Every finding on record at Village Square Healthcare Center

Based on interview and record review, the facility failed to report an allegation of abuse for one of five sampled residents (Resident 1) within 24 hours to the California Department of Public Health (CDPH - a state survey agency that regulates nursing homes) and law enforcement.As a result, investigation into the allegation of abuse was delayed and placed residents at risk for further abuse.Findings:During a record review, the undated admission Record indicated Resident 1 was admitted on [DATE] with diagnoses which included anxiety disorder (a mental health disorder which involved excessing fear or worry), and difficulty in walking.During a record review, the Minimum Data Set (MDS- a federally mandated assessment tool) dated 7/14/26, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition, or thinking skills) of 15, which indicated Resident 1 was cognitively intact. The MDS further indicated Resident 1 did not have any physical or verbal behavioral symptoms directed towards others.During a record review, the undated admission Record indicated Resident 2 was admitted on [DATE] and discharged on 7/24/26 with diagnoses to include psychoactive substance use (the use of a substance that affects the brain and causes changes in mood, thinking, or behavior), and anxiety disorder (a mental health condition which consists of excessive worry, fear or panic).During a record review, the Minimum Data Set (MDS- a federally mandated assessment tool) dated 7/24/26 indicated Resident 2 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition, or thinking skills) of 15, which indicated Resident 2 was cognitively intact. The MDS further stated Resident 2 had verbal behavioral symptoms directed toward others (e.g. threatening others, screaming at others, cursing at others) which occurred one to three days out of the week.During a review of the document titled eInteract Change in Condition Evaluation dated 7/18/26 at 14:00 (2 P.M.), the document indicated, At approximately 1345, CNA [Certified Nursing Assistant] notified this writer that [Resident 1] was calling 911. This writer entered the resident's room and observed the resident in a safe environment speaking with 911 dispatcher by phone. The resident stated 'There is a patient acting like a fruitcake. He is roaming down the hallway in his wheelchair, and I feel in danger.' This writer did not witness the incident, remain with resident until Sherrif's arrived [sic].On 7/31/26 at 9:38 A.M. an interview was conducted with Resident 1. Resident 1 stated on 7/18/26, Resident 1 stated Resident 2 went down the hallway at a fast speed in his wheelchair. Resident 1 stated [Resident 2] comes by and deliberately tries to run me down, its not an accident. Resident 1 further stated Resident 2 made comments to her such as I don't like you, you're not getting out of this facility alive. Per Resident 1, [Resident 2] told me he was going to beat me up. Resident 1 further stated on 7/18/26, Resident 2 parked his wheelchair in the doorway of her bedroom while she was inside, and this made her feel unsafe. Resident 1 stated she reported these incidents to the charge nurse, but was told there was nothing they could do. Resident 1 stated, That's when I called 911.Resident 1 stated she continued to see Resident 2 in the hallways after the incident on 7/18/26, but he had since been discharged from the facility.During an interview with Licensed Nurse (LN) 1 on 7/31/26 at 10:06 A.M., LN 1 stated he was the charge nurse on 7/18/26. LN 1 stated he was informed that Resident 1 called 911 because Resident 2 was going down the hallway too fast. LN 1 stated Resident 2 often went down the hallways at a fast speed. LN 1 stated, [Resident 1] didn't feel safe. LN 1 stated since he did not witness any of Resident 1's allegations against Resident 2, he did not report the incident to the Abuse Coordinator.During an interview with the Social Services Director (SSD) on 7/31/26 at 10:26 A.M., the SSD stated the incident between Resident 1 and Resident 2 were discussed at the morning stand up meeting (a daily meeting in which members of the facility leadership team discuss facility updates and identify items which require attention) on 7/20/26. The SSD stated members of the management team, including the Director of Nursing, Assistant Director of Nursing, Director of Staff Development, were present during the meeting. The SSD stated she offered Resident 2 a room change on a different unit, but Resident 2 refused. The SSD stated, The minute [Resident 1] said she felt unsafe, we should have separated them. The SSD stated Resident 1 and Resident 2 remained on the same unit until Resident 2 was discharged on 7/24/26.During an interview with Licensed Nurse (LN) 2 on 7/31/26 at 11:04 A.M., LN 2 stated on 7/18/26, Resident 1 told her she had called 911 because Resident 2 was being aggressive towards her and was speeding down the hallways. LN 2 further stated Resident 1 reported Resident 2 was harassing her, and she did not feel safe. LN 2 stated Resident 1's allegations were considered abuse, and we should report any form of abuse to the administrator. He's the abuse coordinator. LN 2 stated she did not report Resident 1's allegations to the abuse coordinator.During an interview with the Administrator (ADMIN) on 8/7/26 at 11:57 A.M., the ADMIN stated he was the Abuse Coordinator. The ADMIN stated Resident 1's allegations were allegations of abuse and should have been reported to the Department of Public Health within the required time frame of 24 hours. The ADMIN stated his expectation was to have a safe environment for all the residents. During a review of the facility's undated policy titled Abuse Investigation and Reporting, the policy indicated, All allegations of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ( Abuse) shall be promptly reported to the appropriate local, state and/or federal agencies (as defined by current regulations) and thoroughly investigated by Company management. Findings of abuse investigations will also be reported to local law enforcement and the Office of Ombudsman.

Based on interview and record review, the facility failed to conduct an investigation related to an allegation of verbal and emotional abuse, and to implement measures to protect residents from further incidents of abuse for one of five sampled residents (Resident 1). This failure had the potential to place vulnerable residents at continued risk for abuse.Findings:During a record review, the undated admission Record indicated Resident 1 was admitted on [DATE] with diagnoses which included anxiety disorder (a mental health disorder which involved excessing fear or worry), and difficulty in walking.During a record review, the Minimum Data Set (MDS- a federally mandated assessment tool) dated 7/14/26, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition, or thinking skills) of 15, which indicated Resident 1 was cognitively intact. The MDS further indicated Resident 1 did not have any physical or verbal behavioral symptoms directed towards others.During a record review, the undated admission Record indicated Resident 2 was admitted on [DATE] and discharged on 7/24/26 with diagnoses to include psychoactive substance use (the use of a substance that affects the brain and causes changes in mood, thinking, or behavior), and anxiety disorder (a mental health condition which consists of excessive worry, fear or panic).During a record review, the Minimum Data Set (MDS- a federally mandated assessment tool) dated 7/24/26 indicated Resident 2 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition, or thinking skills) of 15, which indicated Resident 2 was cognitively intact. The MDS further stated Resident 2 had verbal behavioral symptoms directed toward others (e.g. threatening others, screaming at others, cursing at others) which occurred one to three days out of the week.During a review of the document titled eInteract Change in Condition Evaluation dated 7/18/26 at 14:00 (2 P.M.), the document indicated, At approximately 1345, CNA [Certified Nursing Assistant] notified this writer that [Resident 1] was calling 911. This writer entered the resident's room and observed the resident in a safe environment speaking with 911 dispatcher by phone. The resident stated 'There is a patient acting like a fruitcake. He is roaming down the hallway in his wheelchair, and I feel in danger.' This writer did not witness the incident, remain with resident until Sherrif's arrived [sic].On 7/31/26 at 9:38 A.M. an interview was conducted with Resident 1. Resident 1 stated on 7/18/26, Resident 1 stated Resident 2 went down the hallway at a fast speed in his wheelchair. Resident 1 stated [Resident 2] comes by and deliberately tries to run me down, it's not an accident. Resident 1 further stated Resident 2 made comments to her such as I don't like you, you're not getting out of this facility alive. Per Resident 1, [Resident 2] told me he was going to beat me up. Resident 1 further stated on 7/18/26, Resident 2 parked his wheelchair in the doorway of her bedroom while she was inside, and this made her feel unsafe. Resident 1 stated she reported these incidents to the charge nurse but was told there was nothing they could do. Resident 1 stated, That's when I called 911. Resident 1 stated she was unsure what the facility did to prevent Resident 2 from having contact with her. Resident 1 stated she continued to see Resident 2 in the hallways after the incident on 7/18/26, but he had since been discharged from the facility.During an interview with Licensed Nurse (LN) 1 on 7/31/26 at 10:06 A.M., LN 1 stated he was the charge nurse on 7/18/26. LN 1 stated he was informed that Resident 1 called 911 because Resident 2 was going down the hallway too fast. LN 1 stated Resident 2 often went down the hallways at a fast speed. LN 1 stated, [Resident 1] didn't feel safe. LN 1 stated since he did not witness any of Resident 1's allegations against Resident 2, he did not report the incident to the Abuse Coordinator. LN 1 stated he did not monitor Resident 2's whereabouts and did not ensure the residents were separated despite Resident 1's allegations.During an interview with the Social Services Director (SSD) on 7/31/26 at 10:26 A.M., the SSD stated the incident between Resident 1 and Resident 2 were discussed at the morning stand up meeting (a daily meeting in which members of the facility leadership team discuss facility updates and identify items which require attention) on 7/20/26. The SSD stated members of the management team, including the Director of Nursing, Assistant Director of Nursing, Director of Staff Development, were present during the meeting. The SSD stated she offered Resident 2 a room change on a different unit, but Resident 2 refused. The SSD stated, The minute [Resident 1] said she felt unsafe, we should have separated them right away, no matter what. The SSD stated Resident 1 and Resident 2 remained on the same unit until Resident 2 was discharged on 7/24/26.During an interview with Licensed Nurse (LN) 2 on 7/31/26 at 11:04 A.M., LN 2 stated on 7/18/26, Resident 1 told her she had called 911 because Resident 2 was being aggressive towards her and was speeding down the hallways. LN 2 further stated Resident 1 reported Resident 2 was harassing her, and she did not feel safe. LN 2 stated Resident 1's allegations were considered abuse, and we should report any form of abuse to the administrator. He's the abuse coordinator. LN 2 stated she did not report Resident 1's allegations to the abuse coordinator.During an interview with the Administrator (ADMIN) on 8/7/26 at 11:57 A.M., the ADMIN stated he was the Abuse Coordinator. The ADMIN stated Resident 1's allegations were allegations of abuse and should have been reported to the Department of Public Health. The ADMIN stated his expectation was to have a safe environment for all the residents. The ADMIN stated the purpose of investigating allegations of abuse was to make sure residents were kept safe, until the allegations could be either substantiated or not. The ADMIN stated, The ultimate goal is to make sure we investigate and have a safe environment for all residents.During a review of the facility's undated policy titled Abuse Investigation and Reporting, the policy indicated, All allegations of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ( Abuse) shall be promptly reported to the appropriate local, state and/or federal agencies (as defined by current regulations) and thoroughly investigated by Company management. Findings of abuse investigations will also be reported to local law enforcement and the Office of Ombudsman.The Administrator will attempt to prevent any further potential abuse .The Administrator will inform the resident, who is the alleged victim, and/or his/her representative of the status of the investigation and measures taken to protect the safety and privacy of the resident .

Based on interview and record review, the facility failed to provide medication for Resident 1 for 3 consecutive days in 1 out of 3 residents reviewed for pain management. As a result , Resident 1 experienced distress due to not receiving the medication.Findings.An unannounced visit to the facility was conducted on 3/19/26 regarding a complaint related to a specific medication that was not administered by the facility. Per the Facility's admission Face sheet, Resident 1 was admitted to the facility on [DATE] with diagnoses that included Other Psychoactive Substance (chemical compounds that impacts the central nervous system to alter mood, perception, cognition and behavior) Abuse and Encounter for Other Specified Surgical Aftercare. A review of the licensed nurse (LN) admitting progress notes dated 2/28/26 indicated Resident 1 was alert and oriented x4 (a medical assessment term indicating a patient is alert and fully aware of the 4 key areas : person (name) place (location),time (date & time) and situation (why they are receiving care). An interview and record review on 3/19/26 at 11 A.M., with licensed nurse (LN) 1 was conducted. LN 1 stated the facility did not administer Resident 1's methadone (a long-acting synthetic opioid agonist used primarily to treat opioid use disorder) due to the medication was not available for 3 consecutive days; 3/1/26, 3/2/26 and 3/3/26 as indicated by Resident 1's medication administration record (MAR). LN 1 stated Resident 1 was upset and threw water at a staff member because he did not have his medication for 3 days. LN 1 stated Resident 1 was upset and was agitated and had called the emergency 911 number and left the facility against medical advice on 3/3/26. LN1 stated on admission, the facility should have checked that they can meet Resident 1's needs which was the availability of the medication methadone. LN1 stated Resident 1 could have serious side effects by not taking his methadone like withdrawal signs and symptoms. A review of the minimum data set (MDS- a federally mandated assessment tool) dated 3/3/26, brief interview for mental status (BIMS) score for cognition (thought process) was left blank. A review of the physician order report dated 2/28/26- 3/3/26 , Resident 1 was on the following medications.methadone concentrates 10 mg (mg-unit of measurement )/ ml (ml- milliliter- unit of measurement); amt;135 mg; oral for Opioid dependence (a physical state wherein the body requires regular opioid use to function normally and avoid withdrawal symptoms) once a dayhydromorphone 4 mg 1 tablet every 4 hours for breakthrough pain (sudden, intense flare -up of pain) oxycodone 10 mg 1 tablet every 4 hours as needed for pain level of 4-6.oxycodone 20 mg 1 tablet every 4 hours as needed for pain level of 7-10. A review of Resident 1's MAR dated 2/28/26 indicated methadone was not administered on the following dates - 3/1/26, 3/2/26 and 3/3/26, entered as NA or not available. A review of the progress notes dated 3/3/26 indicated LN 1 had called the methadone clinic and had tried to order the medication and arrange for transport that day, but the facility did not have available transportation to pick up Resident 1's methadone himself. An interview on 3/19/26 at 12:30 P.M., with the Director of Nursing (DON) was conducted. The DON stated when the facility accepted any resident for admission, the facility agreed that they will meet and provide the residents' needs. A review of Resident 1's care plan , problem start date 2/28/26 indicated one of the approaches was methadone concentrate 10 mg/ml; amt;135 mg; oral once a day. A review of the facility's record titled, against medical advice (AMA), dated 3/3/26, indicated resident signed the form. A review of the facility's undated policy titled, admission to the Facility, indicated purpose, the facility will admit only those residents whose medical, nursing and rehabilitation care needs can be met. A review of the facility's undated policy, titled Ordering and Receiving Medications from Non -Contract Pharmacies indicated .#4.if non- contract pharmacy is unable to provide ordered medications, the provider pharmacy may be contacted to supply the ordered medication.

Based on interview and record review, the facility failed to ensure residents' controlled medications (medications that can cause physical and mental dependence and are regulated by the Drug Enforcement Administration) were secured in the facility's medication carts. Specifically, controlled substances, including Individual Patient's Narcotic Records (IPNR), were removed from the cart without the licensed nurses' (LNs) knowledge and were left unaccounted for 10 of 10 residents (1, 2, 3, 4, 5, 6, 7, 8, 9, 10). This had the potential for affected residents' medication to not being available in the event they were needed. There were no missed doses for the affected residents.Findings:On 12/12/25, the Department received a facility report incident related to pharmaceutical services. On 1/7/26, an unannounced onsite visit to the facility was conducted. A review of the residents' record were as follows.1.Resident 1 was admitted to the facility on [DATE], with diagnoses which included liver cancer, per the facility's admission Record. A review of Resident 1's physician order dated 11/11/25 indicated, Tramadol 50 mg tablet 1-2 tablets for moderate and severe pain as needed (PRN) every 6 hours.A review of the pharmacy packing slip dated 11/11/25 indicated, the facility licensed nurse (LN) received 30 tablets of Tramadol HCL 50 mg (milligrams).A review of Resident 1's Individual Patient's Narcotic Record (IPNR) indicated, there were 26 tablets left in the med bubble pack (packaging in which a product is sealed between a cardboard backing and clear plastic cover). 2. Resident 2 was admitted to the facility on [DATE], with diagnoses which included chronic back pain, per the facility's admission Record. A review of Resident 2's physicians order dated 8/22/25 indicated, Hydrocodone- Acetaminophen 10-325 mg tablet, give 1 tablet by mouth every 4 hours PRN (as needed) for moderate pain. In addition, the physicians order dated 9/15/25 indicated, Oxycontin 10 mg, give 1 tablet by mouth twice a day for pain management.a. A review of the pharmacy packing slip dated 11/5/25 indicated that the facility's licensed nurse (LN) received 60 tablets of Oxycodone - Acetaminophen (Percocet) 10-325 mg.A review of Resident 2's Individual Patient's Narcotic Record (IPNR) indicated there were 23 tablets left in the med bubble pack (packaging in which a product is sealed between a cardboard backing and clear plastic cover).b. A review of the pharmacy packing slip dated 11/5/25 indicated that the facility's licensed nurse (LN) received 8 tablets of Oxycodone - Acetaminophen (Percocet) 10-325 mg.A review of Resident 2's Individual Patient's Narcotic Record (IPNR) indicated there were 5 tablets left in the med bubble pack (packaging in which a product is sealed between a cardboard backing and clear plastic cover).c. A review of the pharmacy packing slip dated 11/28/25 indicated that the facility's licensed nurse (LN) received 28 Oxycontin ER 10 mg. tablets. A review of Resident 2's Individual Patient's Narcotic Record (IPNR) indicated there were 5 tablets left in the med bubble pack (packaging in which a product is sealed between a cardboard backing and clear plastic cover). 3. Resident 3 was admitted to the facility on [DATE], with diagnoses which included chronic low back pain - intractable, per the facility's admission Record. A review of Resident 3's physicians order dated 10/26/25 indicated, Oxycodone 10 mg., give 1 tablet by mouth every 6 hours PRN (as needed) for pain.A review of the pharmacy packing slip dated 12/3/25 indicated that the facility's licensed nurse (LN) received 30 tablets of Oxycodone HCL(IR) 10 mg.A review of Resident 3's Individual Patient's Narcotic Record (IPNR) indicated there were 0 tablets left in the med bubble pack (packaging in which a product is sealed between a cardboard backing and clear plastic cover). 4. Resident 4 was admitted to the facility on [DATE], with diagnoses which included chronic venous hypertension with ulcer of left and right lower extremities (a severe, chronic, and often painful open skin lesion caused by sustained high pressure in the leg veins), per the facility's admission Record. A review of Resident 4's physicians order dated 10/1/25 indicated, Oxycodone 5 mg., give 1 tablet by mouth every 4 hours PRN (as needed) for moderate pain.There was no packing pharmacy packing slip included in the documentation.A review of Resident 4's Individual Patient's Narcotic Record (IPNR) indicated, there were 17 tablets dispensed by the pharmacy with 5 tablets left in the med bubble pack (packaging in which a product is sealed between a cardboard backing and clear plastic cover). 5. Resident 5 was admitted to the facility on [DATE], with diagnoses which included chronic vascular disorders of intestines- ischemic colitis (reduced blood flow to the large intestine (colon) causes inflammation and damage due to lack of oxygen and causes ongoing or recurring stomach pain, diarrhea, and potential tissue damage over time.), per the facility's admission Record. A review of Resident 5's physicians order dated 8/4/25 indicated, Oxycodone 15 mg., give 1 tablet by mouth every 4 hours PRN (as needed) for epigastric pain.A review of the undated pharmacy packing slip indicated, the facility received 58 tablets of Oxycodone HCL(IR) 15 mg. There was no licensed nurse (LN) signature to reflect the Oxycodone HCL(IR) was received. A review of Resident 5's Individual Patient's Narcotic Record (IPNR) indicated there were 2 tablets left in the med bubble pack (packaging in which a product is sealed between a cardboard backing and clear plastic cover). 6. Resident 6 was re- admitted to the facility on [DATE], with diagnoses which included chronic pain syndrome, per the facility's admission Record. A review of Resident 6's physicians order dated 11/27/25 indicated, Oxycodone 5 mg., give 1 tablet by mouth every 4 hours PRN (as needed) for mild pain. And 15 mg., 3 tablets by mouth every 4 hours PRN for severe pain.A review of the undated pharmacy packing slip indicated, the facility received 90 tablets of Oxycodone HCL(IR) 5 mg. There was no licensed nurse (LN) signature to reflect the Oxycodone HCL(IR) 5 mg. was received. A review of Resident 6's Individual Patient's Narcotic Record (IPNR) indicated there were 90 tablets left in the med bubble pack (packaging in which a product is sealed between a cardboard backing and clear plastic cover). 7. Resident 7 was readmitted to the facility on [DATE], with diagnoses which included end stage renal disease (kidney failure), per the facility's admission Record. A review of Resident 7's physicians order dated 9/24/25 indicated, Oxycodone 5 mg., give 1 tablet by mouth every 4 hours PRN (as needed) for pain management.A review of the undated pharmacy packing slip indicated, the pharmacy dispensed 30 tablets of Oxycodone HCL(IR) 5 mg. There was no licensed nurse (LN) signature to reflect the Oxycodone HCL(IR) 5 mg. was receivedA review of Resident 7's Individual Patient's Narcotic Record (IPNR) indicated there were 7 tablets left in the med bubble pack (packaging in which a product is sealed between a cardboard backing and clear plastic cover). 8. Resident 8 was readmitted to the facility on [DATE], with diagnoses which included cervical disc disorder (a wear and tear condition where the soft, rubbery cushions (discs) between your neck bones (vertebrae) break down, dry out, or bulge, often causing chronic neck pain, stiffness, and nerve pain that radiates into the shoulders or arms) , per the facility's admission Record. A review of Resident 8's physicians order dated 6/18/25 indicated, Oxycodone 20 mg., give 1 tablet by mouth every 4 hours PRN (as needed) for pain.A review of the undated pharmacy packing slip indicated, the pharmacy dispensed 30 tablets of Oxycodone HCL(IR) 5 mg. There was no licensed nurse (LN) signature to reflect 30 tablets of Oxycodone HCL(IR) 5 mg. was received.A review of Resident 8's Individual Patient's Narcotic Record (IPNR) indicated there were 0 tablets left in the med bubble pack (packaging in which a product is sealed between a cardboard backing and clear plastic cover) and missed signatures of licensed nurses. 9. Resident 9 was admitted to the facility on [DATE], with diagnoses which included bilateral osteoarthritis of knee (chronic wear-and-tear disease where the protective cartilage cushioning the ends of bones breaks down over time, causing pain, swelling, and stiffness.), per the facility's admission Record. A review of Resident 9's physicians order dated 11/15/25 indicated, Oxycodone 5 mg., give 1 tablet by mouth every 4 hours PRN (as needed) for moderate pain and 10 mg I tablet by mouth every 6 hours PRN for severe pain.A review of the pharmacy packing slip dated 11/15/25 indicated, the pharmacy dispensed 11 tablets of Oxycodone HCL(IR) 10 mg. There was no licensed nurse (LN) signature to reflect the Oxycodone HCL(IR) 10 mg. was received.A review of Resident 9's Individual Patient's Narcotic Record (IPNR) indicated there were 5 tablets left in the med bubble pack (packaging in which a product is sealed between a cardboard backing and clear plastic cover.A review of the pharmacy packing slip dated 11/15/25 indicated, the pharmacy dispensed 16 tablets of Oxycodone HCL(IR) 5 mg. There was no licensed nurse (LN) signature to reflect the Oxycodone HCL(IR) 5 mg. was received.A review of Resident 9's Individual Patient's Narcotic Record (IPNR) indicated there were 2 tablets left in the med bubble pack (packaging in which a product is sealed between a cardboard backing and clear plastic cover 10. Resident 10 was admitted to the facility on [DATE], with diagnoses which included fracture of left fibula and fibula (leg fracture), per the facility's admission Record. A review of Resident 9's physicians order dated 11/25/25 indicated, Oxycodone - acetaminophen 5-325 mg., give 1 tablet by mouth every 4 hours PRN (as needed) for moderate pain.A review of the undated pharmacy packing slip indicated the pharmacy dispensed 16 tablets of Oxycodone -Acetaminophen 5-235 mg. There was no licensed nurse (LN) signature indicated the pharmacy dispensed 16 tablets of Oxycodone -Acetaminophen 5-235 mg.A review of Resident 10's Individual Patient's Narcotic Record (IPNR) indicated there were 4 tablets left in the med bubble pack (packaging in which a product is sealed between a cardboard backing and clear plastic cover On 1/7/26 at 10:50 A.M., an interview was conducted with the Administrator (ADM) and the Director of Nursing (DON). The ADM stated on 12/19/25 the facility's interim DON received a call from another skilled nursing facility (SNF) about a licensed nurse working through a staffing agency who was involved in a drug diversion case. During the investigation of the other SNF, original narcotic sheets and medication bubble packets were discovered and traced back to their facility. The ADM further stated the involved licensed nurse was immediately removed from the schedule and her account was deactivated.On 1/7/26 at 11:15 A.M., an interview was conducted with the DSD (Director of Staff development). The DSD stated if the pharmacy brought controlled meds to the nursing station, the receiving LN signed the pharmacy packing list, the white form stayed in the facility and the yellow copy goes to pharmacy. The DSD stated staff were trained for shift-to-shift counts. Each nurse counted the number of medications cards and both staff verified and signed. The DSD stated the count matched the quantity of the medications from the CDR and from the med bubble card. On 1/7/26 at 11:40 A.M., an interview was conducted with licensed nurse (LN) 1. LN 1 stated controlled meds were counted before and after the shift. LN 1 stated the outgoing LN reviewed the narcotic count sheet by reading the resident's name, name of the controlled meds, dosage and number of the drugs remained in the count sheet. The incoming LN reviewed the med bubble pack by checking the resident's name, drug name, dosage, and the number of drugs left in the med bubble pack. After all controlled meds are administered from the med bubble pack, the controlled narcotic sheet (CDR) goes to medical records, and the med bubble pack goes to the shredder. LN 1 stated the Nursing supervisor, or DON will be informed if there was a discrepancy during the count of the narcotic. On 1/7/26 at 12 noon, an interview was conducted with LN 2. LN 2 stated that each station had a narcotic binder. The incoming LN counted the medication bubble packs from the drawer. Both incoming and outgoing LN signed the narcotic binder. The outgoing LN read out the resident's name, name of controlled drug, dosage and the number of medications remained from the CDR. The incoming nurse reviewed the meds-controlled bubble pack, name of resident, name of the drug, and the number of meds left in the med bubble pack. LN 2 stated, when new refills were received, the receiving LN was required to document in the narcotic binder the number of cards received, but not the quantity of pills received. LN 2 stated that she worked with LN from the staffing agency regularly 2 stated if there's discrepancy from the count sheet, the nursing Supervisor should be notified. On 1/7/26 at 12:50 P.M., an interview was conducted with LN 3. LN 3 stated that controlled drugs were being counted every beginning of the shift between the incoming and the outgoing LN. The LN signed the narcotic binder. On 1/7/26 at 1:15 P.M., an interview was conducted with the ADM and DON. The ADM and the DON both stated they were unaware that there were discrepancy. The ADM stated after knowing the issue, they have started their own investigation and updated the controlled medications reconciliation policy and procedure. A review of the facility's policy titled, Drug Diversion, dated 12/19, indicated .Drug diversion (theft) is prohibited. Suspected drug diversion will be investigated and in the event that substantial evidence supports a belief that diversion has occurred, appropriate disciplinary and reporting actions will be taken. A review of the undated facility's policy, titled, Medication Destruction, indicated .to destroy medications in accordance with state and federal guidelines. A review of the facility's policy dated 1/20, titled, Ordering and receiving Controlled medications, indicated .Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances, and medications classified as controlled substances by the state law. the pharmacy or nursing care center prepares and individual resident controlled substance record. this log is placed in the MAR or narcotic book to be counted every shift.

Based on observation, interview and record review , the facility failed to ensure a low air loss mattress (help prevent skin breakdown) was in placed or implemented for one of one resident (Resident 1) with a pressure ulcer (localized injury to the skin). This failure had the potential to worsen Resident 1's skin injury. Findings. Per the facility's admission Record , Resident 1 was admitted to the facility on [DATE] with diagnoses which included Pressure Ulcer of sacral (area of the lower back) region, unstageable and Functional Quadriplegia (paralysis affecting all limbs and torso). On 6/26/25 at 11:20 A.M., an interview with Resident 1 was conducted. Resident 1 stated she had complained to a certified nursing assistant (CNA) to checked if the settings were right on the air-loss mattress on her bed. The CNA stated there was a regular mattress on Resident 1's bed and no air-loss mattress. A record review of Resident 1's minimum data set (MDS- a federally mandated assessment tool) dated 5/31/25 indicated Resident 1's brief interview for mental status (BIMS) was 15 which meant Resident 1's cognition (thought process) was intact. On 6/26/25 at 10:45 A.M., an interview with the Treatment Nurse (TXN) was conducted . The TXN stated she did Resident 1's treatment to her wounds daily and that Resident 1 had a low air-loss mattress on her bed for offloading and to aid in healing. The TXN stated the nurses had to check and sign that the low air-loss mattress was on Resident 1's bed. The TXN stated she was not aware that the air-loss mattress was missing for weeks until Resident 1 reported it to the Director of Nursing (DON). On 6/26/25 at 11:00 A.M., an interview and record review with Licensed Nurse (LN) 1 was conducted . LN 1 stated, per the Physician's order report dated 5/5/25 indicated orders for a low air-loss mattress for skin management and prevention and to Monitor for functioning and settings every shift. LN 1 stated she was not aware that Resident 1's air-loss mattress had been missing for weeks. LN 1 stated the treatment nurses should have checked the air-loss mattress before signing it when they did Resident 1's treatment on her wounds. LN 1 stated license nurses were signing off the Treatment Administration Record (TAR) for the low air-loss placement and settings for the months of May and June 25 without checking. A record review of Resident 1's care plan dated 2/11/25, category- pressure ulcer , indicated one of the approaches was a LAL (low air-loss) mattress for skin management and prevention and to monitor for functioning and settings every shift. On 6/26/25 at 12 P.M., an interview with the DON was conducted. The DON stated the low air-loss mattress might have been switched to another bed instead of Resident 1's room which was 207 B. The DON stated 207 B does not need an air-loss mattress since 207B did not have any skin issues. The DON stated it was important to have the air-loss mattress on Resident 1's bed due to Resident 1's multiple skin issues that would aid in wound healing. A review of the facility's undated policy titled, Pressure Ulcer Injury & Skin Care Management indicated .Procedure .#8 The interdisciplinary team .c. considers and includes interventions for pressure ulcer/injury prevention and treatment .d. implements treatment procedures in accordance with professional standards of practice.

Based on observation, interview, and facility policy review, the facility failed to ensure dietary staff covered their facial hair during meal preparation, cold food items were held on the tray line at temperature of 41 degrees Fahrenheit (F) or below, expired food items were discarded, and items in the walk-in freezer were stored in a manner to prevent freezer burn. These deficient practices had the potential to affect all residents who received food from the kitchen. Findings included: 1. A facility policy titled, Personal Hygiene dated 2018, indicated, 6. Beards and or mustaches should be covered during meal preparation and service. During an observation on 05/12/2025 at 8:55 AM, [NAME] #3 prepared fish with his facial hair uncovered. During an observation on 05/12/2025 from 11:38 AM until 11:46 AM, [NAME] #3 took the temperature of the food on the lunch tray line and plated food while their facial hair was not covered. During an observation on 05/13/2025 at 11:50 AM, [NAME] #3 served hot lunch food items and his facial hair was not covered During a concurrent observation and interview on 05/13/2025 at 2:05 PM, [NAME] #4 placed dinner rolls on a sheet pan and his facial hair was uncovered. [NAME] #4 stated he was trained to cover his facial hair but forgot to put on a face cover on. During an interview on 05/13/2025 at 2:07 PM, the Dietary Director (DD) stated staff with facial hair should wear a face cover to protect their hair from getting in the food. The DD stated she expected staff with facial hair to wear a face cover or be clean shaven. During an interview on 05/14/2025 at 11:13 AM, the Registered Dietitian stated she expected all staff with facial hair to wear a face cover, either a beard guard or a surgical mask, or be clean shaven, especially the cooks. During an interview on 05/15/2025 at 9:00 AM, [NAME] #3 stated he was never told to wear a cover for his facial hair. During an interview on 05/15/2025 at 9:43 AM, the Director of Nursing stated she expected dietary staff with facial hair to wear a face cover or to shave. During an interview on 05/15/2025 at 9:46 AM, the Administrator stated he expected staff with visible facial hair to wear a face cover like a beard guard or a surgical mask. 2. The 2022 Food Code published by the United States Food and Drug Administration, indicated, 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding, (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under [paragraph mark] (B) and in [paragraph mark] (C) of this section, Time/Temperature Control For Safety Food shall be maintained: (1) At 57 [degrees] C [Celsius] (135 [degrees] F [Fahrenheit] of above, expect roasts cooked to a temperature and for a time specified in [paragraph mark] 3-403.11(E) may be held at a temperature of 54 [degrees] C (130 [degrees] F) or above; or (2) At 5 [degrees] C (41 [degrees] F) of less. During a concurrent interview and observation of the lunch tray line on 05/13/2025 at 11:45 AM, [NAME] #3, in the presence of the Dietary Director (DD), took the food temperature of the tossed salad that contained lettuce and tomato and the temperature was 55 degrees F. At 11:46 AM, [NAME] #3 took the temperature of the peach yogurt and stated the temperature was 55 degrees F. Once the temperatures were taken, Dietary Aide (DA) #11 informed the Staffing Coordinator (SC) that the cart is ready. The surveyor asked that the temperature of the peach yogurt be taken again and the DD obtained the temperature and stated it was 51.7 degrees F, but it should be 41 degrees F or below. The DD stated she did not have an answer for that when asked why she did not intervene when it was brought to her attention that the food items were above 41 degrees F. During an interview on 05/13/2025 at 12:10 PM, [NAME] #3 stated he was trained that cold foods should leave the kitchen at 41 degrees F or below. When asked why he did not intervene when he obtained food temperatures that were above 41 degrees F, [NAME] #3 stated he did not have a reason. During an interview on 05/13/2025 at 2:07 PM, the DD stated if staff identified cold food items whose temperature was too high, the staff should get rid of the food item. During an interview on 05/13/2025 at 2:20 PM, the SC stated she did not see the cold food temperature monitoring. Per the SC, she expected staff to replace a food item if the temperature was too high with a new food item that had a temperature of 41 degrees F or below. During an interview on 05/14/2025 at 11:13 AM, the Registered Dietician stated she expected the dietary staff to keep cold food items at 41 degrees F or below on the tray line. During an interview on 05/15/2025 at 9:43 AM, the Director of Nursing stated she expected the dietary staff to follow the protocol for what is an appropriate cold/warm temperature for a food item to be served at. During an interview on 05/15/2025 at 9:46 AM, the Administrator stated he expected cold food items to leave the kitchen at a temperature of 41 degrees F or below. 3. During an observation on 05/12/2025 at 9:18 AM, there were nine pre-boiled eggs in the refrigerator in a plastic bag with a use-by-date of 05/11/2025. During an interview on 05/13/2025 at 2:41 PM, the Dietary Director stated staff were expected to monitor cold storage for expired items, and she monitored cold/frozen storage most every day. The DD stated that she checked cold/frozen storage for expired foods when she completed her food order and when foods were put away after delivery. During an interview on 05/15/2025 at 9:43 AM, the Director of Nursing stated she expected food stored in the refrigerator and freezer to be removed when expired. During an interview on 05/15/2025 at 9:46 AM, the Administrator stated he expected food stored in the refrigerator and freezer to be removed when expired. 4. A facility policy titled, Freezer Storage dated 2018, indicated, 5. All foods should be stored in an airtight moisture-resistant wrapper such as a plastic bag or freezer paper to prevent freezer burn. During a concurrent interview and observation of the walk-in-freezer on05/12/2025 at 9:25 AM, there was a 30-pound box of corn kernels in a plastic bag that was loosely rolled down and opened to air. The Dietary Director (DD) stated the bag and box of corn kernels should both have been sealed tightly so that the food was not left opened to air. Also noted in the walk-in freezer was a case of chick breasts stored in a plastic bag that was opened to air. The DD stated staff removed a few items from the box and did not close the bag back. The DD stated that the bag and box of chicken should both have been sealed tightly so that the food was not left opened to air. During an interview on 05/13/2025 at 2:41 PM, the DD stated staff should put items in a storage bag, wrap them in plastic wrap, or place them in a storage container that should be sealed. During an interview on 05/15/2025 at 9:43 AM, the Director of Nursing stated she expected food stored in the refrigerator and freezer to be stored covered. During an interview on 05/15/2025 at 9:46 AM, the Administrator stated he expected food stored in the refrigerator and freezer to be stored covered.

Based on observation, interview, record review, and facility policy review, the facility failed to provide healthcare in a dignified manner when Resident #265 was left exposed during the provision of incontinence care and staff stood while they fed Resident #39. These deficient practice affected 2 (Resident #39 and Resident #265) of 2 sampled residents reviewed for dignity. Findings included: 1. An undated facility policy titled, Quality of Life - Dignity indicated, 10. Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. A Resident Face Sheet indicated the facility admitted Resident #265 on 04/22/2025. According to the Resident Face Sheet, the resident had a medical history that included a diagnosis of end stage renal disease. An admission Minimum Data Set (MDS), with an Assessment Reference Date of 04/28/2025, revealed Resident #265 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident was dependent on staff for toileting hygiene and was frequently incontinent of bowel and bladder. Resident #265's Care Plan included a problem statement initiated 04/30/2025 that indicated the resident was frequently incontinent of bowel and always incontinent of urine. Interventions directed staff to clean and dry the resident's skin after each incontinent episode (initiated 04/30/2025). During an observation on 05/14/2025 at 8:43 AM, Certified Nursing Assistant (CNA) #6 removed Resident #265 from the nurses' station and tool the resident to their room to change the resident's incontinence brief. The door to Resident #265's room was left opened and the resident was noted with their pants and incontinence brief down and their buttocks exposed to the hallway. CNA #6 then left the resident's room and returned with two clean incontinence briefs in his hand. During an interview on 05/14/2025 at 9:02 AM, CNA #6 stated he was trained to provide privacy and dignity during the provision of resident care, to include the pulling of the privacy curtain and the closure of the resident's room door. CNA #6 stated he realized that he left Resident #265's room door opened and the privacy curtain was not pulled around the resident's bed. According to CNA #6, he left Resident #265s's room to go and use the restroom and retrieve supplies. CNA #6 stated he should have pulled the resident's privacy curtain around the resident's bed and closed the room door. CNA #6 stated he knew what he needed to do but was rushing. During an interview on 05/14/2025 at 9:04 AM, Resident #265 stated CNA #6 told them he was going to change their incontinence brief. Resident #265 stated they turned to their right and held onto the siderail, then CNA #6 left them for more than five minutes, while they had their pants down. Resident #265 stated they did not like that and that CNA #6 should have pulled their privacy curtain around their bed or closed their room door so that people who walked by could not see them with their pants down. During an interview on 05/14/2025 at 9:10 AM, the Director of Staff Development stated if a staff member was providing care to a resident and had to leave, the resident should be left in a dignified manner and have their privacy curtain pulled around the resident's bed, the resident room door closed, and some type of covering placed over the resident. During an interview on 05/14/2025 at 11:22 AM, Licensed Vocational Nurse #2 stated if a staff member had to leave a resident in bed to get supplies, the staff member should leave the resident in a low bed, with their call light within reach, and the resident should be covered to promote dignity. During an interview on 05/15/2025 at 9:43 AM, the Director of Nursing stated a resident should never be left in a bed exposed with their privacy curtain not pulled and their room door opened. During an interview on 05/15/2025 at 9:46 AM, the Administrator stated a resident's privacy curtain should have been pulled around the resident's bed and their door closed to provide dignity to the resident. The Administrator stated he expected staff to provide proper healthcare in a dignified manner. 2. An undated facility policy titled, Assisting the Resident to Eat indicated, 11. Assist the resident as necessary. If the resident needs to be fed: a. Sit at eye level in front of the resident. A Resident Face Sheet indicated the facility admitted Resident #39 on 09/09/2016. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side and dementia. Resident #39's Care Plan included a problem stated initiated 07/20/2017, that indicated the resident had impaired communication. Interventions directed staff to position themselves where the resident could visualize their face (initiated 07/20/2017). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date of 04/13/2025, revealed Resident #39 had a Brief Interview for Mental Status (BIMS) score of 2, which indicated the resident had severe cognitive impairment. The MDS indicated the resident was dependent on staff for eating. During an observation on 05/14/2025 at 8:18 AM, Certified Nursing Assistant (CNA) #7 stood to the right of Resident #39 while she fed the resident, who was in bed, breakfast. CNA #7 was noted to bend to offer the resident food and/or drink and Resident #39 had to turn their head to receive the food and/or drink from CNA #7. During an interview on 05/14/2025 at 8:28 AM, CNA #7 stated she was trained to sit next to the resident to feed them. CNA #7 confirmed she did not sit when she fed Resident #39 because there was not chair in the resident's room. During an interview on 05/14/2025 at 8:39 AM, Licensed Vocational Nurse (LVN) #1 stated Resident #39 had to be fed by the staff. According to LVN #1, staff should be seated when they fed the resident for the resident's dignity and positioning. LVN #1 stated she observed Resident #39 being fed at an angle while CNA #7 stood, but noted she did not correct the staff's position. LVN #1 stated if there was not a chair in the resident's room, CNA #7 should have asked for one. During an interview on 05/14/2025 at 9:10 AM, the Director of Staff Development stated staff should be seated when they feed a resident who is in bed to provide dignity in the dining experience. During an interview on 05/15/2025 at 9:43 AM, the Director of Nursing (DON) stated staff should not stand over a resident to assist with dining but sit next to the resident at eye level to make the resident feel comfortable. The DON stated it was very intimidating to a resident to have someone stand over them and that it was not a dignified dining experience. The DON said it was a dignified dining experience when staff were seated so that the resident did not feel rushed. The DON stated that if a staff member did not have a chair, they should get a chair or a stool and be seated. During an interview on 05/15/2025 at 9:46 AM, the Administrator stated he expected staff to feed residents at eye level to provide proper healthcare assistance in a dignified manner.

Based on observation, interview, record review, and facility policy review, the facility failed to assess a resident for their ability to self-administer their medication for 1 (Resident #171) of 25 sampled residents. Findings included: An undated facility policy titled, Self-Administration of Medications indicated, 2. If a resident desires to participate in self-administration, the interdisciplinary team will assess the ability of the resident to participate, by completing a Resident Self Administration of Medication assessment. A Resident Face Sheet revealed the facility admitted Resident #171 on 02/22/2025. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease (COPD) and pneumonia. A significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/09/2025, revealed Resident #171 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #171's Physician Order Report for the timeframe 05/01/2025 - 05/31/2025, revealed an order dated 03/05/2025, for budesonide suspension 0.5 milligram per 2 milliliter (ml), inhale 2 ml once a day for COPD. The Physician Order Report did not specify the resident was able to self-administer their budesonide inhaler. During a concurrent observation and interview on 05/13/2025 at 9:48 AM, the surveyor noted an inhaler on Resident #171's bedside table. Resident #171 stated the inhaler was for their COPD and emphysema. Per Resident #171, yes they know I have it. Resident #171 stated they used the inhaler whenever they needed it. During an interview on 05/14/2025 at 1:28 PM, Certified Nursing Assistant #8 confirmed Resident #171 kept their inhaler at their bedside and she saw the resident self-administer the inhaler. During an interview on 05/14/2025 at 2:00 PM, Licensed Vocational Nurse (LVN) #10 stated there was a form that had to be completed and approved by a doctor before a resident was allowed to self-administer their medication. LVN #10 stated if Resident #171 wanted their inhaler, they were supposed to call the nurse so that the nurse would administer the medication. Per LVN #10, she had never seen Resident #171 with an inhaler. During an interview on 05/15/2025 at 8:44 AM, Registered Nurse (RN) #9 stated a resident would need to have an assessment, along with a physician's order before they were allowed to self-administer or keep any of their medication. RN #9 stated she was not familiar with Resident #171 but if the resident did not have an order or an assessment, the resident should not have an inhaler in their possession. During an interview on 05/15/2025 at 9:16 AM, the Director of Nursing (DON) confirmed the albuterol inhaler was removed from Resident #171's possession and stated the facility would provide an all hands education regarding self-administration of medications. The DON stated it was her expectation that prior to self-administration, residents were assessed and a physician order was obtained.

Based on interview and record review, the facility failed to notify the family of a change in health status for one resident (1). As a result, it affects timely intervention and family ' s decision making to be involved in the care planning and address concern. Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses which included metastatic prostate cancer to liver and lymph nodes (cancer cells spread to liver and lymph nodes) and deep vein thrombosis on right lower extremity (blood clot that travels and stuck in a vein), per the facility's Face Sheet. On 1/23/25, an unannounced visit to the facility was conducted in response to a complaint about an allegation that the family was not notified of the resident ' s change in condition and fall. A review of Resident 1 ' s face sheet indicated, the brother was the emergency contact and responsible party (RP). A review of Resident 1's nursing progress note, dated 1/8/25, indicated Resident 1 became unresponsive, called 911, and transferred out to an acute hospital. During an interview on 1/23/25 at 11:30 A.M. and 11:45 A.M., with the Administrator (ADM) and the Director of Nursing (DON), the ADM acknowledged the facility failed to inform the RP when Resident 1 was transferred to the hospital due to change in condition. The DON stated that Resident 1 ' s contact information included the brother and the sister. During an interview on 1/23/25 at 12:20 P.M. with the Licensed Nurse (LN) 1, LN1 stated that when a resident had a change in condition, resident ' s family would be notified. During an interview on 1/23/25 at 12:56 P.M. with the Social Service Director (SSD), the SSD stated Resident 1 ' s brother was involved with the resident ' s care and was not contacted when Resident 1 was transferred to the hospital. During an interview on 1/23/25 at 1:40 P.M., with LN 2, LN 2 stated Resident 1 ' s brother would come and visit the resident. When resident had a change in condition, the staff should have contacted and inform the family. During a phone interview on 1/30/25 at 2:50 P.M., with certified nursing assistant (CNA) 3, CNA 3 stated he was assigned to Resident 1. CNA 3 stated that he was in the room talking to Resident 1 when the resident suddenly fell back on his bed and became unresponsive. CNA 3 stated he asked for assistance and licensed nurse came in the room. Resident 1 was transferred to the hospital on 1/8/25. During an interview on 1/23/25 at 2:15 P.M. with the ADM and the DON, the ADM and DON stated, staff should have notified the family when Resident 1 was transferred to the hospital, but they did not. During a phone interview on 3/4/25 at 10:42 A.M., with LN 4, LN 4 acknowledged that she should have contacted the family when Resident 1 was transferred to the hospital, but she did not. A review of the facility's policy and procedure, titled, Changes in Resident Condition, undated, indicated . The resident, attending Physician and resident representative (if resident has no capacity to make health care decisions or if resident opts to notify a designated family member) are notified when changes in condition or certain events occur

Based on observation, interview and record review, the facility failed to promote dignity for one of 10 sampled residents (Resident 9) when Certified Nursing Assistant (CNA) 1 was observed standing over Resident (9) while assisting in bed to eat. This deficient practice had the potential to not promote dignity and respect for Resident 9 to cause emotional distress. Findings: A review of Resident 9's Admission Record indicated, Resident 9 was admitted to the facility on [DATE] with diagnoses which included history of schizoaffective disorder (a mental health disorder with a mix of hallucinations and delusions). A record review of Resident 9's minimum data set (MDS - a federally mandated resident assessment tool) dated 12/18/24 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 15 points out of 15 possible points which indicated Resident 9 did not have cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 2/26/25 at 1:11 P.M., an observation was conducted inside of Resident 9 ' s room. CNA 1 was standing over Resident 9 at the side of the bed while feeding Resident 9 in bed. Resident 9 later threw a pitcher across the room toward her roommate ' s side of the room which landed on the floor, and rolled outside of Resident 9 ' s room. On 2/26/25 at 1:13 A.M., an interview was conducted with Licensed Nurse (LN) 2. LN 2 stated Resident 9 is alert but will make non-sensical statements and say random things while talking to her and usually not able to answer questions fully. LN 1 stated CNA 1 should be sitting down at eye-level while feeding Resident 9 to promote dignity and respect. On 2/28/25 at 10:53 A.M., an interview was conducted with CNA 1, in the conference room. CNA 1 stated she was also an restorative nurse assistant (RNA) and does RNA exercises with Resident 9. CNA 1 stated she was helping Resident 9 because Resident 9 had a hard time getting food on her spoon. CNA 1 stated while Resident 9 was eating she was talking about peasants and that did not make sense. CNA 1 stated Resident 9 can also get physical with staff. CNA 1 stated she should have gotten a chair when she was feeding Resident 9 to be at an eye-level which promoted dignity and better communication. On 2/28/25 at 11:40 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated standing over a resident while feeding them can be intimidating for any resident. The DON stated her expectations were for the nursing staff to promote dignity while feeding residents by not standing over them and making eye-contact to promote dignity and respect. A review of the undated facility ' s policy and procedure titled, ASSISTING THE RESIDENT TO EAT indicated, .If the resident needs to be fed: a. Sit at eye level in front of the resident .

Based on observation, interview, and record review, the facility failed to follow the physician ' s order to infuse the intravenous fluid [IVF] (IV- plastic tube inserted in the vein to deliver hydration, medications or nutrition) within 20-hour time for one of 10 residents (Resident 2) receiving an IVF. As a result, Resident 2's IV fluid was consumed over 26 hours. In addition, the IV tubing was not labeled with date and time it was used. This deficient practice had the potential for Resident 2 to experience IV related complications and infections that would impact resident's health and well-being. Findings: A review of Resident 2's Admission Record indicated; Resident 2 was admitted to the facility on [DATE] with diagnoses which included history of heart failure (when the heart muscle doesn't pump blood as well as it should). A record review of Resident 2's minimum data set (MDS - a federally mandated resident assessment tool) dated 2/2/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 15 points out of 15 possible points indicated, Resident 2 did not have cognitive (pertaining to memory, judgement and reasoning ability) deficits. A review of Resident 2 ' s physician's orders dated, 2/26/25 indicated, .sodium chloride 0.9 % parenteral solution; amt: 50 ml [milliliters]/[per] hr [hour]; intravenous Special Instructions: 1 liter for HYPERKALEMIA [high potassium: a mineral that is essential to the human body] . On 2/26/25 at 2:10 P.M., a concurrent observation and interview was conducted with Resident 2, in Resident 2 ' s room. Resident 2 had an IV on his left hand with Sodium Chloride 0.9% via IVF controlled by a flow regulator. Resident 2 stated the IVF was started in the morning. Resident 2 had a remaining IVF of approximately 700 ml in the bag. The IV tubing was not labeled with date and time it was used. On 2/27/25 at 12:05 P.M., an observation was conducted on Resident 2 ' s IVF, in Resident 2 ' s room. Resident 2 ' s IVF contained approximately 300 ml of fluid remaining in the bag. On 2/28/25 at 11:11 A.M., an interview and record review was conducted with Licensed Nurse (LN) 1, in the conference room. LN 1 stated she was the IV nurse for Resident 2. LN 1 stated Resident 2 had an order for IVF dated 2/26/25 for 1 litter (1000 ml) of Sodium Chloride 0.9% at 50 ml/hr. LN 1 stated the IVF should have been infused within 20 hours. LN 1 stated that Resident 2 ' s IVF was started at 9:45 A.M. and should have been completed by 5:45 A.M. on 2/27/25 during the night shift. The IVF had been running over 26 hours. LN 1 stated Resident 2 ' s IV site and IVF should have been monitored for complications such as IV site pain, redness, inflammation (immune response to infection or irritation), third spacing caused by IV not being in the vein, or IV tubing/line blockages. LN 1 stated an IVF that has been on for too long or too slow of a flow could lead to irritation and infection on Resident 2 ' s hand and an inadequate IVF to be administered as prescribed. LN 1 further stated that Resident 2 ' s IV tubing should have been labeled for infection control measures. On 2/28/25 at 11:58 A.M., an interview with the Director of Nursing (DON) was conducted. The DON stated the RNs could have identified any IVF flow issues or complications such as inadequate fluid delivery, phlebitis [inflammation of the vein, and/or infiltration [leaking from the vein in surrounding tissues] and infection. The DON stated Resident 2 ' s IV tubing should have been labeled with date and time to determine when to replace the tubing to prevent infection control issues. The DON stated Resident 2 ' s IV fluid should have been completed timely and discarded appropriately as prescribed within 20 hours (5:45 A.M. on 2/27/25) and not over 26 hours (12:05 P.M. on 2/27/25). A review of the facility ' s policy and procedure titled IV THERAPY undated indicated, .Once started, completely use all parenteral fluids within 24 hours, or discard .

Based on observation, interview, and record review, the facility failed to follow the physician ' s order to infuse the intravenous fluid [IVF] (IV- plastic tube inserted in the vein to deliver hydration, medications or nutrition) within 20-hour time for one of 10 residents (Resident 2) receiving an IVF. As a result, Resident 2's IV fluid was consumed over 26 hours. In addition, the IV tubing was not labeled with date and time it was used. This deficient practice had the potential for Resident 2 to experience IV related complications and infections that would impact resident's health and well-being. Findings: A review of Resident 2's Admission Record indicated; Resident 2 was admitted to the facility on [DATE] with diagnoses which included history of heart failure (when the heart muscle doesn't pump blood as well as it should). A record review of Resident 2's minimum data set (MDS - a federally mandated resident assessment tool) dated 2/2/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 15 points out of 15 possible points indicated, Resident 2 did not have cognitive (pertaining to memory, judgement and reasoning ability) deficits. A review of Resident 2 ' s physician's orders dated, 2/26/25 indicated, .sodium chloride 0.9 % parenteral solution; amt: 50 ml [milliliters]/[per] hr [hour]; intravenous Special Instructions: 1 liter for HYPERKALEMIA [high potassium: a mineral that is essential to the human body] . On 2/26/25 at 2:10 P.M., a concurrent observation and interview was conducted with Resident 2, in Resident 2 ' s room. Resident 2 had an IV on his left hand with Sodium Chloride 0.9% via IVF controlled by a flow regulator. Resident 2 stated the IVF was started in the morning. Resident 2 had a remaining IVF of approximately 700 ml in the bag. The IV tubing was not labeled with date and time it was used. On 2/27/25 at 12:05 P.M., an observation was conducted on Resident 2 ' s IVF, in Resident 2 ' s room. Resident 2 ' s IVF contained approximately 300 ml of fluid remaining in the bag. On 2/28/25 at 11:11 A.M., an interview and record review was conducted with Licensed Nurse (LN) 1, in the conference room. LN 1 stated she was the IV nurse for Resident 2. LN 1 stated Resident 2 had an order for IVF dated 2/26/25 for 1 litter (1000 ml) of Sodium Chloride 0.9% at 50 ml/hr. LN 1 stated the IVF should have been infused within 20 hours. LN 1 stated that Resident 2 ' s IVF was started at 9:45 A.M. and should have been completed by 5:45 A.M. on 2/27/25 during the night shift. The IVF had been running over 26 hours. LN 1 stated Resident 2 ' s IV site and IVF should have been monitored for complications such as IV site pain, redness, inflammation (immune response to infection or irritation), third spacing caused by IV not being in the vein, or IV tubing/line blockages. LN 1 stated an IVF that has been on for too long or too slow of a flow could lead to irritation and infection on Resident 2 ' s hand and an inadequate IVF to be administered as prescribed. LN 1 further stated that Resident 2 ' s IV tubing should have been labeled for infection control measures. On 2/28/25 at 11:58 A.M., an interview with the Director of Nursing (DON) was conducted. The DON stated the RNs could have identified any IVF flow issues or complications such as inadequate fluid delivery, phlebitis [inflammation of the vein, and/or infiltration [leaking from the vein in surrounding tissues] and infection. The DON stated Resident 2 ' s IV tubing should have been labeled with date and time to determine when to replace the tubing to prevent infection control issues. The DON stated Resident 2 ' s IV fluid should have been completed timely and discarded appropriately as prescribed within 20 hours (5:45 A.M. on 2/27/25) and not over 26 hours (12:05 P.M. on 2/27/25). A review of the facility ' s policy and procedure titled IV THERAPY undated indicated, .Once started, completely use all parenteral fluids within 24 hours, or discard .

Based on observations, interviews, and record reviews, the facility failed to ensure a written notice and reason for the bed change was given to a roommate (Resident 6), for one of five residents (Resident 3) who required a bed change. This deficient practice had the potential to negatively affect Resident 6's rights and preferences for a new roommate from the bed change. Findings: A review of Resident 3's Admission Record indicated Resident 6 was readmitted to the facility on [DATE] with diagnoses which included a history of diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). A record review of Resident 3's minimum data set (MDS - an assessment tool) dated 12/13/24 indicated, a Brief Interview for Mental Status (BIMS - a cognitive assessment to quickly a resident's mental status and identify potential cognitive impairments with a score of 0 -15) score of 14 out of 15 (13-15 indicated intact cognitive function) indicated, Resident 3 had no cognition (pertaining to memory, judgement and reasoning ability) deficits. On 2/27/25 at 11:31 A.M., an interview was conducted with Resident 3 (Resident 6's former roommate), in Resident 3's room. Resident 3 stated the room change was convenient because he had dialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidneys are unable to do so) three times per week on Tuesday, Thursday, and Saturday. Resident 3 stated due to the non-working elevators, the second floor had access to a ramp for transportation services during his appointments for pick up and drop off. On 2/27/25 a record review was conducted on Resident 6's medical records. There was no written bed change notification form signed by Resident 6. On 2/27/25 at 2:40 P.M., a concurrent interview and record review was conducted with the Social Services Director (SSD), in the conference room. The SSD stated Resident 3 was moved on 2/13/25, from the third floor to the second floor and had a roommate (Resident 6) for five days until Resident 6 discharged on [DATE]. The SSD stated she did not give Resident 3's roommate (Resident 6) a written room change notification form because she did not know she had to give roommates of bed changes notification of a room change. The SSD stated, it was all new to me. The SSD stated she only gave a written bed change notification for Resident 3. On 2/27/25 at 2:45 P.M., an interview was conducted with the Administrator (ADM), in the conference room. The ADM stated his expectations for a room change notification was to be given verbally and written to any residents in the facility and/or their responsible parties. The ADM stated it was important that room change notifications be given to both the resident that will be moved and their new roommates so that both parties were aware of the situation for doing so and to respect their rights and preferences for the room change. A review of the facility's policy and procedure titled ROOM and ROOMATE ASSIGNMENT dated 12/1/18, indicated, .A roommate will be informed of any new transfer into or out of his or her room. Such information will include why the transfer is being made (within the constraints of confidentiality) and any information that will assist the roommate in accepting his or her new roommate.

Based on observation, interview, and record review, the facility failed to ensure comfortable and home-like environment for four residents (1, 2, 3, 4) when: 1) Televisions (TV) were not functioning properly. 2) Room temperature (temp) levels were warmer (higher) than required. These failures had the potential to affect the resident ' s physical and psychosocial comfort and well-being. Findings: On 9/26/24, an unannounced visit was made to the facility. During an interview with the Director of Nursing (DON) on 9/26/24 at 10:04 A.M., the DON stated that the Director of Maintenance (DM) resigned earlier in the month. On 9/26/24 at 10:54 A.M., an observation was conducted with the Janitorial Supervisor (JS), in the second (2nd) floor nursing station. In the hallway, outside of the service elevator, were three large fans that faced into resident rooms. The JS stated that the fans were placed there to help circulate cool air into resident rooms. On 9/26/24 at 11:11 A.M., an observation was conducted with the JS, in the 2nd floor nursing station. Temperature readings were conducted: - Clean room (the ice machine, cups and a refrigerator were located here) 2nd floor temperature: 84 Fahrenheit (F). - 2nd floor nursing station restroom temperature: 83 F On 9/26/24 at 11:02 A.M., an interview was conducted with Certified Nursing Assistant (CNA) 1, in the nursing station. CNA 1 stated that the temperature fluctuated, but recently, It ' s hot. CNA 1 stated that the staff restrooms restrooms staff were super-hot and stated the temperature .felt like in the high 80 ' s. CNA 1further stated, That ' s why there ' s fans in the hallway. a. A review of Resident 1's record was conducted. Per the Admission Record, Resident 1 was admitted to the facility on [DATE] with diagnoses which included a history of hypertension (high blood pressure; condition where the pressure in your blood vessels is consistently too high.) Resident 1's Minimum Data Set (MDS- a nursing assessment tool that is used to develop a plan of care) dated 8/16/24, indicated a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven day period) score of 15 points out of 15 possible points which indicated Resident 1 was cognitively (pertaining to memory, judgement and reasoning ability) intact. On 9/26/24 11:11 A.M., an observation and interview was conducted with Resident 1, in Resident 1 ' s room with the JS. Resident 1 stated he preferred the temperature in his room to be 75 F to feel comfortable, but stated that the heat did not bother him as much as it did for his roommate (Resident 2). Resident 1 further stated that he would like for the TV (in his room) to work so he could watch his wartime shows, but was unable to because the channels did not pick up a signal. The JS tested Resident 1 ' s TV and stated Resident 1 had the wrong remote, and that the WifFi (wireless network technology that uses a router to pick up TV signals) signal for the TV was not picking up the channels. Resident 1 stated that his TV had been broken for a while at least 3 weeks and that he had been trying to request for it to be fixed. b. A review of Resident 2's record was conducted. Per the Admission Record, Resident 2 was readmitted to the facility on [DATE] with diagnoses which included a history of cerebral infarction (also known as stroke; blood vessel that supplies blood to the brain is blocked or ruptured, preventing oxygen and nutrients from reaching brain cells). Resident 2's MDS dated [DATE], included a BIMS score of 10 points out of 15 possible points which indicated Resident 2 had moderate cognitive deficits. On 9/26/24 at 11:13 A.M., an interview was conducted with Resident 2, in Resident 2 ' s room with the JS. Resident 2 stated I just can ' t stand being hot. Resident 2 stated his ideal temperature for his room would be 72 F and stated that at one point his room was hot, around the 80s to 83s. Resident 2 stated that his roommate's (Resident 1) TV had been broken for over 3 weeks. Resident 1 and Resident 2 ' s room temperature was checked by the JS. The room temperature was 77 F. c. A review of Resident 3's record was conducted. Per the Admission Record, Resident 3 was admitted to the facility on [DATE] with diagnoses which included a history of a left humerus fracture (broken bone of the upper arm). Resident 3's MDS dated [DATE], indicated a BIMS score of 15 points out of 15 possible points which indicated Resident 3 was cognitively intact. On 9/26/24 at 11:17 A.M., a concurrent observation and interview was conducted with Resident 3 and the JS, in Resident 3 ' s room. Resident 3 stated that the temperature (in her room) fluctuated, and stated, It felt like it was in the high 80 ' s. Resident 3 stated that she knew they [the facility] were trying to fix the facility ' s air conditioning (AC) but then they lost their maintenance man. Resident 3 stated she preferred her room temperature to be between 73 to 74 F for comfort. Resident 3 further stated that her TV did not work. The JS tested the TV and stated that Resident 3 had a wrong remote and that the TV router needed to be reset. The JS tried to reset the TV router manually, but was unsuccessful with picking up the channels for the TV. d. A review of Resident 4's record was conducted. Per the Admission Record, Resident 4 was readmitted to the facility on [DATE] with diagnoses which included a history of a respiratory failure (develops when the lungs can't get enough oxygen into the blood making it difficult to breathe). Resident 4's MDS dated [DATE], indicated a BIMS score of 15 points out of 15 possible points which indicated Resident 4 was cognitively intact. On 9/26/24 at 11:21 A.M., an interview was conducted with Resident 4, in Resident 4 ' s room with the JS. Resident 4 stated that when it became too hot for her comfort level, she would have a hard time breathing and since her bed was close to the blinds (window), that the room would feel even hotter. Resident 4 stated that an ideal comfortable temperature for her room was 72 to 73 F. The JS took a room temperature reading at 75 F with Resident 4 responding, Room temp (temperature) is 75 . it ' s a little hotter than I would like. Resident 4 stated that the TV (in her room) only worked on and off when picking up the channels. On 9/26/24 at 11:51 A.M., an interview was conducted with CNA 2, at the 2nd floor nursing station. CNA 2 stated that the temperatures on the second and third (3rd) floor nursing stations can become really hot and uncomfortable for both staff and residents. CNA 2 stated that complications from the uncomfortable heat temperatures may cause staff and residents to become irritable and sweat a lot. CNA 2 further stated that non-working TVs were a problem complaint that some residents in the facility complained about. CNA 2 stated it was important to have working TVs in the resident rooms because residents may feel frustrated and can become bored if they just wanted to watch TV. On 9/26/24 at 11:58 A.M., an interview and observation was conducted with Licensed Nurse (LN) 1, at the 2nd floor nursing station. The nursing station had two small fans by two of the nursing station computers and a floor fan by the printer facing towards the computers. LN 1 stated that the facility can get really hot especially in the clean room and the nursing station restroom that was used by staff, residents and visitors. LN 1 stated that when it gets becomes too hot residents may develop heat complications, such as breathing problems, from being uncomfortable with the temperature. LN 1 further stated it was important to have functioning TVs because residents should be comfortable in their rooms to do what they want while they relax in comfort. On 9/27/24, a review of the temperature (temp) maintenance logs for the P.M. (12 PM to 5 PM) was conducted. The temp readings included: On 9/7/24, three rooms had temp readings of 82 F. On 9/8/24: Four rooms and one hallway had temp readings of 82 F. Three rooms had temp readings of 83 F. Three rooms had temp readings of 84 F. Four rooms had temp readings of 85 F. One room had a temp reading of 86 F. One room had a temp reading of 87 F. One room had a temp reading of 89 F. On 9/27/24 at 12:52 P.M., a concurrent observation and interview was conducted with Resident 1, in Resident 1 ' s room with the JS. Resident 1 stated that his TV was still not working. The JS was unable to turn on Resident 1 ' s TV because Resident 1 ' s TV remote was missing. The JS tried to use Resident 2 ' s (roommate) remote to check if the TV would turn on, but was unsuccessful. Resident 1 stated I like watching TV better than laying here and doing nothing. Resident 1 stated he was not into (not interested in) other activities and liked the comfort of his room to relax while watching TV. On 9/27/24 at 12:57 P.M., an interview and observation was conducted with the Medical Records (MR) staff in Resident 3 ' s room. The MR was observed trying to fix Resident 3 ' s TV and stated he was unable to fix the TV due to the signal of the router. Resident 3 ' s roommate (Resident 4) stated Resident 3 left the room because she was frustrated with the TV not working. On 9/26/24 at 1:01 P.M., an observation was conducted with the JS in the second-floor nursing station. Temperature readings were conducted. - Clean room [ROOM NUMBER]nd floor temperature at 92.3 F. - 2nd floor restrooms at 85 F. On 9/27/24 at 1:11 P.M., an interview was conducted with CNA 3, at the 3rd floor nursing station. CNA 3 stated the 3rd floor can get become extremely hot and unbearable at times especially during the peak (afternoon) hours. CNA 3 stated it had been hot in the facility since the beginning of the month. CNA 3 stated that complications from high heat temperatures may affect residents to show symptoms of heat exhaustion (difficulty breathing, irritable and sweating). On 9/27/24 at 1:55 P.M., an interview was conducted with LN 2, at the 3rd floor nursing station. LN 2 stated sometimes the temperature of the facility fluctuated and can go up or down. LN 2 stated complications from uncomfortable heat temperatures included symptoms such as difficulty breathing, sweating and worse dehydration. LN 2 further stated that TVs should be in working conditions because residents may become annoyed when they want to be comfortable in bed and just watch TV to keep entertained. On 9/30/24 at 1:26 P.M., an observation was conducted with the JS, in the second-floor nursing station. Temperature readings were conducted. - Clean room [ROOM NUMBER]nd floor temperature at 85 F. - 2nd floor restrooms at 85 F. On 9/30/24 at 1:40 P.M., an interview was conducted with the Administrator (ADM), in the conference room. The ADM stated that the AC control ' s most current service was on 9/20/24, per the AC log with an outside contractor [company name]. The ADM stated that the AC control box was not locked and stated that someone (may have) accessed the AC control box which shut down the AC. The ADM stated that the TV situation was an ongoing concern with the cable boxes at the facility, according to their [company name]. The ADM further stated .were supposed to be replaced sometime in September but was pushed back for another project in La [NAME]. The ADM stated that the old TV boxes [router] .when it resets this messes with the WiFi and had been an on-going issue with quick fixes here and there to temporary fix the TV signal. The ADM acknowledged it was important for residents to be feel comfortable with the temperature to prevent heat complications for residents and staff. The ADM stated it was important to start replacing the old TVs to the new smart (modern form of television that uses the power of the internet to capture TV signals and channels) TVs to promote a more home-like living environments for the residents. A review of the facility's home-like environment policy and procedure titled MAINTAINING ROOMS undated, indicated . 4. Check that all televisions, radios, and lamps function properly . 8 . Check thru-wall HVAC unit, if applicable, for proper operation, cleanliness, missing knobs or controls and properly secured power cords .15. Repair or replace faulty equipment and furnishings . Per the facility ' s Room Temperature Log, Temperature must be between 71- 81 degrees.

Based on interview and record review the facility failed to ensure nursing assessments and documentation of resident status was accurately completed for one of three residents (Resident 2), during a closed record review (record of a resident that was no longer at the facility). This failure had the potential for miscommunication of care provided to the resident, and resident harm due to incomplete and inaccurate information documented for Resident 2 ' s status and response to medical care. Findings: On 3/11/24 an unannounced visit was made to the facility in response to a complaint. On 3/11/24 at 2:20 P.M., Resident 2 ' s electronic Admission Record was reviewed. Resident 2 was admitted to the facility on [DATE] at 4:40 P.M., and discharged from the facility on 2/23/24 at 4:12 P.M. Health problems for Resident 2 included: pneumonia; NSTEMI (a type of heart attack); heart failure (a condition where your heart doesn ' t pump enough blood for your body ' s needs); cachexia (a state of ill health involving great weight loss and muscle loss; symptoms include lack of appetite, tiredness, and loss of strength). On 3/11/24 at 2:30 P.M., Resident 2 ' s Admission Data Collection (nursing assessment of Resident 2 on arrival) dated 2/16/24 was reviewed. Resident 2 had an unstageable (cannot determine the severity) pressure wound on the sacrum (a large triangular bone between the hip bones, at the base of the spine). On 3/11/24 at 3:36 P.M. certified nursing assistant (CNA) 1 was interviewed, and a document, undated, on the outside of the Vital Signs Book was reviewed. CNA 1 stated she was uncertain of how often vital signs (a record of body temperature, heart rate, blood pressure, breathing rate, and oxygen saturation [an indication of oxygen in the blood]) should be taken. CNA 1 reviewed the undated document and agreed it was accurate to what was done at the facility. The document directed staff to take vital signs every four hours for 72 hours (three days) after: admission, change in condition, and every fall. CNA 1 stated that the CNAs took vital signs and recorded the vital signs in the book. CNA 1 stated that the book was reviewed by the nurse and that the nurse was responsible for documenting the resident vital signs in the resident ' s clinical record. On 3/11/24 at 3:40 P.M, a concurrent record review and interview was conducted with licensed nurse (LN) 1. LN 1 stated that the nurse needed to review the vital signs before they were documented in the resident record. LN 1 was asked to locate vital signs in the electronic record for Resident 2. LN 1 was only able to locate blood pressure readings for Resident 2 in the Vital Signs section of the record. LN 1 stated that vital signs were also documented in the daily nursing notes. On 3/11/24 at 4 P.M. a concurrent record review and interview was conducted with the quality assurance (QA) LN. Resident 2 was in the facility for eight eight days. Medicare Skilled Daily assessments were completed for Resident 2 on 2/19/24 and 2/20/24. There were no nursing assessments and vital signs documented for 2/17/24 and 2/18/24. A nursing Weekly Summary dated 2/20/24 reflected that Resident 2 had no skin issues, and that Resident 2 had no pain and received no pain medications in the previous week. The Physician ' s Orders for Oxycodone (a narcotic pain medication) were reviewed. When Resident 2 arrived at the facility on 2/16/24, a Physician Order for Oxycodone was active: give 10 milligrams (mg-a unit of measurement) every four hours routine (without Resident requesting). Resident 2 received 10 doses. Per the Physician Order dated 2/18/24 for Oxycodone 10mg, .give every 4 hours as needed for pain and discontinue the routine every four hours Oxycodone. Resident 2 received 24 doses over the next six days, until she was transferred to the hospital on 2/23/24. A Social Worker (SW) note dated 2/23/24 at 2:34 P.M. was reviewed with the QA LN. The resident was seen by the social worker due to complaints of chest pain, and the resident wanted to go to the hospital. The social worker documented that the nurse was informed, and Resident 2 ' s spouse was contacted. A SW note dated 2/23/24 at 6:30 P.M., reflected that 911 was called and Resident 2 was sent to the hospital. A SW note dated 2/25/24 at 11:01 A.M., indicated Resident 2 was admitted to the hospital for low blood pressure. In an interview with the QA LN on 3/11/24 at 4:10 P.M., the QA LN stated no nursing notes could be found for 2/21/24, 2/22/24, or 2/23/24 in Resident 2 ' s chart, and there were no nursing notes, vital signs, or an assessment for sending Resident 2 out to the hospital by calling 911. The QA LN stated there should have been a change in condition note, and a nursing note of Resident 2 ' s complaint of chest pain, a nursing assessment with vital signs, and notifications to the doctor and the family. Further, the QA LN stated there was incorrect documentation regarding Resident 2 ' s pressure wound in the weekly summary, and of the pain Resident 2 was experiencing. Resident 2 had a possibility of untreated pain, or an unrecognized condition change because of the missing vital signs and assessments. On 3/11/24 at 4:30 P.M. a joint interview and record review was conducted with the Administrator (ADM). The ADM stated that nursing care provided was not documented. In addition, the ADM stated it was unusual for the SW to document when a resident had chest pain, and that nursing should have assessed and documented this. The ADM acknowledged that nursing assessments and notes were missing for Resident 2 during the multiple days that Resident 2 was in the facility. The undated document titled, General Documentation Guidelines/Utilization of Forms (For Licensed Nurses and IDT Reviews) was reviewed on 3/11/24 with the ADM. Per this document, Guidelines: All services provided to the Resident, .or any changes in the Resident ' s.condition shall be documented in the Resident ' s medical record. A. For any Changes of Condition (COC).may document the narrative in the nurse ' s notes. B. For any new admission/readmission, initiate: .every shift documentation . for 72 hours.

Based on interview and record review, the facility failed to allow one of two sampled residents (1) to choose their own visitors. As a result, Resident 1 was at risk of decreased social interaction. Findings: Per the facility's Resident Face Sheet, resident 1 was admitted to the facility on [DATE]. Per the facility's Physician Order Report, dated 10/13/23, there was an order for Resident 1 on 8/29/17 for, May visit with her friend .in family room or patio without contact supervision. Per the facility's Resident Progress Notes, on 8/20/23 Resident 1's physician documented, .Her friend (Visitor 1) comes by periodically and she welcomes his visits. There may be some resistance from staff or administration . but unless he is felt to pose some kind of threat (which I don't see), she has a right to have him visit and to hang out with him . On 10/13/23 at 10:15 A.M., an interview was conducted with Resident 1. Resident 1 stated, Visitor 1 was her friend, and she wanted him to continue visiting her. On 10/13/23 at 10:25 A.M., an interview was conducted with the Social Services Director (SSD). The SSD stated, Visitor 1 use to visit with Resident 1, but he was no longer allowed to visit per the request of Resident 1's family. The SSD further stated, Resident 1 had the mental capacity to decide who she wanted to visit her. On 10/24/23 at 3:30 P.M., a telephone interview was conducted with the Receptionist. The Receptionist stated, at the front desk she had a list of people who were not allowed to enter the building, which included Visitor 1. The Receptionist further stated, the note next to Visitor 1's name directed her to not permit Visitor 1 to have contact with any residents, to not permit him to schedule visits with residents, and to call the police if he attempted to visit a resident. Per the facility's Resident Progress Notes, on 10/13/23 Resident 1's physician documented, .(Resident 1) is able to articulate her needs and wants, and who she wants to spend time with. She has the capacity to determine who can visit her socially. (Visitor 1) has been friendly with (Resident 1) for quite a few years and in my opinion, allowing (Visitor 1) to visit (Resident 1) socially is something she has every right to enjoy-and she does enjoy visits from (Visitor 1), as she has repeatedly told me for the last several years .there is no reasonable justification for the facility to refuse to allow (Visitor 1) to visit her. Per the facility's policy, titled Visitation & Access Rights, dated 4/15/2001, .A resident may have visitors of his or her choice at any time .

Based on observation, interview and record review, the facility failed to implement policies and procedures when the physician was not notified regarding a resident's altercation with another resident. (Resident 1) This failure had the potential for Resident 1 to not receive the care needed to prevent repeated altercations with other residents. Resident 1 was admitted to the facility on [DATE] according to Resident 1's face sheet. Resident 1 was admitted with the diagnosis of status post embolization (blockage of blood vessels) of cerebral aneurysm (a weak or thin spot on an artery in the brain that bulges out and fills with blood) according to Resident 1's history and physical. During an interview with Resident 1 on 6/27/23, at 10:15 A.M., Resident 1 stated one night, he yelled at his roommate. Resident 1 stated he couldn't sleep because his roommate kept yelling out for the nurse in the middle of the night. According to Resident 1 he then yelled back at his roommate and told him to Shut up or he will be sorry. An interview was conducted on 6/27/23, at 10:21 A.M. with Social Services (SS). SS stated the Interdisciplinary Team (team members with various areas of expertise who work together toward the goals of their residents) conducted a stand-up meeting daily. SS stated during the 9:00 A.M. stand- up meeting a report was brought up regarding Resident 1. SS stated the report indicated Resident 1 was frustrated he could not sleep because of the roommate's constant yelling out. SS stated the report further indicated a CNA reported Resident 1 yelled at his roommate to shut up or he will come and hit him. An interview and concurrent review of Resident 1's progress notes were conducted on 6/27/23, at 12:00 P.M. with the Director of Nursing. The DON stated Resident 1's progress notes dated on 6/19/23 indicated a CNA overheard Resident 1's altercation with the roommate. According to the DON the progress notes indicated Resident 1 telling the roommate if he did not shut up, he was going to get out of bed to hit and kill him. The DON further stated there were entries in Resident 1's Progress Notes dated 6/20/23 and on 6/23/23 by Resident 1's Nurse Practitioner (NP). The DON stated Resident 1 was examined by the NP on 6/20/23 and 6/23/23, but there was no documentation regarding Resident 1's altercation with the roommate. During an interview on 6/27/23, at 12:03 P.M. with Resident 1's NP, the NP stated she visited Resident 1 on 6/20/23 and on 6/23/23. The NP stated she did not remember being informed of the incident involving Resident 1, otherwise she would have documented it. The NP stated she remembered receiving a call from the DON on 6/24/25 or 6/25/23. The DON was interviewed on 6/27/23, at 4:40 P.M. The DON stated Resident 1's physician or the NP should have been notified regarding Resident 1's altercation with the roommate. The DON stated it was important to notify the physician or the NP to receive any new orders and plan of care for Resident 1. During a review of the facility's undated policy and procedure (P&P) titled, Abuse Investigation & Reporting, the P&P indicated, .All alleged violations involving abuse, neglect, exploitation, or mistreatment .will be reported by the Company Administrator, or his/her designee, to the following persons or agencies .f) The resident's Attending Physician .

Based on record review, facility staff interview, and policy and procedure review, the facility failed to ensure the following systems were in place: 1) expired drugs were not available at the facility for administration to any of the facility's residents either in the facility's drug storage rooms, refrigerators, or in the facility's medication carts, 2) that medications and biologicals had been administered timely to all of the facility's residents, as outlined in the facility's policy and procedures, and 3) that all administered medications had been documented immediately after they had been administered to each resident. This deficiency had the potential for residents at the facility to receive expired medications and medications which had not been administered in accordance with their physician's orders. This failure could have resulted in negative outcomes for these residents. Findings include: 1) Inspection of the facility's medication storage room on Station 2, on 7/26/22 at 1:02 P.M., revealed the following expired medications: inside the Station 2 medication room refrigerator was one open house supply, vial of PPD (Purified Protein Derivative) for the identification of [CONDITION(S)] with a discard/expiration date of 7/22/22. The label on the vial of PPD also read: Discard 30 days after seal broken. Inspection of Station 2's medication cart on 7/26/22 at 3:20 P.M., revealed one vial of [MEDICATION(S)] insulin opened without a discard date or an open date. Concurrent interview with the Interim DON revealed that no one was able to tell when this medication should have been discarded. One vial of [NAME] insulin (used to treat blood sugar control) 100 units/ ml had been also found with no expiration/discard date or open date on the vial. One bottle of Sterile 0.9% Normal Saline (for wound irrigation) had been opened on 5/16/22 but the bottle's label indicated that the container would have been sterile until the bottle had been opened. The label on the bottle also indicated that this product had no preservatives to keep bacteria from growing inside the bottle once it had been opened. One vial of [MEDICATION(S)] (a blood thinner) 50,000 units opened without an expiration/discard date or an opening date on the bottle or the vial. As outlined in the facility's policy and procedures, the expired medications above should not have been available for resident use. Review of the facility's policy and procedure from the facility's Pharmacy provider manual entitled: Storage of Medication, dated 9/2018, read: 14. Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal . A second facility policy and procedure dated 3/2000, entitled: Drug and Biological Storage, read: 4. Store drugs in an orderly manner in cabinets, drawers, or carts. No discontinued, outdated, or deteriorated drugs or biologicals may be retained for use . 2) During medication pass observation on 7/27/22 between 7:52 A.M., and 8:01 A.M., two medication nurses on Station 2 had been interviewed regarding starting to pass the residents their medications prior to 8:00 A.M., contrary to the facility's policy and procedure. LN 2 had been observed passing medications to the residents on Station 2 and during this interview this Nurse indicated that she had already administered all of unsampled Resident 100's daily medications prior to 8:00 A.M. Interview during medication pass observation on 7/27/22 at 8:00 A.M., with LN 1 revealed that he had already administered medications to all of the following five (5) residents their daily medications prior to 8:00 A.M., Unsampled Resident 53, Unsampled Resident 78, along with sampled Residents 71, 73, and 103. According to the facility's medication administration times for all daily medications, these medications are to be administered at 9:00 am. The facility's medication administration policy, dated 3/2000, entitled: Medication Pass, reads: 6. Administer medications within 60 minutes of the scheduled time. Unless otherwise specified by the physician, routine medications are administered according to the established medication administration schedule for the facility. Based on this policy and procedure, all the residents above should have received their medications between 8:00 A.M., and 10:00 A.M., and not before 8:00 A.M., as the interviews above indicated from nursing staff above, which was contrary to the facility's policy and procedure. 3) Immediately after interviewing the two medication Nurses above in finding # 2, on 7/27/22 between 7:52 A.M., and 8:00 A.M., the surveyor asked the facility's Interim DON to check in each of the resident's charts above to see if the Nurses above had documented (in each resident's Medication Administration Record) the exact time at which that they had given each resident's medications that morning prior to 8:00 A.M. None of the medications above had been documented in the resident's medical records immediately after they had been given, contrary to the facility's policy and procedure. Review of the resident's clinical record by the facility's Interim DON on 7/27/22 at 8:30 A.M., confirmed that all of the above residents MARs did not reflect the actual times of administration for their medications. Review of the facility's policy and procedure entitled: Medication Administration General Guidelines, dated 9/2018, read: 1. The individual who administers the medication dose, records the administration on the resident's MAR (Medication Administration Record) immediately following the medications being given. The medication nurses above had failed to follow the facility's policy and procedure above.

Based on medication pass observation, interview with facility staff, review of the resident's clinical record, and review of the facility's policies and procedures the facility failed to ensure that 1 unsampled resident (82) had not been allowed to self-administer her medication without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficiency had the potential for this resident to administer medications to herself, in an unsafe manner, without an appropriate assessment, and without her physician's approval. Findings: During medication pass observation on 7/28/22 at 8:50 A.M., the State surveyor observed unsampled resident 82 being given her daily medications by LN 1. During the medication pass observation, the LN proceeded to pass the [MEDICATION(S)] Spray, (this medication is indicated for the management of the nasal symptoms of seasonal and [MEDICATION(S)] allergic and nonallergic rhinitis in adults), bottle to the resident for the resident to self-administer this medication. This medication had been ordered by the resident's physician on 11/9/21 to be administered as, 2 sprays into each nostril daily, but this order did not contain approval for the resident to self-administer this medication. The resident proceeded to administer the [MEDICATION(S)] Nasal spray to herself, while the LN stood next to the resident and watched. Review of the resident's most recent observation detail list report, dated 7/11/22 at 3:36 P.M., in section 1 read: The resident has expressed a desire to take his/her own medication(s): NO. This document indicated that this resident did not have any desire to self-administer her own medications, contrary to what was observed during the medication pass. Further review of the resident's clinical record and concurrent interview with the facility's Interim DON on 7/28/22 at 10:12 A.M., revealed that this resident did not have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Not only did this resident not have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Concurrent review of the resident's medical record also revealed that this resident's ability to self-administer this [MEDICATION(S)] had not been evaluated or approved by the facility's Interdisciplinary Team (IDT), as outlined in the facility's policies and procedures. Review of the facility's policy and procedure entitled: Self-Administration by Resident, dated 11/2017, read: Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe and the medications are appropriate and safe for self-administration. If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility, during the care planning process. 2. The interdisciplinary team determines the resident's ability to self-administer medications by means of a skill assessment conducted as part of the care plan process . 3. The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment, which is placed in the resident's medical record. Review of the facility's policy and procedure entitled: Medication Pass Guidelines dated 3/2000, reads: Self-Administration - Residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with the guideline for self-administration of medication. Review of the facility's policy and procedure entitled: Medication Administration General Guidelines, dated 9/2018, reads: 15. Residents are allowed to self-administer medications when specifically authorized by the prescriber, the nursing care center's Interdisciplinary Team (IDT), and in accordance with procedures for self-administration of medications . During an interview with the facility's Interim DON on 7/28/22 at 10:12 A.M., she confirmed that the facility was not aware that this resident had a desire to self-administer her own medications and as a result, none of the elements of the facility's policy and procedure for the self-administration of medications had been implemented.

Based on observation, interview, and record review, the facility did not assure that 1 of 4 sampled residents (2) received the necessary services for limited range of motion as designated in the care plan. As a result, Resident 2 had potential to develop further limitations in mobility. Findings: Per the facility's Resident Face Sheet, Resident 2 was admitted on [DATE] to the facility with muscle weakness and lack of coordination. Resident 2's record was reviewed. Per Resident's history and physical, dated 4/7/22, the resident had foot drop. Per Resident 2's physical therapy evaluation, dated 1/2022, the resident required maximum assist with activities of daily living. Per Resident 2's care plan, initiated 10/13/17, the resident was to be observed for changes in range of motion and referred to physical therapy for range of motion services to prevent further contractures. On 7/26/22 at 10:54 A.M. an interview and observation of Resident 2 was conducted. Resident 2 stated he could not lift his feet. Resident 2 appeared to have foot drop (inability to raise the front part of the foot due to weakness or paralysis of the muscles that lift the foot). No splint devices or braces to support the resident's right and left feet in a normal position were utilized. On the following days 7/27/22 at 12:39 P.M., and 7/28/22 at 2:50 P.M., Resident 2 was observed lying in bed with foot drop of the right and left foot. No movement was observed. No splint devices or braces to support the feet in a normal position were applied. On 7/29/22 at 9:16 A.M., an interview and observation was conducted with CNA 11. CNA 11 who took care of Resident 2 stated that they did not have any splints for the resident's foot drop. CNA 11 stated he did not know if they provided range of motion services for Resident 2's foot drop, but the resident needed them. On 7/29/22 at 9:22 A.M., an interview, record review, and observation was conducted with LN 11. LN 11 stated Resident 2 did not have orders for any splints to his feet. LN 11 observed Resident 2 and stated the resident had foot drop. On 7/29/22 at 10:16 A.M. an interview was conducted with the interim DON. The DON stated the standards of care was to provide range of motion services for residents as needed. The DON stated Resident 2 needed treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] On 7/29/22 at 10:22 A.M., an interview was conducted with the rehabilitation manger (RM). The RM stated Resident 2 had foot drop, they needed to evaluate the resident and determine whether the resident needed braces or splints. Per the facility policy, dated 5/2018, titled restorative nursing program - General Overview, .Resident will receive restorative nursing care as needed to help promote optimal safety and independence .

Based on observation, interview, and record review, the facility failed to assess, develop, and implement a plan for ensuring a safe environment for Resident 1 when transferring to and using a shower chair (chair with a hole in the middle of the seat used for showers). The facility also failed to ensure the staff assisting Resident 1 were trained in the use of an appropriate lift to transfer the resident and in the safe positioning of the resident in a shower chair. This resulted in nursing staff leaving Resident 1, who was unable to maintain his balance, unsupervised, sitting on the shower chair, without assistance or support. As a result, Resident 1 fell face forward to the floor and acquired a deep gash from the fall and had to go to the hospital for emergency treatment and received 7 sutures (stitches) to the forehead. Findings: Resident 1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per the same document, Resident 1 had the mental capacity to make his own decisions. Resident 1's clinical records were reviewed on 6/6/19. Per the most recent MDS (Minimum Data Set) (assessment of resident's physical and mental status), dated 1/26/19, Resident 1 was totally dependent on 2 or more nursing staff for transfer to the shower chair and when using a mechanical lift (used to move those who are unable to stand on their own). Per the same MDS, Resident 1 was unstable without staff assistance during transfers. Per the facility record, there was no documented physical therapy evaluation of Resident 1 to determine what mechanical lift was appropriate for use with the resident or how to assist the resident to maintain his balance while he was seated in the shower chair. Per the care plan record for self-care deficit, initiated on 2/25/18, no direction was provided for staff, who assisted the resident with his care, to ensure Resident 1's safety during transfers and use of the shower chair. Per the Nursing Weekly Summary, dated 3/25/19, Resident 1 was totally dependent on 2 or more nursing staff and the use of a mechanical lift. Per a review of Resident 1's nursing note for changes in his condition (Observation Detail List Report), dated 4/3/19, Resident 1 fell and came back from the emergency room with 7 sutures to his forehead. The facility failed to record how Resident 1 fell . Per the emergency physician documentation, dated 4/3/19, Resident 1 suffered an unwitnessed fall onto his head and hit the base of the stand-up lift. Resident 1 suffered a laceration of the left forehead which resulted in 7 stitches. In addition, a CT Scan (computed tomography that reveals anatomic details of internal organs) of the spine indicated the potential for a subdural hematoma (collection of blood outside the brain due to a severe head injury) and recommended a follow up CT scan. A repeat CT scan, on 5/16/19, affirmed Resident 1 had a subdural hematoma. On 6/6/19 at 10:40 [NAME]M., an observation of Resident 1 was conducted. Resident 1 had voluntary use of his head but was not able to move from the neck down. On 6/6/19 at 10:42 [NAME]M., an interview was conducted with Resident 1. Resident 1 stated, on the night of his fall, on 4/2/19, he was sitting on a shower chair in his room. The CNA assisting him used the stand-up lift to transfer him to the shower chair. The stand-up lift is designed to secure the user in an upright position, provides support via knee/foot pads, and back support. The machine has two arms to which the ends of the sling are attached. The sling is positioned around the patients back and under his arms. Resident 1 stated, CNA 1 was alone in the room with him. CNA 1 detached Resident 1's sling from the lift and removed his feet from the foot stand. CNA 1 walked away from the resident and towards the resident's bathroom. Resident 1 stated while CNA 1 was in the bathroom, he fell forward and hit his head on the stand-up lift. Resident 1 stated, I don't think she (CNA 1) understood I could not use my arms or legs or chest so I fell with all my weight onto the base of the lift and hit my head. On 6/13/19 at 2 P.M., an interview was conducted with CNA 1. CNA 1 stated she was alone when she assisted Resident 1 on 4/2/19. CNA 1 stated she used the stand-up lift because she thought it was okay to use it with the resident. CNA 1 stated another CNA taught her how to use the stand-up lift. CNA 1 stated she detached the sling from the stand-up lift and removed Resident 1's feet from the foot stand in order to remove his wet socks. CNA 1 said she went to the resident's restroom and heard a thud. CNA 1 stated she did not see Resident 1 fall because her back was to the resident and there was a privacy curtain blocking her view. CNA 1 stated she did not know about a plan for Resident 1's transfers or use of the shower chair. On 6/13/19 at 2:57 P.M., an interview was conducted with LN 1. LN 1 stated he did not know of a specific process for Resident 1's transfers. On 6/21/19 at 3 P.M., an interview was conducted with the Director of Staff Development (DSD). The DSD confirmed five out of five sampled nursing staff had not been trained on transfers and the use of mechanical lifts. The DSD stated LN 1 and CNA 1 were a part of the sample that had not been trained. The DSD stated the facility should have trained all staff on transfers and mechanical lifts. The DSD stated the facility should have assessed, developed and implemented a plan for Resident 1's positioning while sitting on the shower chair and transferring to the shower chair. On 10/22/19 at 2:25 P.M., an interview was conducted with CNA 3. CNA 3 stated Resident 1 used the stand-up lift to transfer to the shower chair and sit in the shower chair. CNA 3 stated Resident 1 could not bear weight and CNA 3 said she was unaware of a specific plan for the resident's transfers to the shower chair. On 10/22/19 at 2:30 P.M., an interview was conducted with CNA 2. CNA 2 stated Resident 1 used the stand-up lift but they did not have a process for transferring him to the shower chair and sitting up on the shower chair. CNA 2 stated Resident 1 could not bear weight. On 10/22/19 at 2:40 P.M., an interview was conducted with LN 2. LN 2 stated Resident 1's transfers were the CNAs' responsibility. LN 2 stated she was neither trained on, nor did she use the mechanical lifts. LN 2 stated it was physical therapy's job to evaluate Resident 1's needs for transfers to the shower chair and positioning while sitting up in the shower chair. On 10/25/19 at 9:13 [NAME]M., an interview was conducted with CNA 4. CNA 4 stated Resident 1 used the stand-up lift and positioned his knees against the knee pad to support his legs. CNA 4 stated Resident 1 did not bear weight. CNA 4 further stated one of the CNAs showed me how to do it. On 10/25/19 at 9:30 [NAME]M., an interview was conducted with CNA 5. CNA 5 stated they did not have a plan for Resident 1's transfers to the shower chair and while sitting on the shower chair. CNA 5 stated the physical therapy department was the department that evaluated Resident 1's transfers. On 10/25/19 at 9:45 [NAME]M., an interview was conducted with LN 3. LN 3 stated licensed nurses did not use the mechanical lifts and had not been trained on them. LN 3 stated it was the rehabilitation department's responsibility to evaluate Resident 1's transfers to the shower chair and positioning on the shower chair. On 10/25/19 at 10:10 [NAME]M., an interview was conducted with the Director of Rehab (DOR). The DOR stated physical therapy did not evaluate a resident's need for a specific mechanical lift or transfer process. The DOR said the therapy department simply identified the number of people needed for the transfer. It was nursing's job to identify the mechanical lift to be used and the transfer process to the shower chair and the resident's positioning while on the shower chair. Per the facility's policy, dated 8/15/2002, title Resident Transfer: Mechanical Lift .Mechanical lifts require at least a 2 person assist. all staff should be in-serviced on the use of a mechanical lift and demonstrate his/her competency with the device . Per the user manual, entitled Stand Up Patient Lift, RPS 350-1, residents must be able to stand and bear weight if they use the stand-up lift. Per the facility's policy, dated 8/15/2002, entitled Resident Transfers .always choose the safest transfer for the resident and you Nurses and/or therapists determine transfer requirements and the procedures used for each resident .

Based on observation, interview, and record review, facility staff failed to prevent an unstageable pressure ulcer (wound) for 1 of 2 sampled residents (2) treated with an immobilizer (a brace to prevent movement) for a displaced fractured tibia and fibula (non-aligned broken lower leg bones). As a result, Resident 2 was at risk for amputation due to non-healing. Findings: On 1/2/18, an initial on-site visit was made to investigate a complaint involving a medical device caused pressure ulcer. Resident 2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 2 was readmitted on [DATE], from the local hospital with [DIAGNOSES REDACTED]. Record review indicated Resident 2 sustained a spontaneous right lower leg fracture from unknown cause and was treated at the hospital with an immobilizer. Resident 2 returned to the facility on [DATE]. Resident 2's Physician order [REDACTED]. The physician ordered Resident 2's right lower leg monitored every shift for skin integrity (breakdown) and circulation (blood flow). On 9/22/17, by telephone, the physician ordered Skin Prep and A&D ointment to bilateral (both) heels everyday for maintenance and prevention. On 9/12/17, the facility developed a Care Plan for Resident 2's fracture that included, Release right knee immobilizer every shift for hygiene, and, Check for circulation and skin integrity every shift. The disciplines responsible to carry out these tasks were CNA and Nursing. On 1/17/18, Resident 2 was lying in bed asleep with the cover over her head. Resident 2's right leg rested uncovered on a pillow. There was a white gauze (bandage) from mid-foot to mid-shin. Resident 2's right foot extended approximately six inches beyond the pillow with dusky(discolored) toes. The Brief Interview for Mental Status assessment, dated 12/10/17, indicated Resident 2 scored 0 on a 15 point scale. This meant the Resident 2 had severe mental impairment and was dependent for all care. The Quarterly Minimum Data Set (MDS) assessment, on 7/19/17, indicated Resident 2 had no pressure sores. On 1/18/18 at 2:45 P.M., in a joint record review, the DON acknowledged there was no readmission assessment on 9/12/17. Resident 2's Weekly Nursing Assessment Summary, by LN 6 on 9/16/17 and LN 7 on 9/23/17, indicated Resident 2 had no skin issues. On 1/18/18 at 2:23 P.M., LN 1 (Treatment Nurse) said Resident 2's skin integrity was assessed on 9/25/17, two days after LN 7 assessed no skin issues. Per LN 1, the skin integrity assessment required one person to hold Resident 2's leg and one person to assess the skin. On 1/18/18 at 2:23 P.M., LN 1 said, on 9/25/17, LN 6 held Resident 2's right leg, when she assessed a Deep Tissue Injury (DTI - pressure related injury to tissues under intact skin, evidenced by a deep bruise) that measured 5 centimeter (cm) by 2 cm (2½ inch by 2 inch). LN 1 said the DTI was dark purple and from immobilizer pressure against Resident 2's lower leg. LN 1 said located 1 inch below her right posterior (back side) ankle to 2 inches above the ankle, involving hind leg tissue. On 1/18/18 at 2:23 P.M., LN 1 added that the physician ordered foam dressings that she placed to relieve pressure from the immobilizer. LN 1 said, on 10/16/17, the DTI pressure ulcer opened and has not healed, despite treatment. LN 1 said, today, 1/18/18, Resident 2's pressure ulcer measured 7 cm by 3.3 cm by undetermined (UTD) depth due to 80 to 90% slough (mass of dead tissue) on the ulcer base. On 1/18/18 at 2:30 P.M., in a telephone interview, primary care physician said circulatory disease did not cause Resident 2's right lower leg pressure ulcer, however, immobilizer pressure on tissue did. On 1/18/18 at 2:49 P.M., LN 1 said, on 9/25/27, Resident 2's opposite leg was assessed for skin integrity. LN 1 said, a 4 cm by 2 cm (approximately 2 inch by 1 inch) purple colored DTI was found on her left heel. On 1/18/18 at 3:40 P.M., LN 3 (Treatment Nurse prior to LN 1) said his name was not on the September TAR between 9/12/2017 to 9/25/17 because floor nurses were releasing Resident 2's immobilizer checking hygiene, skin integrity, and circulation. Resident 2's September 2017 TAR, initiated on 9/12/17, the right leg immobilizer was to be kept in place but released for hygiene once a shift (every 8 hours). Resident 2's right lower leg was ordered monitored every shift for skin integrity (breakdown) and monitored every shift for circulation. The TAR recorded no initials indicating Resident 2's immobilizer was released and/or skin integrity, circulation monitoring was ever performed on the night shift. The TAR recorded no initials on 9/26, 9/27, 9/23, 9/24, 9/27, 9/29, and 9/30/17 indicating Resident 2's immobilizer was released and/or skin integrity, circulation monitoring was performed on the evening shift. The TAR recorded all tasks were initials as performed 18 of 18 times on the day shift. The facility Nursing Staffing and Sign-in Sheet for 9/23/17 and 9/24/17 was reviewed. The DON acknowledged LN 5 was the sole licensed nurse on the 3rd Floor night shift on 9/23/17 and 9/24/17 and LN 3 was orienting a new nurse to Resident 2's wing to the evening shift on 9/24/17. Both LNs worked immediately prior to the discovery of Resident 2's DTIs, on 9/25/17. On 1/23/17 at 3:22 P.M., in a telephone interview, LN 5, said Resident 2's immobilizer was checked maybe 30% of the time. LN 5 said he didn't release Resident 2's immobilizer for hygiene. LN 5 said he checked skin integrity with two fingers and felt inside the immobilizer. LN 5 said he never picked up Resident 2's right lower leg visual assessment as that required two people. LN 5 said Resident 2 screams and it woke residents. On 1/23/2018 at 4 P.M., LN 3, with the DON present, acknowledged working the evening shift on 9/24/17, before Resident 2's pressure ulcers were discovered. LN 3 said he didn't assess Resident 2's right leg for hygiene, skin integrity or circulation nor did he sign the TAR with his initials. LN 3 said he released the immobilizer for a while. On 1/23/18 at 4:20 P.M., the DON acknowledged Resident 2's evening and night shift nurses, on 9/24/17, failed to monitor/assess Resident 2's right lower leg for skin integrity, circulation and release the immobilizer for hygiene. Resident 2's Turning / Repositioning Monitoring sheet, started on 9/20/17, lacked initials that Resident 2 was repositioned on 9/24/17 at 12 A.M., 2 A.M., 4 A.M., 6 A.M., 10 A.M., 12 P.M., 2 P.M., 4 P.M., 6 P.M., 8 P.M., and 10 P.M., a 24 hour period. Review of Resident 2's Progress Notes documentation indicated LN 10 recorded, on 9/20/17 at 4:19 P.M., Turned and repos (repositioned) every two hours as scheduled for comfort and circulation. On 9/22/17 at 3:21 A.M., LN 9 recorded Changing and repositioning by CNAs every two hours. On 9/23/17 at 3:09 A.M., LN 6 recorded Repositioned every two hours. There was no Progress Note entry on 9/24/17. >>>>>>>>>>>>> On 1/24/18 at 4:45 A.M., in a telephone interview, CNA 4, Resident 2's caregiver on the night shift on 9/24/17, said she was a two person assist for turning with the immobilizer. CNA 4 said Resident 2 would cry out. CNA 4 said she did not turn Resident 2 fully side to side. On 1/24/18 at 5:22 A.M., in a telephone interview, LN 5, who worked night shift on 9/23/17 and 9/24/17, said he thought CNA 4 was turning Resident 2 because there was a turn sheet posted on the wall. LN 5 was unaware CNA 4 wasn't signing the turn sheet. LN 5 now said he released Resident 2's immobilizer 30% of the time at 4 A.M. and left the immobilizer open for the day shift to find. On 1/24/2018 at 6:30 A.M., in a telephone interview, CNA 5, Resident 2's caregiver on the day shift on 9/24/17, said no one ever asked her to hold Resident 2's leg to perform an assessment. CNA 5 said Resident 2 was very difficult to turn because her immobilized leg wouldn't turn very far. On 1/24/18 at 6:30 A.M., in a telephone interview, CNA 7, Resident 2's caregiver on the evening shift on 9/24/17, said she turned Resident 2's upper body at the waist during brief (diaper) changes two to three times a shift. CNA 7 said Resident 2 legs were not turned because she screamed. CNA 7 said no one ever asked her to hold Resident 2's right leg for assessment. Resident 2's weight was reviewed. Resident 2 weighed 138 pounds on 9/14/17; 141.5 pounds on 10/21/17; 138 pounds on 11/19/17; 138.5 on 12/10/17 and 138 pounds 1/21/18. MD statement . The facility's P/P entitled Wound Care, revised 2/2020, indicated, The superficial dermis (skin) can tolerate ischemia (lack of oxygen) for 2-8 hours without major damage; however, the deeper muscle and connective tissue can tolerate just 2 hours without damage. As the amount of pressure increases, the time before ischemia decreases. The facility's P/P entitled Pressure Ulcer Preventive Measures Policy, effective date 3/00, indicated, Reposition bed- and chair-bound residents at least every two hours.When using specialty support devices follow the manufacturers instructions. Per Resident 2's October 2027 TAR, there were no initials indicating immobilizer release and/or skin integrity, circulation or hygiene monitoring was performed on the night shift, or 32 of 32 times; on the evening shift there were no initials on 20/3, 20/4, 20/9, 20/20, 20/24, 20/25, 20/26, 20/20, 20/26, 20/28 and 20/32/27, or 22 of 32 times; and, on the day shift, each day was initialed 32 of 32 times as performed.

Based on observation, interview, and record review, facility staff failed to provide pain management after 1 of 1 sampled residents (1) sustained a right lower leg injury. As a result, Resident 1 experienced extreme pain from an acute (new) displaced (non-aligned) tibia/fibula fracture (broken two lower leg bones). In addition, Resident 1 did not receive pain medication/management or treatment of [REDACTED]. Findings: Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Brief Interview for Mental Status assessment (standardized cognitive assessment), dated 7/19/17, indicated Resident 1 scored 00. This meant severe mental impairment that left Resident 1 dependent for all care. The Quarterly Minimum Data Set (MDS) assessment, dated 7/19/17, indicated Resident 1 did not walk and required the assistance of two persons for transfers. Resident 1 was impaired on one side of her body and incontinent of bowel and bladder, per the MDS. Resident 1 wore incontinence care briefs (diapers). Per review of Resident 1's Emergency Department (ED) Emergency Physician Documentation, dated 9/11/17 at 9:06 P.M., Resident 1 suffered a tibia/fibula fracture (mildly non-aligned broken lower leg bones) due to unknown cause. While in the ED an immobilizer (splint) was applied and narcotic pain medication was administered. Resident was admitted to the ED approximately 46 hours after initial injury assessment. On 10/10/17 at 6:31 A.M., LN 1 said on 9/9/17 at 11:15 P.M. she was called to assess Resident 1's right mid-shin swelling and bruising. LN 1 said she was bothered by the pain Resident 1 experienced when she touched the area. LN 1 said she called her supervisor LN 7, who viewed Resident 1's leg. LN 1 said she told LN 7, Resident 1 had nothing ordered for pain. LN 1 said she followed LN 7's instructions to monitor Resident 1's leg, but didn't notify Resident 1's physician until she left a message on his answering machine, on 9/10/17 at 8 A.M. On 10/9/17 at 11:20 A.M., Resident 1 was observed. CNAs performed a three person transfer from the bed to a wheelchair. A black immobilizer was in place on her right leg. Resident 1's eyes were closed and she shook her head side to side, not responding to questions. Per review of the S-BAR form (progress note documentation of a change of condition) , dated 9/10/17 at 4:20 A.M., LN 3 documented Resident 1's right lower leg (shin) area had some bruising, swelling of leg, pain on movement and touch. LN 3 assessed Resident 1's pain level at 8 out of 10 points, or severe. On 10/10/17 at 5:57 A.M., CNA 3 said, on 9/9/17 at 11 P.M., Resident said twice in her native language, My right leg hurt. CNA 3 said, she saw Resident 1's right lower mid-leg area was swollen and a little blue. CNA 3 called LN 1 to the room to see Resident 1's swollen leg, and hear Resident 1's complaints of leg pain. On 10/10/17 at 6:31 A.M., LN 1 was interviewed. LN 1 said, on 9/9/17 at 11:15 P.M. she was called into Resident 1's room to assess Resident 1's mid-shin (half way between ankle and knee) for swelling and dark colored bruising. LN 1 said Resident 1's cry of pain was different and the resident had nothing ordered for pain. LN 1 said she called LN 7, the night supervisor, to assess Resident 1's leg, and made her aware there was no order for pain medication. LN 1 said LN 7 looked at Resident 1's leg and advised LN 1 to monitor and notify the physician. LN 1 said she monitored Resident 1's leg and but made the decision not notify MD 1 (Resident 1's physician) until 8 A.M. the next morning, on 9/11/17. Per Resident 1's Progress Note, dated 9/10/17 at 8:09 A.M., and documented by LN 1, Resident 1 slept off and on through the night related to right leg pain shin (lower leg) bruising and swelling. Also, MD 1 was not notified of Resident 1's change of condition through the night. On 9/10/17 at 7:55 A.M. LN 1 documented a voice message was left for the MD on his answering machine. On 10/11/17 at 6:50 P.M., in a telephone interview, LN 7, the night supervisor, said she assessed Resident 1's leg with LN 1 on 9/9/17 and concluded immediate hospitalization wasn't needed. LN 7 acknowledged she told LN 3 to notify the physician and monitor the resident's injury. LN 7 said she expected licensed nurses to call the doctor when she said to notify the physician and expected them to medicate residents for pain. On 10/10/17 at 8:30 A.M., LN 4 said she was assigned to the opposite side of the nursing station, when CNA 1 and CNA 5 reported Resident 1's leg injury and pain to her on 9/10/17 at approximately 7:30 A.M. LN 4 said she saw Resident 1 was in a wheelchair across from the nursing station after breakfast. LN 4 said Resident's right mid-shin was swollen and discolored. LN 4 said she told CNA 1 and CNA 5 to put Resident 1 back to bed with a pillow under her right lower leg for support. LN 4 said she told LN 3 about Resident 1's right leg. On 10/11/17 at 9:30 A.M., LN 3 was interviewed by telephone. LN 3 said she only worked one day a month for the facility and, on 9/10/17 she was Resident 1's assigned LN on the day shift. LN 3 said Resident 1's leg bruise was purple. LN 3 said her supervisor, LN 2, went with her to assess Resident 1's leg in her room. LN 2 said when they touched the bruised leg, Resident 1 complained of pain. LN 3 said she could not remember giving Resident 1 any pain medication. LN 3 said as long as Resident 1 did not move, she seemed comfortable. On 10/11/17 at 11 A.M., LN 2, the day supervisor on 9/10/17, was interviewed by phone. LN 2 said, on 9/10/17 at around 9 A.M., Resident 1's right lower leg was assessed to have black and blue bruising from mid-shin to two inches above the ankle. LN 2 said there was 3+ (tight tissue) swelling around the entire leg. LN 2 said it was the injury was extremely painful. LN 2 said Resident 1 was guarded and defensive and she moaned when touched. LN 2 said she assumed the licensed nurses had medicated her for pain. On 10/11/17 at 3:21 P.M., LN 6, who worked evenings on 9/11/17, said Resident 1 remained quiet with no movement except for brief changes. LN 6 said CNAs did not turn Resident 1 to keep pain at a minimum. On 10/11/17 at 4 P.M., LN 5 said she worked the day shift on 9/11/17. LN 5 said she knew Resident 1 had something terrible like a fracture when she saw her shiny swollen and darkly bruised lower right leg. LN 5 said the dark bruise and swelling was from below the resident's knee to three inches above the ankle. LN 5 said, on 9/10/17 at 4 P.M., the Nurse Practitioner ordered a portable x-ray for the next day but no pain medication. LN 5 said she couldn't understand why the portable X-ray wasn't done first thing in the morning. LN 5 said she called the company, around 9 A.M., to hurry. LN 5 said it never occurred to her that Resident 1 did not have pain medication ordered. LN 5 said she thought Resident 1 was administered pain medication before the portable X-ray was done. The ambulance service documentation entry on 9/11/17 at 4:30 P.M., recorded Resident 1 had not been medicated for pain when they performed a three person sheet lift transfer to a stretcher for transport to the hospital ED. On 10/11/17 at 10:30 A.M., Resident 2, who was Resident 1's roommate, was interviewed. Resident 2 scored 14 out of 15 on the Brief Interview for Mental Status assessment, dated 8/19/17. This meant Resident 2 was alert, oriented and a capable historian. Resident 2 said, one night, facility staff came in asking Resident 1 a lot of questions in another language and then Resident 1 screamed in pain. Resident 2 said Resident 1 had never screamed like that when staff treated her. Resident 2 said, that at first, Resident 1 screamed only when staff touched her, and then she screamed when they came near her. Resident 2 said, It was awful. Resident 2 said Resident 1's screaming went on for days. On 10/12/17 at 1:30 P.M., the DON acknowledged the facility failed to assess, identify and notify MD 1 for pain treatment orders. On 1/11/18 at 9:40 A.M., MD 1, Resident 1's attending physician and the facility Medical Director said, the facility LN's never reported to him that Resident 1 was in pain. MD 1 said Resident 1 spoke a language that many facility staff spoke but the staff failed to translate her pain level to him. The facility's P/P entitled Pain Management, initiated 12/1/2005, indicated, To identify patients experiencing pain, develop, implement, and evaluate care plans for the management of pain, monitor and document the patient's response to pain management interventions. Pain refers to any type of physical pain or discomfort in any part of the body. Pain may be localized to one area or maybe more generalized. It may be acute or chronic, continuous or intermittent, or occur at rest or with movement.Observe both verbal and non-verbal patients for signs and symptoms of pain, notify a nurse immediately. Notify the physician. The facility's P/P entitled Changes in Resident Condition, initiated (MONTH) 4, 2008, indicated, The resident, attending Physician and legal representative or designated family members are notified when a change of condition or certain events occur.

Based on observation, interview and record review, the facility staff failed to protect 1 of 1 sampled residents (1) during a toilet to a wheelchair transfer. As a result, Resident 1 fell and experienced pain and discomfort from an acute right non-displaced tibia fracture (aligned broken bone in the lower leg). In addition, Resident 1 did not see a physician for treatment of [REDACTED]. Findings: Resident 1 was admitted to the facility on [DATE] and 6/25/17, with [DIAGNOSES REDACTED]. Medical record review of Resident 1's Emergency Physician Documentation, on 7/3/17 at 8:47 A.M., Resident 1 fell on both knees at facility. The Emergency Physician Documentation recorded an acute (new) fracture of the right proximal tibia (part of leg bone nearest the knee) with an abrasion below the right knee. On 7/11/17, the medical record review indicated Resident 1 scored 15 out of 15 points on the Brief Interview for Mental Status assessment, dated 4/13/17. This meant Resident 1 was alert, oriented to make decisions. The Minimum Data Set (MDS) assessment, on 4/13/17, indicated Resident 1 did not walk and required the assistance of one person for all transfers, which triggered a care plan. Resident 1's balance was not steady and required staff to stabilizer her when moved on and off the toilet and transferred between the wheelchair and bed, per the MDS, which triggered (alerted facility to create) a care plan. A review of Resident 1's Care Plans failed to find a care plan for her individual transfer/support needs from toilet to wheelchair. The Physical Therapy Evaluation Summary, completed on 6/28/17, indicated Resident 1 was unable to walk and required 75 % physical assistance. The Occupational Therapy Evaluation Summary completed on 6/28/17, indicated Resident 1 was 100% dependent for toilet transfers. Resident 1 could not stand or step without loss of balance. On 7/10/17 at 4:10 P.M., Resident 1 was observed sitting in bed. A leg immobilizer (light weight splint) was on her right leg. Resident 1's right lower leg had discolored bruising from knee to ankle. On 7/10/17 at 4:10 P.M., Resident 1 said, on 7/2/17, she put the bathroom call light for staff assistance with personal hygiene after using the toilet. Per Resident 1, CNA 1 came to help. Resident 1 said she told CNA 1 she couldn't stand, but CNA 1 had me stand. Resident 1 said CNA 1 lifted her into a standing position but couldn't support me. Resident 1 said she fell and fractured my knee. Resident 1 said the wheelchair and bathroom grab bars were too far to reach. Resident 1 said her wheelchair wasn't next to the toilet, motioning with her hands the distance was 14 to 16 inches away. Resident 1 said this fracture had caused her pain and numbness in her right leg, especially upon moving or turning in bed. Resident 1 said CNA 1 didn't use a gait belt (strap used used as a belt by caregivers in transfers) to help lift and balance her. On 7/12/17 at 6:07 A.M., in an interview, CNA 1 said she saw Resident 1's bathroom call light around 4:30 P.M. CNA 1 said she assisted Resident 1 to stand up from the toilet and step forward towards the opposite wall grab bars. CNA 1 said she didn't use a gait belt because Resident 1 didn't need that kind of help. CNA 1 said she cleaned Resident 1 and applied a new brief and then Resident 1's knees gave out. CNA 1 denied Resident 1 fell to the floor. CNA 1 said CNA 2 heard her cries for help and assisted her to get Resident 1 back to bed. CNA 1 said she reported this to the nurses (LN 1 and LN 2) immediately. On 7/13/17 at 3:50 P.M., the DON provided CNA 1's written statement. It was dated, 7/2/17 at 4:30 P.M. and indicated, As I was getting (Resident 1) off the toilet she stand up and she was complaining her knees hurts and then while I was helping her to the (wheel)chair her knees give out. On 9/5/17 at 1:30 P.M., CNA 2 said she was familiar with Resident 1's care but wasn't assigned to her, on 7/2/17. CNA 2 said she took Resident 1 by wheelchair to the bathroom toilet. CNA 2 said Resident 1 could not take steps. CNA 2 said she parked Resident 1's wheelchair next to the toilet and physically lifted Resident 1 to stand and turn to sit on the toilet. CNA 2 said she placed the red bathroom call light in Resident 1's hand and told her to pull it when she was finished. CNA 2 said she was in the hallway and heard Resident 1's roommate crying out. CNA 2 said she entered the bathroom and saw CNA 1 there and Resident 1 was on her knees in front of the toilet. CNA 2 said Resident 1 complained her right leg was hurt and numb. CNA 2 said she helped CNA 1 lift Resident 1 under her arms first to the toilet. CNA 2 said she stayed with Resident 1 and CNA 1 left to get the licensed nurse. CNA 2 said LN 3 came into the bathroom and examined Resident 1's right knee. CNA 2 said LN 3 told them it wasn't Resident 1's knee but her leg. CNA 2 said LN 3 directed them to have Resident 1 stand (bear weight) to transfer back to the wheelchair. LN 3 then directed Resident 1 be put back to bed. On 7/12/17 at 10:30 A.M., in a telephone interview, LN 3 said, on 7/2/17 at around 5:30 P.M., she was asked to assess Resident 1 for right knee pain. LN 3 didn't ask Resident 1 what caused the pain. LN 3 said she had no knowledge Resident 1 fell . LN 3 explained Resident 1 didn't verbalize she had fallen until 8 P.M., when she continued to complain of right knee pain. LN 3 said she notified the on-call physician and x-rays were ordered. On 9/5/17 at 3 P.M., LN 1 said she was was administering medications on 7/2/17 and when CNA 1 reported Resident 1's right knee was hurt in a transfer. LN 1 said she asked LN 3 to go to the room and assess Resident 1's knee. LN 1 said she saw Resident 1 later when she was complaining of right leg pain so the physician was called for x-ray orders. Record review of Resident 1's facility X-ray Report, dated 7/3/17 at 2:57 A.M., indicated Resident 1's leg bone had a non-displaced fracture through the proximal tibia. This report was faxed to the physician at 3 A.M. Resident Progress Notes documentation by LN 5, dated 7/3/17 at 12:45 P.M., entry indicated, Pt (patient) came back from ER . Pt had non displaced (aligned bone) fracture through right tibia, there is a knee immobilizer in place. On 9/7/17 at 12:19 P.M., PT (Physical Therapist) 1 was interviewed with the DON and Administrator 2. After reviewing the Physical Therapy Summary, dated 6/28/17, PT 1 said Resident 1 required an assist of one person assuming up to 70% of the lift for the transfer. PT 1 said Resident 1 would need a strong person for the assist. PT 1 said he did not share his report with licensed nurses but expected them to read it in the medical record. On 9/11/17 at 2:12 P.M., in a joint conference with the DON and Administrator 2, Occupational Therapist (OT) 1 explained the Occupational Therapy Summary, dated 6/28/17. OT 1 said the evaluation of the Resident 1's functional ability was made 5 days before her fall. OT 1 continued that Resident 1 could not maintain a standing balance and, when standing with support, could not take a step. OT 1 said this evaluation became part of Resident 1's record and was not reported to licensed staff. OT 1 said she taught one CNA at the bedside how to work with the resident. On 9/11/17 at 11 A.M., CNA 1's personnel file was reviewed with the DON. In orientation, on 11/11/16, CNA 1 watched a video on how to transfer residents. Per the DON, the facility doesn't complete an evaluation of performance until 1 year after orientation. CNA 1 did not attend Transfers inservice training provided CNAs in February, (YEAR). On 9/11/17 at 2:24 P.M., in an interview, the DON acknowledged there was no transfer care plan in place to direct CNA care in Resident 1's transfer needs. The DON acknowledged Nursing Services was responsible for Resident 1's injury fall during the toilet to wheelchair transfer. On 9/14/17 at 10:45 A.M., the DSD explained a correct pivot transfer that a CNA should use after positioning the wheelchair next to the toilet. The DSD indicated the resident stood while the CNA used her own leg and foot to brace the resident's foot and leg while turning the resident's other foot. The resident is turned/pivoted which enables the resident to sit on the wheelchair without taking a step. The facility's Individual Safety Responsibilities: Nursing, signed by CNA 1 on 11/11/16, indicated, Nursing Aides are required to wear and use gait belts while on duty. They are considered part of the uniform. They are to be used with dependent patients. The facility's P/P entitled Fall Prevention, release date 12/1/2005, indicated, This is a program that has been designed to make a concerted effort to provide each patient with adequate supervision and assistive devices to prevent or decrease the risk of injury from falls. The facility's P/P entitled Resident Transfer: Gait Belt, release date 08/15/2002, indicated, A gait belt is used to transfer residents who do not have full function to safely transfer or ambulate without assistance, or who prefer using a gait belt.

Based on observation, interview, and record review, the facility failed to ensure that Resident 22 did not attach two electrodes to his chest, attach a cord to each electrode, and plug the cord into the third prong ground of his room wall socket. As a result, Resident 22 was at risk for electrocution (death by electric shock). Findings: Resident 22 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. rate) per the hospital discharge summary. On 1/6/14 at 8:30 A.M., during the initial tour, Resident 22 was observed sitting on the edge of his bed with two electrode patches stuck to his chest, each with an insulated wire attached running to the floor and plugged into the third ground prongs of a standard wall outlet. Resident 22 stated that "grounding" helps him feel better. Resident 22 further stated, "I've been doing it for two months." On 1/6/14 at 8:40 A.M., during an interview, LN 1 stated, "He's had it for awhile. He bought it himself." On 1/6/14 at 8:45 A.M., during a joint observation and interview, the Director of Staff Development (DSD) stated she had not seen the electrodes before and had no idea Resident 22 was doing this. The Nursing Home Administrator (NHA) and Director of Nursing (DON ) stated they had no knowledge that Resident 22 was plugging himself into the wall outlet and acknowledged that it could be a risk for electrocution. On 1/6/14 at 8:50 A.M., during a joint record review, the NHA and DON were unable to locate any care plan or notes indicating Resident 22's physicians were aware of this practice or approved the electrode connections. The DON stated, "There are no orders nor is there any care plan related to the electrodes being plugged into the wall." As a result on 1/6/14, at 10:16 A.M., an Immediate Jeopardy was called and the NHA and DON were informed and an interim Plan of Correction was requested. On 1/6/14 at 11 A.M., during a joint record review, Resident 22 provided product information related to the grounding product. The NHA acknowledged that the product information indicated that if the user was taking medications they should consult a physician before using the grounding device. The NHA stated that there was no indication in the clinical record that Resident 22's physician had reviewed and approved of its use. On 1/6/14, at 12 P.M., during an observation and interview, Licensed Electrician (LE) 1 observed the wall outlet in Resident 22's room and stated, "This is a loop ground and it is not safe to have him (Resident 22) plug himself into." (Loop ground refers to an unwanted current of electricity). LE 1 further stated, "He (Resident 22) could be electrocuted if anything in the loop became energized (to supply an electric current). If it were an isolated ground it would be safer and the plug would be an orange color, that plug is not." On 1/6/14 at 1 P.M., during an interview related to the immediate measures taken to ensure resident safety, the NHA stated, "(Resident 22's) electrodes have been removed, he (Resident 22) has agreed to an alternate grounding method, an electrical contractor has been called to install a safer grounding alternative, his physicians have been notified, and the electrodes will not be returned until the physicians have approved them for use." On 1/6/14 at 1 P.M., the survey team abated the Immediate Jeopardy as a result of receiving a satisfactory plan of correction.