) placement to the left neck and chest. During a review of Resident 1 ' s Procedure Report (PR) dated 11/18/2022, the PR indicated, Resident 1 had a repeat excision to the left neck and left chest skin burn areas with split-thickness autographing (remove a thin layer of skin from one part of your body (donor site) and use it to close the surgical site that needs to be covered (recipient site). During an observation on 11/15/2022 at 10:56 a.m., on the facility ' s smoking patio, there were three residents observed smoking cigarettes. A Certified Nurse Assistant (CNA 1) was observed lighting residents ' cigarettes with a cigarette lighter. A smoking apron (apron that offers smokers protection from cigarette burns) were observed hanging on a rack near the smoking area. All three residents were not wearing a smoking apron. During an interview on 11/15/2022 at 11:04 a.m. CNA 1 stated, the Director of Staff Development (DSD) assigned her to supervise residents on the smoking patio on 11/15/2022. CNA 1 stated, alert residents keep their own cigarettes and lighters. CNA 1 stated, the residents that can walk, talk, and eat on their own are alert and oriented. CNA 1 stated, the residents that are not alert get smoking aprons and must be watched. CNA 1 stated, CNA 3 told her on 11/9/2022, she was in the breakroom and heard a resident screaming. CNA 3 ran out of the breakroom and saw Residents 1 ' s shirt on fire. CNA 1 stated Resident 1 had a lit cigarette in his pocket. CNA 1 stated Resident 1 keeps his cigarettes and lighter with him. CNA 1 stated Resident 1 goes to smoke on a patio and was allowed to smoke anytime without supervision. During an observation on 11/15/2022 at 11:10 a.m., Resident 2 was observed wheeling in a wheelchair on the smoking patio. Resident 2 was observed pulling a pack of cigarettes and a lighter out of his pocket. Resident 2 was observed not wearing a smoking apron. CNA 1 assisted Resident 2 to light his cigarette. Concurrently, during the observation on 11/15/2022 at 11:10 a.m., CNA 1 stated Resident 2 was alert resident. During an interview on 11/15/2022 at 11:16 a.m., Resident 2 stated he was on the smoking patio when Resident 1 burned himself on 11/9/2022 at 2:45 p.m. Resident 2 stated he heard Resident 1 screaming and yelling, and he saw about 12-inch-high flames of Resident 1 ' s flannel shirt. Resident 2 stated no facility staff were supervising residents on the smoking patio at the time of the incident. Resident 2 stated, Resident 1 ' s left side of the chest was reddish brown in color and starting to bubble. Resident 2 stated he grabbed a smoking apron and the facility ' s fire blanket (sheet used to smother the flames and extinguish the fire before it gets out of control) and attempted to place it on Resident 1. During an interview on 11/15/2022 at 11:43 a.m., CNA 2 stated Resident 1 ' s left side was paralyzed, and he used a wheelchair for moving around the facility. CNA 2 stated Resident 1 kept his cigarettes and a lighter with him and was non-compliant with smoking time schedule and smoked any time he wanted. CNA 2 stated the residents were only supervised during smoking times. During an interview on 11/15/2022 at 11:54 a.m., CNA 3 stated she was in the breakroom with coworkers on 11/9/2022 and heard Resident 1 screaming. CNA 3 stated she ran out the breakroom to the patio and saw Resident 1 with smoke coming from him. CNA 3 stated she removed her sweater and put it over Resident 1. CNA 3 stated CNA 4 got the fire blanket, located on the wall of the smoking patio, but did not use it. CNA 3 stated she removed a shirt from Resident 1 and his left chest was red in color. During an interview on 11/15/2022 at 12:20 p.m., the Restorative Nurse Assistant (RNA) stated if a resident has their own lighter and cigarettes, the residents can smoke when they want to, and the charge nurse will supervise them. During an interview on 11/15/2022 at 12:39 p.m., the Charge Nurse (CN) stated that on 11/9/2022 at 2:45 p.m., she heard shouting coming from the smoking patio and saw Resident 1 trying to pat the flames out on his shirt. The CN stated there was smoke too. The CN stated she saw CNA 4 getting a fire blanket and a smoking apron located on the smoking patio. The CN stated she went back to the floor to ask for help from the Treatment Nurse and Registered Nurse Supervisor. The CN stated she went back to the patio and saw Resident 1 being agitated and wanted to continue to smoke. Resident 1 was shouting at staff for his cigarette and lighter. The CN stated she visually assessed Resident 1 and his left chest, left neck, and his left arm had charred (burned and blackened) skin. The CN stated only residents were on the smoking patio when the incident happened. The CN stated there were no facility staff supervising the resident on 11/9/2022 when the incident happened. The CN stated all the residents on the smoking patio on 11/9/2022, had their own cigarettes and lighters. The CN stated during nonscheduled smoking time, no facility staff were supervising residents ' smoking. The CN stated, in the future all residents, who smokes, should be supervised while smoking to prevent mishaps or accidents. During an interview on 11/15/2022 at 2:01 p.m., the Treatment Nurse (TN), stated on 11/9/2022 at 2:45 p.m., she went to the smoking patio and saw Resident 1 ' s left chest was singed (slightly burnt), the area was red and blistered with white tissue. The TN stated Resident 1 was still smoking after he burned himself. During an interview on 11/15/2022 at 2:10 p.m., the Activity Director (AD) stated at the time the incident occurred it was not a scheduled time for a smoking break, no facility ' s staff were supervising the residents and there was no supervision in between the smoking scheduled times. The AD stated Resident 1 kept his cigarettes and lighter. Resident 1 had a smoking assessment done on 2/23/2022, the SA indicated, Resident 1 was a dependent smoker and needed staff assistance and supervision while smoking. Smoking assessment determine if a resident could smoke independently. When a resident assessed as being a dependent smoke, the AD keeps the residents ' cigarettes and lighter locked. The AD stated a resident could smoke independently if a resident does not have tremors and was able to follow facility ' s smoking policy. The AD stated all residents during smoking should be supervised by facility ' s staff for safety and to prevent accidents. During an interview on 11/15/2022 at 2:33 p.m., the Registered Nurse (RN) 1, stated on 11/09/2022 at 2:45 p.m., she heard screaming on the smoking patio. RN 1 stated she went to the smoking patio and saw a smoke coming from the left side of Resident 1 ' s shirt. RN 1 stated, Resident 1 was still trying to smoke a cigarette. RN 1 stated she was explaining to Resident 1 that he had a burn and to stop smoking. Resident 1 was still in his wheelchair. RN 1 stated staff was wheeling Resident 1 back to his room when Resident 1 began punching the walls, punching the medication cart, cursing at the staff, and hitting himself on the head with his fist. The RN 1 stated she notified the Director of Nursing (DON) and the medical doctor on 11/9/2022 of the accident. RN 1 stated Resident 1 ' s upper left chest, left inner upper arm had blackened skin from the fire. RN 1 stated she thinks Resident 1 was alert and oriented to name, place, time, and situation and was mentally stable, although Resident 1 had aggressive behavior, including cursing at staff, refusing care, and punching trash cans. RN 1 stated Resident 1 was not supervised by staff on the day when resident sustained a skin burn from smoking. The RN 1 stated all residents who smoke need supervision to ensure safety, even if the resident was an independent smoker. The RN 1 stated all resident who smoke were required to use a smoking apron. During an interview on 11/15/2022 at 3:43 p.m., the DON stated, RN 1 notified her regarding the incident on 11/9/2022, that Resident 1 sustained a skin burn with redness to the left chest while smoking on the patio. The DON stated Resident 1 did not have any staff supervision because it was not the scheduled time for smoking. The DON stated all residents were required to wear a smoking apron. The DON stated Resident 1 kept his cigarettes and a lighter, so he would smoke whenever he wanted. The DON stated Resident 1 always kept a lot of tissue paper in his shirt pocket and wore a flannel shirt. RN 1 stated she thinks that was what ignited the flames. The DON stated she thinks Resident 1 was still capable of smoking independently because he knew what he wanted, knew his name, the date and time. The DON stated Resident 1 was a responsible smoker because he knew everything, and it was an accident because he had a lot of tissue in his pocket. During an interview on 11/15/22 at 4:15 p.m., the DSD stated, there was no facility staff supervising the residents when Resident 1 burned himself on the smoking patio on 11/9/2022. During a review of the facility ' s policy and procedure (P&P) titled, ' Smoking Policy-Residents ' dated 2021, the P&P indicated, any resident who has been classified as non-responsible shall not be permitted to smoke without the direct supervision of a responsible staff member, family member, visitor or volunteer worker and direct supervision must be provided throughout the entire smoking period. Residents assessed to be at risk should turn over cigarettes and other smoking articles to the Activity Director for proper handling and/or distribution during smoke breaks. The facility shall provide reasonable means of providing direct supervision to those residents wishing to smoke.

Based on observation, interview, and record review, the facility failed to ensure the residents maintained acceptable parameters of nutritional status, such as usual body weight and hydration status based on the resident's comprehensive assessment for two of 31 sampled residents (Resident 9, 143) including: 1. Failure to implement prompt nutritional interventions to avoid Resident 9 to sustain a progressive significant weight loss and to promote healing of a right heel Unstageable -Deep Tissue Injury (DTI) pressure-related injury under intact skin) to the right heel. 2. Failure to develop a care plan interventions to increase Resident 9's oral intake. 3. Failure to ensure Resident 9's physician was notified of the significant and progressive weight loss. 4. Failure to evaluate the effectiveness of Resident 9's nutritional interventions as per plan of care. 5. Failure to ensure the interdisciplinary team (IDT) including the physician and Resident 9's family, thoroughly assessed the resident for causal factors affecting intake of food and liquids. 6. Failure to implement the facility's policy on Impaired Nutrition - Unplanned Weight Loss Clinical Protocol by the Registered Dietician (RD) not identifying whether Resident 9's intake was adequate to meet her nutritional needs; by the physician not ordering and the staff not implementing appropriate general or cause-specific interventions. 7. Failure to implement the facility's policy on Nutrition and Hydration to Maintain Skin Integrity by not ensuring adequate nutritional status to decrease the risk of developing of a pressure sore associated with poor nutritional status, by not providing small frequent meals, between meals snack and to provide caloric high and protein rich foods. 8. Failure to ensure Resident 143's weight loss of 25 pounds, was planned weight loss with corresponding plan of care, goals and interventions to archive gradual planned weight loss. Findings: a. During survey from 7/3/18 to 7/10/18, Resident 9 was intermittently observed to be sleepy either in bed or up in a wheelchair. Resident 9 appeared thin and underweight. A review of resident 9's clinical record indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 6/22/18, Resident 9 was assessed as having impaired cognitive (ability to reason, learn, remember, understand, and make decisions) skills for daily decision making and totally dependent on staff for activities of daily living (ADL). According to the MDS the resident required extensive one person physical assistance with meal consumption and was on mechanically altered therapeutic diet. The MDS assessment indicated Resident 9 had weight loss of five percent or more in the last month or loss 10 percent or more on last six month and was not on physician-prescribed weight-loss regiment. The MDS assessment also indicated Resident 9 had one Unstageable-Deep Tissue Injury ((DTI) - pressure-related injury under intact skin) to the right heel, measured 5.0 centimeters (cm) in length and 4.5 cm in width, and was at risk for developing a pressure sore. A review of a physician's orders for Life-Sustaining Treatment (POLST), dated 5/22/18, indicated Resident 9 chose to have artificial nutrition when in need, including feeding tube (a tubing to provide nutrition directly into the stomach). According to the physician's order, dated 4/30/18, Resident 9 was on no added salt (NAS) pureed food diet with nectar-thickened consistency liquids. According to a speech therapist's (ST) plan of care, dated 5/1/18, Resident 9 was exhibiting moderate swallowing impairment of 50-75 percent and required thickened liquids. A review of the Nutritional Progress Notes, dated 6/11/18, completed by a registered dietitian (RD), indicated Resident 9 had a significant 12 pounds weight loss from prior month and the resident's current weight was 150 pounds (lb), with variable to fair oral intake on average. RD documented recommendations included weekly weights for three weeks, evaluate the appetite stimulants, enteral nutrition versus hospice, discontinue eight ounces of extra water, as it was, Too much and Resident 9 would not drink it. According to Weight Management Review form, dated 6/12/18, Resident 9's Ideal Body Weight (IBW) range was 104-115-126 lb, and the Usual Body Weight (UBW) range was 158-162 lb. This form indicated that on 6/12/18, Resident 9 weighed 150 lb and had a significant weight loss of 12 pounds from 162 lb from the prior month, which was a total of 7.4% weight loss in 30 days. A review of the Weekly Weight Log indicated Resident 9's weight were: 1. On 6/17/18, the resident's weight was 143 lb. 2. On 6/24/18, the resident's weight was 140 lb. 3. On 7/1/18, the resident's weight was 138 lb. According to the weekly weights for three weeks from 6/17/18 to 7/1/18, Resident 9 lost additional five lb. A review of the Nutritional Assessment note dated 6/28/18, completed by the RD, indicated Resident 9's estimated daily nutritional requirements, based on 150 pounds, were 1,500 to 1,704 calories, 55 g of protein, 1,500 to 1,704 milliliter (ml) of fluids. There was no documentation evidence RD evaluated Resident 9's current diet was providing the resident with nutrient needs as estimated, and there was no documented evidence the resident's amount of consumed food on a daily basis was evaluated for nutritional adequacy as estimated needs. A review of a certified nursing assistant (CNA) ADL Tracking form dated 4/2018, indicated Resident 9 ate between 75 to 100 percent for breakfast and lunch and ate 25 to 74 percent at dinner. According to this form Resident 9 was not offered and consumed snacks and/or nutritional supplement during the month of 4/2018. A review of the CNA ADL Tracking form dated 5/2018, indicated Resident 9 ate between 50 to 100 percent for breakfast, lunch, and dinner. The form did not indicate Resident 9 was offered and consumed snacks and/or nutritional supplement for 26 days out of 31 days to compensate for inadequate meal intake. during the day. Further record review indicated no documented evidence the attending physician was notified of the significant weight loss and was consulted regarding ordering appetite stimulant and nutritional supplements to improve Resident 9's nutritional status. This was verified during an interview with Registered Nurse Supervisor (RNS) on 7/9/18 at 11:36 a.m. A review of the CNA ADL Tracking form for 6/2018, indicated Resident 9 ate between 75 to 100 percent for breakfast and lunch and 25 to 74 percent for dinner. The form did not indicate Resident 9 was offered snacks and/or nutritional supplement during the month of 6/2018 to compensate for the low meal intake during the day. According to Resident 9's the Short-Term Problem care plan, dated 6/19/18, for a significant 12 lbs weight loss in 30 days, the interventions included to notify the physician if any change in condition. There were no documented interventions to improve Resident 9's food intake such as feeding program, small frequent foods, nourishment between meals, etc. This was confirmed during an interview on 7/9/18 at 10:08 a.m., with the Dietary Service Supervisor (DSS) and at 11:20 a.m., with the Assistant Director of Nursing (ADON). A review of Resident 9's laboratories results dated 6/13/18, indicated Resident 9's [MEDICATION NAME] (blood protein) level was 3.1 grams per dl (g/dl). A reference range is 3.5 to 5.7 g/dl. Blood Urea Nitrogen ((BUN)-kidney function) level was 28 mg/dl. BUN reference range is 3.5 to 5.7 g/dl. Creatinine level was 1.29 milligram (mg)/dl. Creatinine reference range is 0.60 to 1.20 mg/dl. Although the [MEDICATION NAME] was below the reference range and the BUN and Creatinine were above the reference range (suggestive of dehydration), there was no documented evidence the RD made recommendations to improve nutrition and hydration before 7/5/18. This was verified during an interview with the RD on 7/9/18 at 3:22 p.m. There was a plan of care dated 7/1/18, for Resident 9's nutritional problem related to Dementia and needing assistance with meals. Under this plan of care interventions included monitoring, recording, and reporting emaciation (abnormally thin or weak), muscle wasting, significant weight loss (three pounds in a week, greater than 5 percent in one month, greater than 7.5 percent in 3 months, and greater than 10 percent in 6 months). There were no listed interventions to improve Resident 9's food intake such us feeding program, small frequent foods, nourishment between meals, etc. This was confirmed during an interview on 7/9/18 at 10:08 with the dietary service supervisor (DSS) and at 11:20 a.m., with the Assistant Director of Nursing (ADON). A review of the RD's Dietary Progress Notes dated 7/5/18, indicated Resident 9 had a weight loss of two pounds in a week and 12 pounds in a month. The RD progress notes indicated Resident 9's intake was 50 percent and the resident had a DTI to the right heel. RD documented enteral nutrition ((EN) - nutrition provided by means of surgical insertion of gastrostomy tube directly into the stomach) and documented recommendations for appetite stimulant for 60 days, house nourishment 60 ml twice a day with medication pass, and to discuss with family hospice (end of life) care. During an interview on 7/9/18 at 3:22 p.m., the RD stated Resident 9 was placed on a weekly weight monitoring for three weeks and watched if a weight loss was consistent. There were no new recommendations for the low blood [MEDICATION NAME], increased level of BUN and Creatinine dated 6/13/18. The RD stated, Had I known the resident had skin injury, I would have asked the physician to order Pro-Stat® supplement (liquid protein formula) and an appetite stimulant. RD stated, I totally missed the skin injury on the resident's right heel. The RD did not explain the reason prompt nutritional interventions were not developed and implemented when Resident 9 was noted with the significant weight loss on 6/12/18. A review of a Physician's Order dated 7/6/18, indicated to give Resident 9 two ounces of house nourishment twice a day. A review of the Physician's Order dated 7/9/18 indicated to start Resident 9 on [MEDICATION NAME] oral suspension 400 mg in the morning for appetite stimulation. During an interview on 7/9/18 at 10:08 a.m., the DSS stated Resident 9 should have been offered high protein nourishment, milk shakes, or fortified diet for the significant weight loss. During an interview on 7/9/18 at 11:20 a.m., ADON stated Resident 9's significant weight loss should had dietary interventions to prevent further weight loss. During an interview on 7/9/18 at 11:23 a.m., the DON stated the charge nurses and the weight variance committee must had communicated Resident 9's weight loss concerns to the physician. During an interview on 7/9/18 at 11:36 a.m., RNS 1 stated the licensed nurses must communicate the residents' weight concerns and recommendations to the physician. RNS 1 stated Resident 9's physician interventions depended on information provided by the weight management review team. During an interview on 7/9/18 at 11:44 a.m., Certified Nursing Assistant (CNA 4) stated Resident 9 used to feed herself in the past but was not able anymore. CNA 4 stated Resident 9 was usually sleepy at breakfast. A review of the facility's policy and procedures titled Impaired Nutrition - Unplanned Weight Loss clinical protocol dated 4/2013, indicated the dietician will identify whether the resident's intake is adequate to meet his or her nutritional needs. The physician must document the clinical basis for the conclusion that nutritional status and or weight are unlikely to stabilize or improve. The physician will authorize, and the staff will implement appropriate general or cause-specific interventions with careful considerations to the resident's choice, feedings tubes that should be consistent with resident treatment wishes as expressed through an advanced directive, and end of life. The policy also indicate to evaluate the care plan to determine if interventions are implemented and effective in attaining the established nutritional and weight goals and evaluate the resident's response to interventions based on defined criteria for improvement or worsening of nutritional status. A review of the facility's policy and procedures titled Nutrition and Hydration to Maintain Skin Integrity dated 10/2010, indicated poor nutritional status is associated with increased risk for pressure ulcer (wound) development; provide small frequent meals and or between meal snacks to reach caloric and protein goals; and use of tube feeding or supplementation determined by physician and multidisciplinary team. A review of the facility's Consultant Dietician Job Description dated 2014, indicated the dietician must be able to communicate effectively with medical personnel, staff, and residents to explain medical nutrition therapy. According to an undated facility's policy and procedures titled, Nutritional Care Management indicated a written list of the Dietician's recommendations for individual residents will be given to the Dietary Service Supervisor and the Director of Nurses or designee. b. On 7/3/2017 at 4:05 p.m., to 5 p.m., observed Resident 143 sitting on a wheel chair next to the bed in his room. The dinner tray was placed on the bedside table opened but Resident 143 needed assistant with his meal. The meal tray contained, small portion of pureed potatoes, vegetable soup that was thickened, 120 ounces of milk and 120 ounces of cranberry juice that were not opened. On 7/10/2018 at 12 p.m., to 1:30 p.m., Resident 143 was observed sitting on his wheelchair close to the bed without his lunch tray while other the residents were eating lunch. On the same date at 1:35 p.m., certified Nursing Assistant (CNA) 3 who was assigned to Resident's 143 stated he was busy feeding other residents and as soon as he was done, Resident 143 would be assisted with the meals. At 1:45 p.m., Resident 143 was assisted with his meals by CNA 3. During a concurrent interview with CNA 3 stated Resident 143 had to be fed as the last resident, all the time. CNA 3 further stated Resident 143 does not eat half of his meals. A review of Resident 143's Admission Record indicated the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 143's Minimum Data Set (MDS), a standardized resident assessment and care screening tool, dated 3/27/18 and 6/13/18, indicated the resident's cognitive skill for daily decision- making was impaired. The resident was totally dependent on staff with his activities of daily living (bed mobility, transfer, dressing, eating, toilet use and personal hygiene usually made self-understood and understood others, had no impairment in cognitive skills, and required extensive assistance from staff with activities of daily living. The MDS also indicated the resident had a prescribed weight loss greater than five 5 percent (%). A review of the History and Physical form dated 7/18/17, documented by the physician indicated Resident 143 did not have the capacity to understand and make decisions. A review of the physician's recapitulation order, dated 7/5/18, indicated Resident 143 was on mechanical soft, diet with no added salt, finely chopped soft texture, regular consistency, small portion every meal. The diet indicated to add eight ounces of water. A review of Nutritional Assessment (NA) form dated 5/28/2018, for Resident 143 indicated a skin assessment report of a Stage II decubitus on a left dorsal foot. It also indicated the resident had good meal intake when eating small meals. On 6/11/18, the same form indicated Resident 143 had significant monthly weight loss of 24 pounds and ideal body weight (IBW) of 210 lbs. The form indicated the resident's family no longer provided snacks to the resident and a gradual weight loss of 10 percent would be encouraged in six months and to conduct weekly weight within three weeks. The Nutritional Assessment form also indicated Resident 143 preferred extra protein, meat, and vegetables. The NA indicated IBW of 128 lbs (154%). A review of the facility's monthly weight log dated 6/10/18, indicated Resident 143 weight was as follows: 1. On 12/17 weighted 235 lb. 2. On 2/18 weighed 234 lb. 3. On 3/18 weighed 232 lb. 4. On 4/18, weighed 233 lb. 5. On 5/18, weighed 234 lb 6. On 6/18 weighted 210 lb. During six month, Resident 143 lost 25 lb or 11.4 percent (%). A review of the interdisciplinary team (IDT) / Weight Management Review (WMR) form, dated 6/12/18 for Resident 143 indicated a weight loss of 10.3% in 30 days, 9.5 % in 90 days, and 10.6% in 180 days. WMR form also indicated resident had significant weight loss of 25 lbs in 30 days. IDT recommendations indicated the above weight loss were planned weight loss and was beneficial weight loss to the resident. Another comment was the physician was notified and registered dietician (RD) will continue to monitor weekly weight times three weeks and resident was placed on small portion of food with all meals. A review of the weekly weight sheets for Resident 143 dated 4/11/18, 4/14/18, 4/28/18, 5/5/18, 5/12/18, 6/16/18, 6/23/18 and 6/30/18, did not include the weekly weights for the resident. A review of RD recommendations for specific resident nutritional care dated 6/4/18, 6/7/2018 6/11/18, 6/14/18, 6/17/18, 6/18/18, 6/25/18, 6/28/18, 6/30/18, 7/2/18 and 7/5/18 had no indication Resident 143's clinical records were reviewed by the dietician. A review of Resident 143's clinical records indicated a Laboratory result dated 6/5/2018 that indicated [MEDICATION NAME] level of 3.4 for a range of 3.5 to 5.7, calcium 8.3 (8.6 -10.3) and total Protein of 5.9 for a range of (6.4 - 8.9). A review of Resident 143's Activities of Daily Living Tracking Form dated 4/1/18 to 4/30/18, and 5/1/18 to 5/31/18, 6/1/18 to 6/30/18, and 7/1/18 to 7/9/18 indicated the resident's meal intake consumption ranged from 25 to 74 %. There was no documented evidence that meal substitutes were offered to the resident when there was a meal intake less than 75 percent to prevent weight loss. A review of the Resident 143's care plan at risk of nutritional status dated 7/6/16, secondary to [DIAGNOSES REDACTED]. Goals included resident will maintain adequate nutritional status as evidenced by maintaining weight within ideal body weight and intake of at least 75 % each meal; Resident will have no significant weight changes of 5 % or more in ninety days (90). The nursing interventions were; monitor and record, meal intake, and report to physician weight loss of 3 pounds in a week, 5 percent in a month and 7.5 % in three months. Assist with meals, encourage 80 - 100 % of diet served; explain risk of continued weight loss to family and patient; allow sufficient time to chew and swallow, report food intake less than 75 % to physician and dietician to assess nutrition and hydration as needed. There was no documented evidence the resident's weight loss was planned, how much weight the resident was expected to lose, and over what period of time. A review of Resident 143's short care plan significant weight loss of 25 lbs (10.3 %) in thirty 30 days, 9.5 % in 90 days and 10.6 % in 180 days dated 6/18/18, indicated resident will have no weight loss in thirty days. The nursing interventions included, diet as ordered, offer substitute to the foods that resident does not like, monitor frequency of food intake, provide good oral care, registered dietician will continue to monitor weight monthly and as needed and labs as ordered. A review of the licensed nurses notes dated 6/18/18 to 6/30/18 and 7/1/18 to 7/9/18, had no documented evidence that the physician was informed regarding Resident 143's significant weight loss of 11.4 % in a month. A review of the Advance Directive acknowledgement Form dated 6/13/13 indicated a family member, was a responsible party when Resident 143 did not have the capacity to make medical decisions. On 7/8/2018 at 10:45 a.m. during an interview with the dietary supervisor (DS) stated it was Resident 143's preference to lose weight. DS stated an IDT met with the family member to discuss Resident's 143 significant weight loss and the family member said it was ok for a gradual weight loss. On 07/09/18 at 9:38 A.M., during an interview with the MDS coordinator, she confirmed that there was no physician's order for Resident 143's weight loss. However, the MDS assessment dated [DATE] section K indicated Resident 143 had a weight loss of more than five percent. The MDS indicated the weight loss was a prescribed weight loss. MSD coordinator further stated staffs are required to obtain doctor's order. MDS coordinator stated if an order was not obtained, then, the facility failed to provide nourishment to the resident thereby causing significant weight loss. On 07/9/18 at 02:52 P.M., during an interview with the registered dietician (RD) stated the significant weight loss for Resident 143 was because the family members were no longer bringing snacks. When questioned RD stated resident was placed on a small portion every meal for gradual weight loss and weekly weight. When RD was asked if there was an order from the physician to place the resident on a small portion of food, RD stated she made recommendation for small food portion but was not sure who prescribed gradual weight loss. When RD was asked if the resident had significant weight loss of 11.4 % in a month what will she recommend? RD stated her first reaction would be to put the resident on weekly weight. When RD was asked if her recommendation was carried out, RD stated she was not sure if the weekly weight was taking or ordered. When questioned, RD stated she did not evaluate the weekly weight as recommended. When asked, RD stated weekly weight was the only recommendation she made for the significant weight loss for Resident 143. On 07/10/18 at 9:35 A.M., during an interview with the director of nursing (DON) stated when a resident had significant weight loss, IDT would meet and recommend weekly weight times four, monitor meal and fluid intake, speech evaluation and nutritional consultation will be initiated and the physician , family members and the resident will be notified regarding the weight variance. When asked DON stated nutritional supplements, speech therapist, vitamins, fluid intake monitoring was not implemented. DON stated the family members were informed but not sure, if the physician was notified. However, clinical record had no documented evidence that the physician was informed regarding the significant weight loss of 11.4%. On 07/10/18 at 10:31 A.M., during an interview with certified nursing assistant CNA 2 stated licensed nurses will give him the order for weekly weight, he will then input it in the computer, and initiate the weight the following day and continue for the next three more weeks. CNA 2 stated he was not aware Resident' 143 was placed weekly weight time three. On 07/10/18 at 1:08 P.M., during an interview with the assistant director of nursing, (ADON) stated when a significant weight loss was observed, the physician would be notified immediately, as well as resident's significant other. ADON stated they failed to notify the physician regarding the resident's significant weight loss. On 07/10/18 at 2:40 P.M., during an interview with Resident 143's responsible party (RP) stated the facility informed her regarding the weight loss. RP stated Resident 143's weight loss was because of the facility serving him the same kind of food almost every day. RP stated she asked the facility to change the resident's diet or provide different kinds of food/menus to stimulate his appetite. RD further stated authorization was not given to the facility to place Resident 143 on weight watching or small portion of food. RP stated the physician gives order not RP.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services for three of 24 sampled residents (Residents 19, 22 and 23) by failing to: 1. Ensure Resident 19's left hand and leg were assessed for the cause of pain, monitored for the effectiveness of the as needed (PRN) pain medication and notified the physician to get an order for [REDACTED]. 2. Ensure Resident 22 and Resident 23 who were on fluid restriction were monitored for fluid intake as indicated in the plan of care. This deficient practice placed the residents at risk of fluid overload, swelling and discomfort. Findings: a1. On January 10, 2014, at 10:45 a.m., Resident 19 was observed in the front lobby, sitting in a wheelchair with both lower extremities elevated on a pillow. The resident was wearing plastic braces on both lower extremities and her left leg had slid off the footrest and was resting on a pillow between the footrest. Resident 19 was crying and stating her left leg was hurting. Staff members were observed walking by the resident in the lobby however, no staff members stopped and asked the resident why she was crying. The assistant director of nurses (ADON) saw and heard the resident crying out and he came over and took the resident to her room. The ADON did not ask the resident why she was crying. In another observation on January 10, 2014, at 11:10 a.m., Resident 19 was sitting in a wheelchair in the dining room. The resident was crying, frowning holding her left hand up and stating her hand was hurting. The activity staff kept telling the resident to wait a minute and she would be right there, but continued assisting other residents in the dining area for approximately 5 minutes. The activity staff left the dining area and went across the hall to the smaller dining area without assisting Resident 19 or reporting to the nursing staff that the resident was complaining of pain in her left hand. At that time the evaluator intervened and asked the activity staff member what had been done to address the resident's complaint of pain. She stated she should have reported to the charge nurse that the resident was in pain. According to the admission record, Resident 19 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), a standardized assessment and care screening tool, dated April 9, 2013, indicated Resident 19 had no cognitive impairment and was able to make her needs known. The resident required extensive assistance to totally dependence on staff with all her care needs, and had functional limitation in range of motion to her upper and lower extremities. The MDS indicated the resident had pain presence, the pain frequency was frequent and the pain intensity was moderate. The physician's orders [REDACTED]. The Pain Assessment Flow Sheet for the month of January, 2014, indicated the resident last received the [MEDICATION NAME] 5/500 mg for pain in her left hand on January 9, 2014, at 5 p.m. During an interview conducted with Resident 19 on January 14, 2014, at 7:45 a.m., she stated she had pain in her left hand due to arthritis (a medical condition affecting a joint or joints, causing pain, swelling, and stiffness) and the nurses were giving her pain medication, but it does not work. Resident 19 stated on a pain scale of 1 to 10 (10 being the worst pain a person could experience), her pain level was between 9 and 10 on the pain scale. On January 15, 2014, at 3:15 p.m., during an interview with licensed vocational nurse 11 (LVN 11) stated the resident was able to make her needs known, and was able to say what her pain scale level was on a level of 1 to 10. LVN 11 stated she did not think the pain medication was effective for Resident 19, but she did not give the [MEDICATION NAME] every day, and she waits until the resident asks her for the [MEDICATION NAME]. She stated she should have called the physician and informed him that the [MEDICATION NAME] was not working and asks for scheduled routine pain medication. a2. During an observation on January 10, 2014, at 4:10 p.m., Resident 19 was heard moaning, and when asked, the resident stated she had pain in her left hand on a pain scale level of 10. The resident stated she had pain daily and the pain pills were not working. Resident 19's Pain Assessment Flow Sheet, dated January 10, 2014, at 4:30 p.m., indicated the resident's pre-[MEDICATION NAME] (before) pain level was 7 out of 10. [MEDICATION NAME] 5/500 milligrams (mg) tablet was given. The post-[MEDICATION NAME] (after) pain level documentation indicated 0 out of 10 at 5:30 p.m. However, the time of record review was at 4:32 p.m., a discrepancy of 58 minutes. During concurrent interview with LVN 12, who administered the [MEDICATION NAME] on January 10, 2014, at 4:30 p.m., she stated she intended to go back and re-assess the resident's pain, but she did not and documented the post-[MEDICATION NAME] result without assessing Resident 19. LVN 12 stated post-[MEDICATION NAME] assessments should be done 30 minutes to an hour after the pain medication was administered. A review of the Pain Assessment Flow Sheet indicated from December 1 to 27, 2013, Resident 19 received [MEDICATION NAME] 5/500 mg 21 times for severe left hand and lower extremities pain. During an interview and record review with the assistant director of nurses (ADON) on January 10, 2014, at 4:45 p.m., she confirmed Resident 19 had been complaining of severe pain to her left hand. The ADON stated the licensed nurses should have assessed the resident's left hand and notified the physician to identify the cause of the resident's pain and to get a scheduled routine pain medication. The ADON also stated Resident 19's pain should have been reassessed 30 minutes to an hour after the pain medication was administered. The facility's policy and procedure titled, Pain-Clinical Protocol, dated January 29, 2013, indicated the staff will evaluate and report how much and how often the individual asks for as needed (PRN) pain medication. If more than occasional [MEDICATION NAME] requests, and depending on the success of non-pharmacological (interventions that does not involve drugs) interventions, the physician will consider changing to regular administration of at least one [MEDICATION NAME] with another medication for PRN use, increasing the standing dose of an existing [MEDICATION NAME], or switching to another [MEDICATION NAME]. c. On January 14, 2014, at 12:40 pm, Resident 22's over bed table was observed with a two liter bottle of soft drink, two 500 milliliter (ml) bottles of water and one 120 ounce can of juice. One bottle of water was half empty. The beverages on the table did not include what had been served to Resident 22 during the breakfast meal. A review of to the admission record indicated Resident 22 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the History and Physical from the general acute care hospital dated February 2, 2013, Resident 22 had [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The breakdown of fluids on each shift was as follow: 1. For 7 am - 3 pm shift = 300 ml. 2. For 3 pm - 11 pm shift = 100 ml. 3. For 11 pm - 7 am shift = 100 ml The physician's orders [REDACTED]. A resident care plan dated February 8, 2013, addressed Resident 22 being on a fluid restriction. The nursing approaches included informing the resident and her significant others about the fluid restriction and monitoring the resident's intake and output. A resident care plan dated February 8, 2013, addressed Resident 22 being on [MEDICAL TREATMENT]. The nursing approaches included the amount of fluids allowed on each shift including the additional fluids to be served with meals. On January 14, 2014, at 12:40 pm, during a general observation of the room, there were no visible signs or postings to make family and/or visitors aware Resident 22 was on a fluid restriction. On January 14, 2014, at 3:30 pm, during an interview with licensed vocational nurse (LVN 10), he stated he wasn't aware of the beverages on Resident 22's over bed table. LVN 10 agreed Resident 22's fluid restriction was not being enforced as per the physician order [REDACTED]. On January 15, 2014, at 3:05 pm, Resident 22 stated she did not remember the staff telling her or reminding her not to drink a lot of fluid on a daily basis. Resident 22 stated the nurses have not explained to her the problems associated with drinking excess fluids (fluid retention, swelling, shortness of breath). d. On January 14, 2014, at 1:05 pm, an observation of Resident 23's lunch revealed one cup of water (240 ml), one cup of coffee (180 ml), and one small carton of juice (120 ml). Resident 23 had consumed approximately one third cup of coffee and one fourth cup of water at that time. The observation did not include the additional fluids served and consumed by the resident during breakfast. A review of the admission record indicated Resident 23 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The daily allowance of fluid was as follow: 1. For 7 am - 3 pm shift = 300 ml. 2. For 3 pm - 11 pm shift = 240 ml. 3. For 11 pm - 7 am shift = 100 ml. The physician's orders [REDACTED]. A resident care plan dated May 5, 2012, addressed Resident 23 being on a fluid restriction. The nursing approaches included informing the resident and his significant others about the fluid restriction and monitoring the resident's intake and output. A review of the Intake and Output Record for January 2014 indicated Resident 23 consumed the same amount of fluids on each shift on a daily basis. The notes indicated Resident 23 consumed 500 to 540 ml of fluid on the day shift, 360 ml of fluid every evening and 100 ml of fluid every night and did not exceed what the physician's orders [REDACTED]. However, the amount of fluids observed on Resident 22's lunch tray was equivalent to the amount of fluids supposedly consumed during the entire day shift. On January 14, 2014, at 1:05 pm, during a general observation of the room, there were no visible signs or postings to make family and/or visitors aware Resident 23 was on a fluid restriction. On January 14, 2014, at 3:30 pm, LVN 10 stated the staff (CNAs) are supposed to add up all of the fluids consumed by Resident 23 and then write the amount down. He stated the CNA will usually tell him the amount and he enters it onto the I & O Record. However, LVN 10 had no documentation as to Resident 23's intake for the 7 am - 3 pm shift nor could he definitely say the CNA told him how much fluid Resident 23 consumed for that day. LVN 10 agreed Resident 23's intake and output was not being enforced as per the physician's orders [REDACTED]. The facility's policy and procedure on Intake, Measuring and Recording (no date) indicated the purpose of the procedure was to accurately determine the amount of liquid a resident consumes in a 24 hour period. It was indicated the resident and family/visitors were to be informed of the procedure as well as a sign posted the resident's room. The resident's fluid intake was to be recorded as soon as possible and the total recorded at the end of the shift.

Based on observation, interview and record review, the facility failed to ensure two of 14 sampled residents (22, 33) were provided the necessary care and services including assessment and monitoring: Resident 22's arteriovenous shunt (AV (a diversion of blood from an artery directly to the vein)) bruit (the unusual sound that blood makes when it rushes past an obstruction in an artery, heard by using a stethoscope), and thrill (vibration felt by the examiner on palpation) were not assessed and monitored after [MEDICAL TREATMENT] (a procedure to remove fluid and waste products from the blood and to correct electrolyte imbalances) treatment as indicated in the resident's care plan. This deficient practice placed Resident 22 at risk of unrecognized malfunction of resident's AV shunt that may result in delayed [MEDICAL TREATMENT] treatment. Resident 33's [MEDICATION NAME] (blood pressure medication) was not held when the resident's systolic blood pressure (the blood pressure when the heart is contracting) was below 120 millimeter mercury (mmHg) (normal systolic range 90 to 140 mmHg) as ordered by the physician. This deficient practice had the potential for the resident's blood pressure to further decrease that may result to weakness, dizziness and placed the resident at risk for fall. Findings: a. According to the admission record, Resident 22, was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 22's Minimum Data Set, standardized assessment tool, dated May 15, 2014, indicated the resident's cognitive skills for daily decision-making were moderately impaired and required extensive assistance from the staff for activities of daily living. There was a physician's orders [REDACTED]. On May 31, 2014 at 11 a.m., Resident 22 was observed lying in bed with a cloth dressing wrapped around her left upper arm AV shunt. A review of Resident 22's [MEDICAL TREATMENT] Communication Form under the section of post (after) [MEDICAL TREATMENT] treatment dated March 10, 14, 17, 21, 24, 28, 31, and April 4, 18, 21, and 25, 2014, revealed no documented assessment and monitoring by licensed nurses for thrill and bruit of the resident's left AV shunt after the resident received the [MEDICAL TREATMENT] treatment. A review of Resident 22's Licensed Personnel Weekly Progress Notes dated March 10, 14, 17, 21, 24, 28, 31, and April 4, 18, 21, and 25, 2014, revealed no post [MEDICAL TREATMENT] monitoring by the facility staff of Resident 22's left AV shunt for the presence of bruit or thrill. There was a care plan dated February 16, 2014, for [MEDICAL TREATMENT] need related to end stage [MEDICAL CONDITION]. The interventions included to monitor AV graft (shut) at left arm for redness, pain, signs and symptoms of infection, presence and absence of bruit and thrill, bleeding and to notify the physician at once. During an interview and record review of Resident 22's medical record with the director of nurses (DON) on May 31, 2014, at 2 p.m., the DON stated the licensed nurses are responsible to document the resident's AV shunt monitoring for bruit and thrill in the [MEDICAL TREATMENT] Communication form during pre and post [MEDICAL TREATMENT]. The DON stated the licensed nurses should be monitoring the resident's left AV shunt for presence and absence of bruit and thrill. The DON could not provide documentation that the licensed nurses assessed and monitored Resident 22's bruit and thrill after the resident received [MEDICAL TREATMENT] treatment. b. During a revisit survey, a review of the admission record indicated Resident 33 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set, a assessment tool, dated February 20, 2014, indicated the resident's cognitive skills for daily decision-making were intact. According to the MDS the resident required limited assistance from the staff for her activities of daily living. The resident had a physician's orders [REDACTED]. There was a plan of care dated February 21, 2011, for the potential exacerbation of elevated blood pressure and its complications. The interventions included to administer medication as ordered. A review of the Medication Administration Record [REDACTED]. On May 31, 2014 at 3:30 p.m., during an interview registered nurse 1, stated [MEDICATION NAME] HCL 0.2 mg should have not been administered due to the resident's low blood pressure reading of 110 mmHg.