Every finding on record at Vineyard Post Acute

Based on interviews and record reviews, the Licensed Nurses (LN) failed to notify the Responsible Party (RP, a person designated to makes healthcare and/or financial decisions for a person who is no longer able) for one resident (Resident 1) of three sampled residents, when:LN 1 (Licensed Nurse 1) did not notify Resident 1's RP that Resident 1 had eloped (when a resident leaves the facility unattended, without permission, or without staff awareness) on 2/28/26;and,LN 2 did not notify Resident 1's RP on 3/1/26 that Resident 1 had a fever of 100.4 degrees Fahrenheit (F, a unit measurement of temperature).These failures decreased the facility's potential to ensure Resident 1's RP was well informed regarding Resident 1's health status and plan of care.Findings:A review of Resident 1's admission record indicated medical diagnosis of Dementia (a progressive state of decline in mental abilities), Bipolar Disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), Cognitive Communication Deficit (an communication impairment due to poor memory or attention) and Repeated Falls. The admission record also indicated Resident 1's emergency contact number one and RP was his daughter.A review of Resident 1's Brief Interview on Mental Status (BIMS) conducted on 12/11/25, indicated a score of 6, which meant Resident 1 had a severe cognitive impairment (when you have problems remembering things, concentrating, making decisions and solving problems).A review of Resident 1's Order Summary Report, indicated Resident 1 had the following active orders:- Resident [1] is not capable of making his own health decisions [dated 10/24/24].- Wanderguard(R) to alert [Resident 1's exit-seeking behavior [dated 9/13/25].A review of Resident 1's change of condition note dated 2/28/26 at 7:25 a.m., indicated, episode [sic] of elopement early this morning, last time we check [sic] resident is [sic] at around 0400 [4 a.m.] and resident is still in his bed, [sic] resident went out of the building and went as far as the baseball field across the facility according to the police who found him [sic] brought him back here at around 0500 [5 a.m.] Wanderguard(R) is in place but it did not alarmed [sic] when resident went out of the facility. There was no documented evidence that the LN notified Resident 1's RP of his elopement.A review of Resident 1's progress note dated 3/1/26 at 10:29 p.m., documented by LN 2 indicated, .COC [Change of Condition] D1 [Day 1] for fever. Resident noted sneezing. At [5:54 p.m.] T [temperature]100.4 [F] forehead (non-contact), Acetaminophen administered, at [6:20 p.m.] fever 101.1 [F] noted.Resident [1] was congested so MD [physician] was notified for congestion medicine. There was no documented evidence that the LN notified Resident 1's RP of his fever.During an interview with Resident 1's RP on 3/30/36 at 11:55 a.m., , the RP stated she had not been informed by the facility that Resident 1 had an eloped. The RP stated she learned about his elopement from a friend who recognized her father's name during a dispatch call related to the incident. The RP also stated she visited Resident 1 on 3/2/26 after the elopement incident and noticed he was coughing which was new.During a concurrent record review and interview with the DON (Director of Nursing) on 3/30/26 at 3:45 p.m., the DON reviewed Resident 1's progress notes dated 2/28/26. The DON stated she expected licensed nurses to complete a change of condition report for an elopement and fever and notify the resident's RP.During an interview with LN 2 on 4/1/26 at 1:37 p.m., LN 2 stated she remembered Resident 1 had a fever on 3/1/26 and acknowledged she had not reported this to Resident 1's RP because she did not know she had to report it. During an interview with the DON on 4/1/26 at 2:42 p.m., the DON stated she checked Resident 1's progress notes and acknowledged she did not see any documented evidence that indicated Resident 1's changes of condition on 2/28/26 and 3/1/26 were reported to his RP.A review of the facility's policy and procedure (P&P) titled Wandering and Elopements dated March 2019 indicated, When the resident returns to the facility, the director of nursing services or charge nurse shall.notify the resident's legal representative (sponsor).document relevant information in the resident's medical record.A review of the facility's P&P titled, Change in Resident's Condition or Status, dated February 2021 indicated, Our facility promptly notifies the resident.and the resident representative of changes in the resident's medical/mental condition and/or status (e.g. changes in level of care, billing/payments, resident rights, etc.).Unless otherwise instructed by the resident, a nurse will notify the resident's representative when.there is a significant change in the resident's physical, mental, or psychosocial status.Regardless of the resident's current mental or physical condition, a nurse or healthcare provider will inform the resident of any changes in his.medical care or nursing treatments.

Based on observations, interviews, and record reviews, the facility failed to provide adequate supervision to one resident (Resident 1) of three sampled residents, when Resident 1 eloped (when a resident leaves a facility unattended, without permission, or without staff awareness) from the facility on [DATE].This failure decreased the facility's potential to prevent injury illness to Resident 1.Findings:A review of Resident 1's Elopement and Wandering Risk Observation/assessment dated [DATE], indicated a score of 12. According to this assessment, a score of 10 or greater would be considered at risk for wandering or elopement.A review of Resident 1's admission record indicated he was admitted to the facility in [DATE] with diagnosis of Dementia (a progressive state of decline in mental abilities), Bipolar Disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), Cognitive Communication Deficit (a communication impairment as a result of issues with memory and thinking processes), Atrial Flutter (a heart rhythm disorder that results in the upper chambers of the heart beat too fast [around 300 beats per minute; normal is 60-100 beats per minute]) Repeated Falls. The admission record indicated Resident 1's emergency contact number one and Responsible Party (a person designated to make decisions about healthcare and finances when a person is no longer able to do so for themselves) was his daughter.A review of Resident 1's Brief Interview on Mental Status (BIMS) conducted on [DATE], indicated a score of 6, which meant Resident 1 had a severe cognitive impairment (when you have problems remembering things, concentrating, making decisions and solving problems).A review of Resident 1's Order Summary Report, indicated Resident 1 had the following active orders:- Resident [1] is not capable of making his own health decisions [dated [DATE]].- Apixaban oral tablet 5 mg [milligrams, a unit of measure] Give 1 tablet by mouth two times a day for atrial flutter [dated [DATE].- Anticoagulant medication (apixaban)- Monitor for [signs and symptoms of bleeding because it is a common side effect] every shift [dated [DATE]].- Attention Nurses: Wanderguard(R) is expiring on [DATE]. Please make sure to notify Activity Director for replacement. every shift [sic]. [dated [DATE]].- Wanderguard(R) to alert [Resident 1's exit-seeking behavior [dated [DATE]].- Wanderguard(R) function checked by maintenance staff [dated [DATE]].- Check Wanderguard(R) for placement. Location left ankle every shift {dated [DATE].A review of all Resident 1's care plans indicated:-On [DATE], a care plan was initiated for Resident 1's risk of falls related to his history of repeated falls. Resident 1's goal was to minimize his risk of falls. Staff were expected to keep Resident 1 within supervised view as much as possible in order to help him meet his goal.-On [DATE], a care plan was initiated for Resident 1's risk of elopement and wandering related to his impaired safety awareness. Resident 1's goal was for his safety to be maintained. Staff were expected to implement the following interventions to help Resident 1 meet his goal: Identify a pattern of wandering and intervene as appropriate and place a Wanderguard(R) on his right wrist.-On [DATE], a care plan was initiated for Resident 1's risk of bleeding associated with his use of anticoagulants. Resident 1's goal was to minimize side effects of the medication. Staff were expected to provide Resident 1 with safety measures to avoid injury to help him meet his goal.-On [DATE], a care plan was initiated because Resident 1 had an unwitnessed fall. Resident 1's goal was to minimize his risk for additional falls. Staff were expected to implement the following interventions to help Resident 1 meet his goal: anticipate and meet his needs and provide verbal reminders to ask for assistance as needed.A review of Resident 1's change of condition note dated [DATE] at 7:25 a.m., indicated, episode [sic] of elopement early this morning, last time we check [sic] resident is [sic] at around 0400 [4 a.m.] and resident is still in his bed, [sic] resident went out of the building and went as far as the baseball field across the facility according to the police who found him [sic] brought him back here at around 0500 [5 a.m.] Wanderguard(R) is in place but it did not alarmed [sic] when resident went out of the facility.During a concurrent observation and interview with Resident 1 on [DATE] at 2:40 p.m., Resident 1 was observed sitting on his bed. Resident 1 stated he remembered going out of the building late at night to see his friend who was a policeman and lived one-and-a-half houses away from the facility. Resident 1 stated he did not remember if he had his wander alarm on or if the door alarm sounded. Resident 1 stated he did not hurt himself /while he was out. While this surveyor and Resident 1 stood in the front lobby, Resident 1 pointed toward the closest baseball field from the facility to indicate where he had gone when he left the facility at night. In order to get to the baseball field, Resident 1 would have had to cross a neighborhood intersection with a three-way stop sign to get to the nearest baseball field.During a concurrent record review and interview with the DON (Director of Nursing) on [DATE] at 3:45 p.m., the DON stated nobody noticed that Resident 1 had left the facility. The DON also stated she was not sure if Resident 1's care plan was updated after the elopement incident on [DATE]. The DON reviewed Resident 1's care plan regarding his risk of wandering and elopement dated initiated on [DATE] and acknowledged it had not been updated to indicate Resident 1's elopement incident on [DATE].During an interview with the Activity Director (AD) on [DATE] at 10:29 a.m., the AD stated she was on leave from work which started on [DATE] and the Human Resources Director (HRD) helped with the activity department. The AD stated she and anyone who was designated to carry out her duties while she was out on leave was responsible for keeping track of the expiration date of the Wanderguard(R).During an interview with the HRD on [DATE] at 10:50 a.m., the HRD stated she did not recall anyone informing her that Resident 1's Wanderguard(R) had expired.During an interview with the DON on [DATE] at 2:42 p.m., the DON stated there was a potential for Resident 1 to have fallen and sustained injuries when he eloped.During an interview with the Maintenance Director on [DATE] at 4:31 p.m., he stated he checked the door alarm system to ensure it was functioning properly every Friday and that he kept a log of the weekly checks. He stated when the door alarm was activated, the alarm would be loud enough for staff to hear and respond to. The Maintenance Director further stated there were monitors at Nurse Station 1 and Nurse Station 2 that would notify the nurses which door was alarming. The Maintenance Director stated he was unable to determine how Resident 1 was able to leave the building through the front door without sounding the alarm.A review of the facility's policy and procedure (P&P) titled, Wandering and Elopements, dated [DATE], indicated, The facility will identify residents who are at risk of unsafe wandering.If identified as at risk for wandering, elopement.the resident's care plan will include strategies and interventions to maintain the resident's safety.

Based on observations, interviews and record reviews, the facility failed to ensure only authorized personnel had access to one out of four medication carts when Medication cart #2 was unlocked when it was unattended.This failure could result in unauthorized access to medications and unintentional ingestion which could lead to overdoses, drug interactions, or severe adverse effects.During a concurrent observation and interview on 3/10/26 at 12:25 p.m., while walking in the hallway with the Nursing Supervisor (NS), medication cart #2 that was parked outside of room [ROOM NUMBER], was unlocked and unattended. The NS walked over medication cart # 2 and locked the cart. The NS stated medication carts should always be locked when left unattended. NS stated medication carts needed to be locked as unauthorized people, including residents, might access the medications in the medication cart which could jeopardize their safety. Licensed Nurse (LN) A was then seen coming out of room [ROOM NUMBER], LN A stated she oversaw cart # 2 and had left it unlocked and unattended. LN A stated the facility policy was to ensure medication carts were locked when unattended, for resident safety, so confused residents could not access the medications inside the medication cart.During an interview on 3/10/26 at 2:27 p.m., the Director of Nursing (DON) stated medication cart must always be locked when unattended because only nurses were authorized to access the medications. The DON stated leaving the medication cart unlocked while unattended was a safety issue and made it possible for unauthorized people to access the medications in the cart.A review of the facility's policy and procedure (P&P) titled Administering Medications, revised 4/2019, the P&P indicated, .the cart must be visible to the personnel administering medications and all outward sides must be inaccessible to residents or others passing by.

Based on interview, and record review, the facility failed to ensure professional standards of care were followed for one of three sampled residents (Resident 1) when: 1. A physician's weekly order to collect labs was not followed, 2. A SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition [COC] among the residents) was not initiated after the facility received abnormal lab results pertaining to Resident 1's kidney (organs that filters blood to removed waste, excess fluid and toxins from the body) function, and; 3. The abnormal lab results was not reported to Resident 1's physician. This failure increased Resident 1's risk for prolonged pain, discomfort, and a delay in care and treatment which decreased the facility's potential to prevent Resident 1's kidneys from critical injury. A review of Resident 1's admission record indicated she was initially admitted to the facility in December 2025 with medical diagnosis which included displaced bimalleolar fracture of right lower leg (fractures of both the tibia [the larger bone in the lower leg] and fibula [the outer and smaller bone in the lower leg] resulting in injuries to both sides of the ankle [a joint that connects the foot to the lower leg]) and chronic kidney disease (a progressive condition where kidney damage prevents them from filtering waste from the blood effectively, leading to waste buildup and kidney failure). A review of Resident 1's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 12/15/25, indicated her Brief Interview of Mental Status (BIMS-a cognition [the processes of thinking and reasoning] assessment) score was 12, which indicated her cognition was moderately impaired (a score of 1-7 indicates cognition is severely impaired, 8-12 indicates cognition is moderately impaired, and 13-15 indicates cognition is intact). A review of Resident 1's order summary report indicated the following active order as of 12/10/25, CBC (complete blood count- a blood test that measures key parts of the blood), BMP (basic metabolic panel-a blood test that measures the body's chemical balance, metabolism [a chemical process that occurs in the body to convert food into energy], and kidney function) weekly in the morning every Wednesday for four (4) weeks. A review of Resident 1's electronic Medication Administration Record (MAR) dated December 2025 indicated the CBC and BMP were documented on 12/17/25 and 12/31/25 as completed [check marked]. A review of Resident 1's Electronic Medical Record (EMC) (other than the eMAR) did not include any evidence that the CBC and BMP were collected on 12/17/25. A review of Resident 1's Lab Results Report dated 1/02/26, indicated a CBC and BMP were collected on 12/31/25 at 7:05 a.m. The report indicated the CBC and BMP were reported on 1/02/26 at 11:51 a.m. The report was flagged [meaning, it required attention]. The report indicated Resident 1's WBC (white blood cells-a blood cell that helps attack infection or injury in the body) was 14.2 K/mm3 (thousands per cubic millimeter- measure of unit used to report WBC counts) [a normal range is between 3.8-10.1]. Resident 1's BUN (blood urea nitrogen- measures the amount of nitrogen from waste in the blood to evaluate kidney function) was reported as 42 mg/dL (milligrams per deciliter- a unit of measure) [a normal range is between 6-25]. The report indicated Resident 1's creatine (measures how efficiently kidneys filter waste from muscle metabolism) was 1.34 mg/dL [a normal range is 0.60-1.20]. The report also indicated Resident 1's BUN/CREAT ratio (a medical marker of kidney function) was 31 [a normal range is 9-30]. Resident 1's WBC, BUN, creatine, and BUN/CREAT was all flagged as high. A review of Resident 1's EMR indicated no evidence that a SBAR was completed on 1/02/26, or that the physician was contacted regarding the abnormal lab results that were reported to the facility on 1/02/26. A review of Resident 1's SBAR form, dated 1/03/26 at 5 p.m., indicated, [Resident 1] Increased edema [swelling in the body tissues caused by excess fluid buildup] to BLEs [bilateral lower extremities]. A review of Resident 1's SBAR form, dated 1/04/26 at 9 p.m., indicated, Decrease urine output.lower abdominal pain or tenderness.AM [morning] staff reported the resident [Resident 1] have difficulty voiding [urinating]. The writer performed a bladder scan [a device used to measure how much urine is in the bladder] and results shows the resident [Resident 1] is retaining urine about 1 L [liter- a metric unit of capacity]. A review of Resident 1's progress notes, type Nurse's Note, dated 1/07/26 at 11:31 a.m., indicated, Resident [Resident 1] notes with c/o [complaints of] pain level 10/10 [numerical pain scale ranging from 0 [no pain] to 10 [worst imaginable pain]], located in her back. Resident noted to be in distressed.MD [medical doctor] order for resident to be sent to ER [emergency room] for further evaluation.A review of Resident 1's ED (Emergency Department) Provider Notes dated 1/08/26, indicated, Chief complaint.patient presents with back pain.BUN 102 mg/dL, creatine 1.67 mg/dL.Clinical Impressions.Back pain.urinary tract infection [UTI- an infection in the bladder/urinary tract].AKI [acute kidney injury- a sudden loss of kidney function where the kidneys can no longer filter waste from the blood, leading to a buildup of waste products and fluid in the body].dehydration [a condition where your body loses more fluid than it takes in].During an interview on 1/22/26 at 2:43 p.m. with Licensed Nurse 1 (LN 1), she stated when lab values were out of range nurses were required to report this information to the MD for review. LN 1 further stated provider notification should be documented by the reporting staff in the resident's EMR. During an interview and concurrent record review on 1/22/26 at 12:05 p.m., the DON stated she expected nursing staff to contact the MD to report critical or abnormal lab results and document this notification. The DON stated she expected a SBAR to be completed if lab values were out of range. The DON verified Resident 1's MD orders for weekly CBC and BMP placed on 12/10/25. The DON confirmed Resident 1's December 2025 eMAR indicated that the CBC and BMP were completed on 12/17/25, but there was no evidence of this on Resident's 1 EMR. The DON stated, I don't know what happened to this [the lab collection]. The DON was given the opportunity and inquired with the facility's medical record department to provide documents indicating the CBC and BMP were collected, and results communicated to the MD, but she was unable to provide the evidence requested. The DON further confirmed Resident 1's BUN of 42 mg/dL, creatine of 1.34 mg/dL, BUN/CREAT ratio of 31, and WBC of 14.2 K/mm3 from 1/02/26 should had been reported to the MD, but was unable to locate evidence of this. The DON further stated, I would expect that [the labs] to be included in the SBAR to inform the MD so that the doctor can do the interventions right away. The DON stated, If an elevated BUN is left untreated, it can cause kidney injury. The DON stated if nurse staff documented an order as complete, she expected it to be completed. A review of the facility policy and procedure (P&P) titled, Test Results, revised in 2007, indicated, The resident's attending physician will be notified of the results of diagnostic tests [medical procedures used to identify, rule out, or monitor disease]. Should the test results be provided to the facility, the attending physician shall be promptly notified of the results.The director of nursing services or charge nurse receiving the test results, shall be responsible for notifying the physician of such test results.A review of the facility's P&P titled, Change in a Resident's Condition or Status, revised in 2021, indicated, Our facility promptly notifies the resident, his or her attending physician.of changes in the resident's medical.status.A review of the facility's P&P titled, Charting and Documentation, revised in 2017, indicated, The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.The following information is to be documented in the residents medical record.changes in the resident's condition.Documentation in the medical record will be.complete, and accurate.A review of the facility's P&P titled, Job Description: LPN (Licensed Practical Nurse) LVN (Licensed Vocational Nurse), dated 2018, indicated, Notify the resident's attending physician.when there is a change in the resident's condition.Administer professional services such as.taking blood.Obtain.lab tests as ordered.A review of the facility's P&P titled, Job Description: RN (Registered Nurse), dated 2024, indicated, Notify the resident's attending physician.when there is a change in the resident's condition.Obtain.lab tests as ordered.

Based on observation, interview, and record review, the facility failed to ensure garbage was properly contained when an outside garbage dumpster was overfilled, which prevented the lid from closing, and resulted in the food debris and trash surrounding the area and garbage can lids in the kitchen were not closed and the exterior surfaces were smeared with food debris.These failures decreased the facility's potential to prevent an infestation of insects and other pests, prevent offensive odors and contribute to cross-contamination from unsanitary environmental conditions.Findings:During a concurrent observation and interview in the garbage disposal area of the facility with the Dietary Manager (DM) on 12/15/25 at 8:50 a.m., several large garbage dumpsters were observed. The dumpster nearest to the facility's back door was full of garbage bags, and the lids on each side of the bin were unable to close. The ground surrounding the garbage disposal area was wet and littered with small bits of food debris and trash. The DM could not say exactly when the trash was scheduled for pickup or explain why the other garbage bins had not been utilized when the one closes to the door was so full.During a concurrent observation and interview in the garbage disposal area of the facility with the Maintenance Director (MTD) on 12/15/25 at 9:19 a.m., the MTD stated the facility staff should not be overfilling any of the garbage dumpsters so that the lids cannot close tightly. During a concurrent observation and interview in the kitchen with the DM on 12/16/25 at 9:15 a.m., a grey trash bin located in the food preparation area was stuck open, with food debris wiped along the top edges. In addition, a black trash bin in the kitchen was not completely closed, with the contents of the bin seen to be almost spilling out. The DM stated these bins should be cleaned so the lids could close tightly. The DM also stated new lids would be ordered to replace the inoperable ones.During an interview on 12/17/25 at 3:23 p.m., the MTD stated it was important for all garbage to be contained in bins with tightly covered lids so as not to attract rodents and other pests, and so the areas do not stink.A review of the facility's Policy and Procedure (P & P) titled, Sanitation, dated November 2022 indicated, All kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects.garbage and refuse containers are in good condition, without leaks, and waste is properly contained in dumpsters/compactors with lids (or otherwise covered).A review of the Food and Drug Administration (FDA) Food Code 2022, Section 5-501.110 Storage Refuse, Recyclables, and Returnable, dated January 2023indicated, Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. proper cleaning of garbage storage areas and receptacles so that unsanitary conditions can be eliminated.

Based on observation, interview and record review the facility failed to ensure its medication rate was below five percent when four errors were observed during 28 medication passes, resulting in a 14.29% error rate.This failure decreased the facility's potential to ensure medication was administered as ordered by the physician and decreased the expected efficacy of the medication. (Cross-reference F760 & F761)Findings:During a medication pass observation on 12/17/25 at 9:46 a.m., Licensed Nurse A (LN A) administered the following medications to Resident 20:Empagliflozin (medication used to manage blood sugar levels) 10 milligrams (mg-a unit of measure) by mouth.Apixaban (medication used to prevent and treat blood clots) 5 mg by mouth.Metoprolol Tartrate (medication used to treat various heart and blood vessel conditions) 25 mg by mouth.A record review of Resident 20's Medication Administration Record (MAR) dated 12/1/25 through 12/31/25 indicated empagliflozin was scheduled to be given daily at 8 a.m. and apixaban and metoprolol tartrate were scheduled to be given twice daily at 8 a.m. and 8 p.m.During a medication pass observation on 12/17/25, at 11:20 a.m., LN B was preparing to administer six units of lispro insulin (a rapid acting medication which manages blood sugar levels via an injection into the fatty tissue just under the skin) for Resident 4. LN B prepared an expired vial of insulin dated 12/8/25, stated the expiration date on this bottle is 12/8 and withdrew six units of insulin. LN B recapped the insulin syringe, grabbed an alcohol wipe to prep Resident 4's skin, locked the medication cart and turned toward Resident 4's room. Before reaching Resident 4's threshold, LN B was asked to recite the date. LN B correctly identified date. LN B was then asked to recite the expiration date written on the insulin bottle again. LN B reiterated 12/8. Oh, I can't use this. LN B stated she was unsure why she did not catch this error when preparing the insulin syringe.During an interview in the facility conference room on 12/17/25, at 2:47 a.m., the Director of Nursing (DON) stated medication administration was considered on time as long as it was within a one-hour time frame before or after the scheduled time. She further stated a late medication administration can cause reduced efficacy for the resident recipient. The DON stated expired medications should not be given for the same reason. Furthermore, the DON stated expired insulin products had the potential for preservative breakdown resulting in possible bacterial growth.A review of the facility's policy titled Administering Medications, revised April 2019, indicated, Medications are administered in a safe and timely manner, and as prescribed.The expiration/beyond use date on the medication label is checked prior to administering.the individual administering the medication checks to verify.the right time.

Based on observations, interviews and record review the facility failed to ensure two residents out of 10 sampled residents were free from significant medication errors when:Resident 20 received a dose of Metoprolol Tartrate (medication used to treat heart and blood vessel conditions by slowing heart rate and lowering blood pressure) 45 minutes late; and,Resident 4 would have received a dose of expired lispro insulin (a rapid acting medication which manages blood sugar levels via an injection into the fatty tissue just under the skin) if not asked by the surveyor to recite the expiration date a third time prior to entering the resident room.These failures decreased the facility's ability to maintain medication safety and placed the residents at risk for harm. (Cross-reference F759 & F761)Findings:A review of Resident 20's admission record indicated she was admitted to the facility on [DATE] with diagnoses of Hypertension (persistent high blood pressure), Artherosclerotic Heart Disease (condition where the blood vessels supplying blood to the heart muscle become hardened and narrow due to buildup of fat, cholesterol, calcium and other substances) and Atrial Fibrillation (a heart rhythm characterized by a rapid heart rate and chaotic electrical signals in the upper chamber of the heart causing quivers instead of full contractions). A review of Resident 4's admission record indicated he was admitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes Mellitus (a chronic condition where the body does not produce enough insulin or becomes resistant to its effect which, if left untreated, could lead to multiple organ failure).During a medication pass observation on 12/17/25 at 9:46 a.m., Licensed Nurse A (LN A) was observed administering metoprolol tartrate 25 milligrams (mg-a unit of measure) by mouth to Resident 20. A record review of Resident 20's Medication Administration Record (MAR) dated 12/1/25 through 12/31/25, indicated metoprolol tartrate was scheduled to be given twice daily at 8 a.m. and 8 p.m. to treat and prevent hypertension.A record review of Resident 4's Medication Administration Record (MAR indicated Resident 4 had a blood sugar level of 282 on 12/17/25 at approximately 11 a.m. Based on Resident 4's sliding scale (a prescribed variable dose based on a person's current blood sugar level) order, Resident 4 was to receive six units of lispro insulin via subcutaneous injection (delivered via injection into the fatty tissue just below the skin) before meals. During a medication pass observation on 12/17/25 at 11:20 a.m., LN B was preparing to administer six units of insulin for Resident 4. LN B prepared an expired vial of insulin dated 12/8/25 by wiping the top of the vial with an alcohol pad, stated the expiration date on this bottle is 12/8 and withdrew six units of insulin. LN B recapped the insulin syringe, grabbed an alcohol pad to prep Resident 4's skin, locked the medication cart and turned toward Resident 4's room. Just before reaching Resident 4's threshold, LN B was asked to recite the date. LN B correctly identified date. LN B was then asked to recite the expiration date written on the insulin vial again. LN B reiterated 12/8. Oh! I can't use this. LN B stated she was unsure why she did not catch this error when preparing the insulin syringe.During an interview in the facility conference room on 12/17/25 at 2:47 a.m., the Director of Nursing (DON) stated medication administration was considered on time as long as it was within a one-hour time frame before or after the scheduled time. She further stated a late medication administration can cause reduced efficacy for the resident recipient. The DON stated expired medications should not be given for the same reason. Furthermore, the DON stated expired insulin products had the potential for preservative breakdown resulting in possible bacterial growth.A review of the facility's policy titled Administering Medications, revised April 2019, indicated, Medications are administered in a safe and timely manner, and as prescribed.The expiration/beyond use date on the medication label is checked prior to administering.the individual administering the medication checks to verify.the right time.

Based on observations and interviews, the facility failed to ensure expired insulin (a hormone medication used to control blood sugar levels) vials were removed from the facility's medication carts when inspection of two medication carts revealed one expired vial of insulin in each location.This failure decreased the facility's opportunity to maintain resident safety and placed these residents at risk for harm. (Cross-reference F759 & F760)Findings:During a concurrent observation and interview on 12/17/25 at 10:05 a.m., an open vial of insulin glargine (a long-acting insulin used to maintain steady blood sugar levels via an injection into the fatty tissue just under the skin) was found during inspection of Medication Cart 1. The box containing the insulin glargine was marked as Open 11/17/25; DC [discontinue] 12/15/25. Licensed Nurse A (LN A) stated, This insulin has expired, it should be thrown out. During a concurrent observation and interview on 12/17/25 at 10:23 a.m., an open vial of insulin lispro (a rapid acting medication which manages blood sugar levels via an injection into the fatty tissue just under the skin) was found during inspection of Medication Cart 3. The box containing the insulin lispro was marked as 11/8/25 opened: DC 12/8/25. LN B stated the expiration date on this vial was incorrect and further stated, Insulin expires 28 days after opening, the date on this insulin should be 12/6/25.During an interview on 12/17/25 at 10:34 a.m., the Director of Nursing (DON) stated all expired medications should be removed from the medication carts by the licensed nursing staff and properly disposed of. She stated expired medications can have a reduced or increased intended efficacy and further stated expired insulin products had the potential for preservative breakdown resulting in possible bacterial growth.A review of the facility's policy titled Medication Labeling and Storage, revised February 2023, indicated, Multi-dose vials that have been opened or accessed.are dated and discarded within 28 days.

Based on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when:1. The following were observed in the facility kitchen: kitchen floors were dirty and littered with food debris and trash; the ceiling vent cover located directly over the clean and ready-to-use dish storage area was covered with reddish-black and blackish-brown dirt and dust; the wall behind the hand-washing sink was cracked and uneven, with heavy orange and black colored residue in the crevices; one plastic green cutting boards were excessively scratched with deep gashes; and, the stove top/burners had extensive caked-on food and rust-colored residue;2. The temperature log for a resident snack refrigerator indicated out-of-range temperatures recorded on multiple days;3. Fresh ready-to-eat oranges stored in the walk-in refrigerator had skins that were discolored and broken open; and,4. Individual hand-sanitizing wipe packets were stored directly beside ingestible resident food items.These failures decreased the facility's potential to prevent food-borne illnesses or poisoning in a highly susceptible population who received food from the kitchen and/or snack refrigerators.Findings:1. During an initial tour of the kitchen on 12/15/25 at 8:50 a.m. a concurrent observation and interview with the Dietary Manager (DM) was conducted. Upon entrance, the floor in front of the stove/oven and food preparation area was littered with debris and covered with a dull blackish/grey residue. The DM stated that the floor was cleaned daily but acknowledged that it looked dirty because it was right after the daily morning meal service. During a concurrent observation and interview with the DM on 12/15/25 at 8:55 a.m. in the kitchen, a square ceiling vent cover had reddish-black and blackish-brown material on it and small pieces of this debris, was over the clean dish storage area. In addition, there was a large crack in the ceiling adjacent to the vent. The DM stated the vent cover needed to be replaced as dirt/debris could fall onto clean cups, plates and other dishes and be served to residents during meal service. During a concurrent observation and interview in the kitchen with the DM on 12/16/25 at 9:15 a.m., the wall area behind the hand-washing sink was observed to be cracked and uneven, with a heavy orange and black colored residue in multiple crevices around the back of the sink. The DM agreed it did not look clean. During a concurrent observation and interview in the kitchen food preparation area with the DM on 12/16/25 at 9:20 a.m., the cutting boards were examined. One large green cutting board was heavily scratched with the green coating completely gone and had several deep gashes in the plastic. The DM stated cutting boards were generally replaced every month, and this one had reached its life expectancy and needed to be replaced immediately.During a concurrent observation and interview in the kitchen with Maintenance Director (MTD) and DM on 12/17/25 at 3:23 p.m., the stovetop/burner/oven was inspected. The stovetop area was heavily covered in caked/burnt-on food droppings and had a general rusty appearance. The DM stated the stove/oven was cleaned daily; however, the stovetop was noted to be in the same condition as was seen the day prior. The DM agreed that uncleaned food on surfaces could become moldy and cross-contaminate food served to residents. The MTD stated he removed the vent cover above the clean-dish storage area and acknowledged it was indeed very rusty and dirty and had created a contamination hazard to the ready-for-use dishes below. The MTD stated it has since been replaced.During an interview on 12/18/29 at 1:07 p.m. with the Registered Dietitian (RD), the RD stated cutting boards with deep scratches posed a hazard to residents because pieces of the plastic cutting board material could become mixed with food as it's cut/sliced and be ingested by residents in their meals. Additionally, the RD stated food could become embedded in the deep crevices and remain on the board after washing, causing food-borne illness due to cross-contamination.During a review of the facility's Policy & Procedure (P & P) titled, Sanitation, dated November 2022, indicated, All kitchens, kitchen areas and dining areas are kept clean, free from garbage and protected from rodents and insects.All utensils, counters, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning.2. During a concurrent observation and interview on 12/17/25 at 9:38 a.m., Certified Nursing Assistant E (CNA E) stated residents were allowed to have outside food brought in for them, and that resident foods were kept in a refrigerator in the nursing station. This refrigerator was inspected, and the December temperature log was reviewed. The log showed notable temperatures as follows:12/5/25= 43 degrees12/7/25= 44 degrees12/9/25= 42 degrees12/11/25= 42 degrees12/13/25= 45 degrees12/16/25= 45 degreesDuring an interview on 12/18/25 at 10:15 a.m. with Licensed Nurse D (LN D), LN D stated residents are allowed to have food brought in and kept in snack refrigerators. LN D stated nursing staff was responsible for maintaining the refrigerator but stated she did not know the acceptable temperature ranges for safe food refrigeration.During an interview on 12/18/25 at 10:30 a.m. with Licensed Nurse E (LN E), LN E stated she believed night-shift nurses were responsible for checking the refrigerator temperatures and stated she did not know acceptable temperature ranges for safe food refrigeration, but she thought this information was listed on the temperature log sheet itself.A review of a blank copy of the facility's Refrigerator Temperature Log, not dated, indicated, Temperature Ranges: Refrigerator 35 - 45 [degrees] F [Fahrenheit] .A review of the facility's P & P titled Food Receiving and Storage, dated November 2022, indicated, Food and Snacks Kept on Nursing Units-All food items are to be kept at or below 41 degrees Fahrenheit are placed in the refrigerator located at the nurses' station and labeled with a 'use by' date.A review of the Food and Drug Administration (FDA) Food Code 2022, Chapter 3, section 501.17, indicated commercially processed food prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days.3. During a concurrent observation and interview in the facility's walk-in refrigerator with the DM on 12/16/25 at 9:15 a.m., a carton of tangerines was observed. Several of the fruit had skins with green-colored spots, and some were yellow all over. One of the fruits had a break in the skin with hard black matter coming through the skin. The DM stated some of the fruits inside this carton should not be served to residents.During an interview on 12/19/25 at 1:08 p.m., the RD stated that spoiled or damaged fruit should be removed from the refrigerator because the food stored there is considered ready for resident use and might make it on to a resident's food tray for consumption.A review of the facility's P&P titled Food Receiving and Storage dated November 2022 indicated, Refrigerated foods are.monitored so they are used by their 'use-by' date, frozen, or discarded.4. During a concurrent observation and interview on 12/15/25 at 9a.m. with the DM, the dry food storage area was toured. A shelf with self-serve food packets of jelly, peanut butter, and other condiments was inspected, and boxes of hand-sanitizer wipes were stored among these edible items. The DM stated the boxes of hand-sanitizer should be moved to the Janitor's closet, instead of stored with food items. During an interview on 12/19/25 at 1:10 p.m., the RD stated hand-sanitizing wipes should not be stored with food in dry storage, since the individual packets might become mixed with condiment packets and other small, packaged food items. The RD agreed residents with cognitive decline may confuse the small packages and ingest something inedible and harmful.A review of the facility's P & P titled Food Receiving and Storage, dated November 2022 indicated, Pesticides and other toxic substances and drugs will not be stored in the kitchen area or in storerooms for food or food preparation equipment or utensils. Soaps, detergents cleaning compounds or similar substances will be stored in separate storage areas from food storage and labeled clearly.

Based on interview, observation, and record review, the facility failed to ensure bathroom call lights (a system to notify nursing staff for help) were accessible when two pull strings to trigger the call light system were too short for residents to reach and four pull strings were missing in six sampled bathrooms.This failure decreased the facility's potential to respond to residents' calls for assistance and increased the risk for falls.During an observation on 12/15/25 at 9:13 a.m. in room [ROOM NUMBER] and subsequently in Rooms 21, 24, 25, and 26, the bathroom call light systems had no call light string.During an observation on 12/15/25 at 9:27 a.m. in room [ROOM NUMBER] the bathroom call light system had a short pull string measuring approximately 10 in. (inches- a unit of measure).During an observation and concurrent interview on 12/16/25 at 12:10 p.m. with Certified Nurse Assistant C (CNA C), in room [ROOM NUMBER], the bathroom call light system had a broken call light string. The call light string was approximately 2 in. in length. CNA C verified the call light string was broken. CNA C stated, Residents can not pull that [the string], they [the residents] need more string. CNA C stated the importance of the call light string was so residents can call for help while unattended in the bathroom. CNA C stated the Maintenance Department should be aware that they needed to be repaired. During a concurrent review of the maintenance binder (a communication binder between staff and the maintenance department where repairs are reported), CNA C confirmed the broken call light string had not been reported. CNA C further stated, If it was [reported], it hasn't been fixed. CNA C verified the bathroom was shared between resident rooms [ROOM NUMBERS].During an observation and concurrent interview on 12/16/25 at 12:25 p.m. with CNA D, in room [ROOM NUMBER], the bathroom call light system had no call light string. CNA D stated there should be a string on the call light. CNA D further stated, If the residents cannot reach the button or it's too hard to push [the call light button], it should have a string. CNA D confirmed the bathroom call light system with no string should had been reported to maintenance for repair. CNA D stated, The string is very important.During an interview on 12/17/25 at 2:55 p.m. with the Maintenance Director (MTD), he confirmed maintenance staff was responsible for replacing bathroom call light strings. The MTD stated the pull strings were needed so residents can call for help when using the bathroom. The MTD stated the replacement bathroom call light strings were approximately 16 in. long. The MTD further stated residents could not reach a 16 in. string if they [the residents] were on the floor and not near the toilet. The MTD confirmed CNAs should report broken, missing, or items that require replacement in the maintenance binder. The MTD stated he had not noted entry into the maintenance binder regarding missing or broken bathroom call light strings.A review of the facility's policy and procedure (P&P) titled, Resident Safety, dated 2001, indicated, Resident safety to prevent accidents are facility wide priorities.Employees.demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents.

Based on observation, interview and record review the facility failed to properly dispose of and monitor destruction of an assortment of medications when:The collection receptacle had multiple fully intact medications of different forms which were retrievable by staff; and,24 medication disposition sheets, representing 172 prescriptions, were not signed or witnessed by licensed staff.This failure decreased the facility's potential to prevent drug diversion (illegally taking prescription drugs for unauthorized use, like self-medication, selling, or addiction) and theft of resident medications.Findings:During a concurrent observation, interview, and record review in the Station 2 medication room with Licensed Nurse B (LN B) on 12/17/25 at 9:10 a.m., the medication destruction bin was noted to contain multiple undestroyed medications. These included fully retrievable intact medications in different forms such as powder, capsules, tablets, inhalers and injector pens (a handheld device used to inject medication into the fatty tissue just under the skin). There was no liquid or undesirable product to destroy the medication was noted in the bin. LN B stated the proper way to dispose of medications was to open all containers and packages, pour medication into the disposable container, then add the liquid deactivator to the bin covering the medication. Upon observation, a stack of disposition sheets was found in a pile next to the Medication Disposition Sheet binder. The stack of sheets contained 24 incomplete medication disposition sheets which were not witnessed by a licensed staff member. LN B stated when a non-controlled medication was discontinued, the tag which contained the resident name, medication, dose and prescription number should be removed from the medication container and placed on the medication disposition sheet. The licensed staff should then place the quantity of medication that was disposed of. The licensed staff completing the form must sign at the bottom where indicated, along with the signature of another licensed staff as a witness. LN B stated the completion of the medication disposition sheet signified the medications were placed in the bin, destroyed and rendered unretrievable.During an interview on 12/17/25 at 10:34 a.m., the Director of Nursing (DON) stated to destroy medications nurses were expected to remove all medication from their containers and place them in the collection receptacle. Nurses would then add the liquid medication destroyer to the medication to dissolve the pills, which would make them non-retrievable. The DON confirmed the collection receptacle in Medication room [ROOM NUMBER] was unacceptable and was not an appropriate practice. The DON further confirmed the medication disposition sheets needed to be completely filled out and signed by two licensed nurses to confirm the medication was destroyed to deter drug diversion.A review of the facility's policy titled Discarding and Destroying Medications, revised June 2025 indicated, Medications.are disposed of in accordance with federal, state, and local regulations governing management of non-hazardous pharmaceuticals.The medication disposition record contains, as a minimum, the following information: resident's name, name and strength of the medication, prescription number, name of dispensing pharmacy, date medication destroyed, quantity destroyed, method of destruction, reason for destruction, signature of witness(s).

Based on interview and record review, the facility failed to notify the state mental health authority after one resident (Resident 70) of six sampled residents experienced a decline in mental illness.This failure decreased the facility's potential to ensure Resident 70 received appropriate required mental health services and treatment.Findings:A review of Resident 70's admission Record indicated Resident 70 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities)), major depressive disorder (a mood disorder that causes persistent sadness and loss of interest in activities), psychosis (a state where a person loses touch with reality, characterized by symptoms like hallucinations (seeing/hearing things not there)) and delusions (strong false beliefs leading to disorganized thoughts and speech), and anxiety.A review of Resident 70's Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 11/3/25, indicated moderate cognitive impairment, a need for assistance with self-care activities, and a need for staff assistance or was totally dependent on staff for transfers. During a review of the state mental health authority's correspondence to the facility regarding Resident 70's Preadmission Screening Resident Review (PASRR- a required form to help ensure that individuals with mental disorders or intellectual disabilities are not inappropriately placed in nursing homes for long term care) dated 11/5/25, indicated, After reviewing the Positive Level I Screening and speaking with [Facility] staff, a Level II Mental Health Evaluation was not scheduled for the following reason.The individual has no serious mental illness (SMI).No functional limitations in the past 6 months.To reopen, the facility must resubmit a new Level I Screening.SNFs [Skilled Nursing Facilities] must submit another screening as a Resident Review (RR).During an interview on 12/17/25 at 10:20 a.m. with the MDS Coordinator (MDSC), the MDSC stated the admissions department and the IDT (Interdisciplinary Team, a group of healthcare professionals working together for holistic patient care) were responsible for ensuring PASRR Level I screenings were completed correctly and PASSR Level II's were completed when necessary. During a review of Resident 70's physician's note, dated 12/15/25 at 12 a.m., indicated, .11/26/25.staff has been noting that patient has been refusing most of meal.12/9[/25].sertraline [medication used to treat depression] increased to 75 mg [milligrams, a unit of measurement].[daughter] agreeable with dose increase.because [Resident 70] seems more withdrawn than usual.discussed that med doses can be changed to best support him.11/12/25.[physician discussed with] daughter.that [Resident 70] reports feeling depressed.11/18/25.[Resident 70] feels his depression is 'situational' and feels ok today.11/24[/25] 11 [pound] weight loss in 6 days, consider secondary to depression.11/25[/25].[Resident 70's] unwillingness to take medications, clenching of draw [sic, supposed to be jaw], grinding teeth, worsening of mask facies [sic] and tics [sudden involuntary movements or sounds caused by a nervous system condition]. overall symptoms are concerning for extraperitoneal [sic, supposed to be extrapyramidal (involuntary movement disorders or uncontrolled muscle contractions caused by certain antipsychotic medications] symptoms.12/8[/25] discussed with staff and nursing team, [Resident 70] continues to have decreased appetite unwilling to take medication and clenching of jaw.[Resident 70's] noncompliance with [oral intake] more likely behavioral.A review of Resident 70's behavior note dated 12/9/25 at 1:58 p.m. indicated, .[Resident 70] needs encouragement to complete [Activities of Daily Living, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves].[Resident 70] has [history] of episodes of FTT [Failure to Thrive, a general decline in physical and cognitive function].During a concurrent interview and record review with the MDSC on 12/18/25 at 12:35 p.m., Resident 70's Order Summary Report, dated 12/18/25 was reviewed. The MDSC agreed Resident 70 was on multiple medications for mental illness, manifested by behaviors that interfered with activities of daily living, necessitating a recent new medication for anxiety started on 12/17/25. The MDSC stated she was aware the PASRR process was to ensure residents were placed in an appropriate type of facility, and residents received necessary services from the state mental health authority The MDSC further stated the IDT team would restart the PASRR screening process for Resident 70.

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident 72) of 27 sampled residents obtained informed consent (a voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for the use of bedrails when Resident 72's responsible party (RP- a person who makes health care decisions on behalf of the resident when the resident does not have the mental capacity to do so) did not give informed consent for the use of side/bed rails.This deficient practice decreased the facility's potential to decrease Resident 72's risk for falls, serious injury, and entrapment (when a person becomes trapped in the bed rail gaps, often resulting in serious injury or death).Findings:A review of Resident 72's admission record indicated she was admitted to the facility in May 2017 with medical diagnosis which included senile degeneration of the brain (dementia- a progressive state of decline in mental abilities) and delirium (a serious disturbance in a person's mental abilities that results in a decreased awareness of one's environment and confused thinking). Resident 72's admission record also indicated her son was her RP. A review of Resident 72's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 9/19/25, indicated her Brief Interview of Mental Status (BIMS-a cognition (the processes of thinking and reasoning) assessment) score was one, which indicated she had severe cognitive impairment (a score of 1-7 indicates cognition is severely impaired). A review of Resident 72's active order summary report indicated the following order was placed on 10/20/25, May have bilateral [both sides] 1/4 side rails placed on the middle of bed as enabler for bed mobility and positioning.A review of Resident 72's care plans was last conducted on 10/15/25 and indicated report indicated a focus on Resident 72's use of 1/4 side rails. This care plan listed the following interventions licensed nursing staff was supposed to implement Follow facility fall protocol.Recommend bilateral side rails up when in bed for safety during care provision .Discuss risks and benefits and obtain consent.A review of Resident 72's facility document titled Bed Rail and Entrapment Risk Observation/Assessment dated 5/21/25, 6/12/25, and 7/23/25 indicated bed rails were currently in use. These documents also indicated, I (Resident or Resident Representative) have been informed of the risks and benefits related to the use of side/bed rails, including the risks associated with entrapment.Yes [was check marked].I am providing my Informed Consent signature for the use of side/bed rails and understand the risks and benefits.Yes [was check marked]. Print Name (Resident/Resident Representative). documented typed text as self .Signature and Date [were left blank].Print Name (Staff obtaining signatures). During an observation on 12/17/25 at 10:28 a.m., Resident 72 was lying in bed with 1/4 side rails installed on both sides of her bed. During an interview on 12/17/25 at 10:40 a.m., Licensed Nurse B (LN B) stated she believed an informed consent should be obtained for the use of bed rails. LN B further stated she was not aware of the facility's policies and procedures (P&P) related to the use of bed rails. During an interview on 12/17/25 at 10:45 a.m., LN C stated she was unsure of the facility's P&P related to the use of bed rails or where to obtain the policies. During an interview on 12/17/25 at 4:18 p.m., the Director of Staff Development (DSD), stated she was unsure if an informed consent was required for the use of 1/4 side rails. The DSD further stated she believed it was the responsibility of nursing staff to obtain the consent for the use of bed rails. The DSD stated if the resident had an RP, she expected the RP to sign the informed consent for the use of bed rails. The DSD stated, The risk [of bed rail use] is entrapment and injury to the resident. During an interview and concurrent record review on 12/18/25 at 2:25 p.m. the Director of Nursing (DON) reviewed Resident 72's bed rail and entrapment risk assessment dated [DATE] and confirmed the typed text name of the person signing the consent was Resident 72. The DON confirmed a wet signature on the document; however, she could not confirm who's signature it was. The DON stated the typed text name of the person who gave the consent should be the name of the person who signed the consent. The DON verified it was not appropriate for Resident 72 to sign her own consent. Subsequently, the DON reviewed Resident 72's bed rail and entrapment risk assessments dated 5/21/25, 6/12/25, and 7/23/25. The DON stated the informed consents were not completed. The DON confirmed the documents were not signed by Resident 72's RP. The DON stated, It can be dangerous if the resident doesn't understand why they [the bed rails] are used. The DON discussed the use of bed rails increased the resident's risk of skin issues, falls, and entrapment, especially if the resident was confused. A review of the facility's P&P titled, Bed Safety and Bed Rails, dated 2001, indicated, The use of bed rails or side rails.is prohibited unless the criteria for use of bed rails have been met, including.informed consent.Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent.

Based on interview and record review, the facility failed to provide specialized rehabilitative services in accordance with the physician's orders for one resident (Resident 6) of four sampled residents when Resident 6 received physical therapy (PT) three times out of 12 scheduled sessions between 11/27/25 and 12/17/25 and received occupational therapy (OT) once out of three expected sessions between 11/27/25 and 12/3/25.This failure resulted in Resident 6 feeling frustrated and increased the risk of his physical deconditioning.Findings:During a review of Resident 6's Face Sheet (a summary of the resident's information), Resident 6 was admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD- a chronic lung condition caused by damage to the lungs and results in limited airflow into and out of the lungs), generalized muscle weakness, and depression (a serious mood condition causing persistent sadness and loss of interest, affecting thoughts, feelings, and daily life). A review of Resident 6's Order Summary Report indicated an order for PT Evaluation and Treatment as indicated, dated 11/12/25. Resident 6's report further indicated the following active orders: PT re-Clarification: Please continue skilled PT 5x/wk [five times a week] for 4wks [four weeks] . OT re-Clarification: Please continue skilled OT 3x/wk [three times a week] for 4wks .During a concurrent observation and interview on 12/15/25 at 9:37 a.m., Resident 6 was lying in bed as he stated being very upset about therapy. Resident 6 stated therapy schedules varied each week. Resident 6 stated he would be notified of afternoon sessions, which would later be cancelled, or he would be told there was not enough time. Resident 6 stated it was disrespectful to be told one thing then see another one done.A review of Resident 6's care plan with a focus area for ADL (Activities of Daily Living/Mobility), initiated on 11/12/25, indicated Resident 6 had an actual/at risk for ADL/mobility decline and required assistance related to behavioral symptoms, recent hospitalization and weakness. Interventions and tasks directed staff to provide occupational and physical therapy referrals and treatments as indicated.During a concurrent interview and record review on 12/17/25 at 9:44 a.m. with the Director of Rehab (DOR), Resident 6's Projections (a combined schedule of PT and OT), dated 11/13/25 to 12/17/25, was reviewed. The DOR confirmed Resident 6 had orders for PT five times a week, and OT three times a week. The Projections indicated during the three-week period of 11/27/25-12/17/25, Resident 6 had 12 PT sessions scheduled. The Projections further indicated 0/40 on nine dates: 11/18/25, 11/19/25, 11/21/25, 11/24/25, 12/9/25, 12/11/25, 12/12/25, 12/15/25, and 12/16/25. The DOR stated 0/40 meant therapy was scheduled but not provided. Further review of the Projections indicated Resident 6 was scheduled for and received OT only once, on 12/3/25, during the seven-day period of 11/27/25 to 12/3/25. When queried why the number of therapies scheduled per week did not consistently match the orders, the DOR did not respond. The DOR stated Resident 6 had several days of missed therapy.During an interview on 12/17/25 at 12:55 p.m., the Director of Nursing (DON) stated therapy was needed for residents to get better and stronger, which were the goals for discharge. The DON stated it was her expectation for therapy orders to be followed as ordered.During an interview on 12/17/25 at 2:26 p.m., the Administrator stated therapy orders follow the same policy as medications and treatments and should be given as ordered.

Based on observation, interview, and record review, the facility failed to ensure respiratory equipment was clean and in a usable state for one resident (Resident 42) out of 27 sampled residents when the oxygen concentrator in Resident 42's room had visible dust and debris in the vents and needed a filter change.This failure decreased the facility's potential to prevent bacteria and debris from directly entering Resident 42's lungs, placing her at risk for infection.Findings:A review of Resident 42's face sheet indicated admission to the facility on [DATE] with diagnoses of pneumonitis (a condition in which the delicate tissue and tiny air sacs in the lungs become swollen and intensely irritated) and Acute Respiratory Failure with Hypoxia (a serious condition in which the respiratory system fails to provide enough oxygen to the blood to support vital organ function). A review of Resident 42's physician orders, dated 12/5/25, indicated, Oxygen 2 L [liters, a unit of measure] via nasal cannula [a flexible device used to deliver oxygen through the nose] continuous per concentrator/tank.A review of Resident 42's Care Plan indicated the following goals and interventions: A care plan dated 12/4/25 indicated Resident 42 required the use of oxygen related to her acute respiratory failure. Resident 42's goal was to be compliant with oxygen therapy and to maintain unlabored breathing and a patent airway. To reach this goal, staff were expected to change humidification and oxygen tubing, monitor for signs of hypoxia (the body's tissues do not receive enough oxygen to function properly) and to observe oxygen precautions. A care plan dated 12/9/25 indicated Resident 42 had an altered respiratory status/difficulty breathing related to pneumonitis due to inhalation of food and vomit. Resident 42's goal was to be free of complications from her shortness of breath and to exhibit no signs of poor oxygen absorption. To meet this goal, staff were expected to provide oxygen as ordered and to encourage sustained deep breaths. A review of the facility's Deep Cleaning Checklist dated 12/11/25, indicated Resident 42's room was deep cleaned. The checklist housekeeping staff followed did not include wiping down or cleaning visible dust on the outside filters of Resident 42's oxygen concentrators. During an observation in Resident 42's room on 12/15/25 at 10:25 a.m., an oxygen concentrator (a medical device that pulls air from the surrounding environment, filters out impurities and delivers medical-grade oxygen to residents with a respiratory condition) was located near Resident 42's bed. The oxygen concentrator was noted to have no preventative maintenance sticker on the machine. The outside filters on both sides of the concentrator had visible clumps of lint and dust. During a phone interview on 12/16/25 at 10:22 a.m., Resident 42's family member stated Resident 42 had previously been diagnosed with Respiratory Syncytial Virus (RSV-a common respiratory virus which could lead to serious lung infections, especially in older adults) and was hospitalized . The family member stated Resident 42 had required the use of oxygen ever since. During an interview on 12/17/25 at 8:27 a.m., the Administrator stated the oxygen concentrators belonged to the facility. He further stated the maintenance department was responsible for preventative maintenance and proper functioning of the oxygen concentrators. During an interview on 12/17/25 at 2:55 p.m., the Maintenance Director (MTD) stated the oxygen concentrators were checked daily by housekeeping staff during their rounds and would remove any visible dirt on the oxygen concentrators, including washing the outside filters to remove dust and debris. The MTD stated all oxygen concentrators were rented locally through a vendor. He stated the vendor made monthly visits to the facility and was responsible for all filter changes, troubleshooting of equipment malfunction and preventative maintenance. The MTD further stated the facility kept two or three extra concentrators on hand, in the event one was urgently needed. The MTD could not find a preventative maintenance sticker on the oxygen concentrator in Resident 42's room and provided contact information for the vendor. He declined to open the internal filter flap, as he was sure the oxygen concentrator was a rented piece of equipment. The MTD acknowledged the outside filters of the oxygen concentrator needed cleaning. A review of an email exchange with the area manager of the facility's local oxygen vendor on 12/17/25 at 7:32 p.m., indicated, I verified that is not our concentrator and has no history in our inventory system. During a concurrent observation and interview on 12/18/25 at 8:36 a.m., the MTD was informed the oxygen concentrator in Resident 42's room was not owned by the vendor per the vendor area manager. The MTD agreed to open the internal filter flap which was stuck shut and required the use of the MTD's pocketknife to be opened. The internal compartment and filter were dirty and had visible dust and debris throughout. The MTD acknowledged the machine needed to be cleaned, including a filter change. During an interview on 12/18/5 at 8:47 a.m., the Administrator stated the facility maintenance staff was responsible for maintaining cleanliness and functionality of the respiratory equipment. During an interview on 12/18/25 at 11 a.m., the Infection Preventionist (IP) stated a dirty filter in an oxygen concentrator would not properly filter the air coming through it. In turn, this could allow micro-organisms to contaminate the air the resident breathed in through the nasal cannula. A review of Job Description: Maintenance Director, dated February 2024, indicated an essential duty was to make periodic rounds to check equipment and to assure that necessary equipment is.working properly.A review of the facility's policy titled Maintenance Service, dated December 2009, indicated, The maintenance director is responsible for.maintenance service to assure that.equipment are maintained in a safe and operable manner.

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) received care within professional standards of practice when licensed nursing staff failed to administer physician ordered pain medications to treat her moderate to severe pain, which led to ceaseless pain that worsened in numerical order and severity. This failure resulted in Resident 1 experiencing severe pain and had the potential to result in suffering and feelings of abandonment.A review of Resident 1's admission record indicated she was admitted to the facility in August, 2025 with medical diagnoses which included surgical aftercare of the digestive system (postoperative care after a procedure of the digestive system, which includes monitoring for complications, managing pain and medications, and regular follow-ups with a doctor).A review of Resident 1's clinical record included the following documents:A Nursing Care Plan initiated on 8/18/25, indicated Resident 1 had Pain, with the stated goal, Pain will be relieved to a tolerable level as indicated by resident, using verbal or non-verbal communication to the extent possible, with nursing care interventions which included, Administer treatment as ordered. Assess for pain every shift, and as indicated. Notify physician if resident experiences unmanageable or intolerable pain.A review of Resident 1's medication administration record (MAR - a daily documentation record where licensed nursing staff document medications and treatments administered to a resident) dated 8/18/25 at 12:26 p.m., indicated Medical Doctor 1 (MD1) ordered the following medication for mild pain: Acetaminophen (A medication, also called Tylenol used to treat pain) Tablet 325 MG (milligram).Give two tablet by mouth every 4 hours as needed for Mild Pain. and contained documented administrations of Acetaminophen with correlating pain scale entries of five (5) (Numeric pain scale where 0 indicates no pain, and 10 is the worst pain experienced during a person's lifetime) at 6:30 a.m., six (6) at 3:04 p.m., and six (6) at 7:25 p.m. on 8/19/25, as well as seven (7) at 10:50 a.m., on 8/20/25.A review of Resident 1's MAR dated 8/19/25 at 5:15 p.m., indicated MD 1 ordered the following medication for moderate to severe pain: Morphine Sulfate (A controlled substance to treat moderate to severe pain) Oral Solution 20 MG/ML (Milliliter = ML).Give 0.5 ml by mouth every 6 hours as needed for moderate to severe pain (5-10), and indicated Resident 1 did not receive any administrations of Morphine Sulfate for pain relief on 8/19/25, 8/20/25 or 8/21/25.A review of a progress note dated 8/19/25 at 10:44 p.m. entered by Licensed Nurse 2 (LN 2), indicated, Complaint of pain to surgical site, medicated with Tylenol with minimal effect. A review of a progress note dated 8/21/25 at 4:47 a.m., entered by Licensed Nurse 3 (LN 3), indicated, Resident complains of generalized pain, but resident's PRN (As needed) morphine has not been delivered yet . Resident reports Acetaminophen causes nausea.A review of a facility document titled, Change of Condition, dated 8/21/25 at 9:22 p.m., entered by Licensed Nurse 1 (LN 1) indicated Resident 1 was sent to a general acute care hospital (GACH) around 9:14 p.m. on 8/21/25 due to persistent nausea and vomiting with high blood pressure and tachycardia (heart rate above 100 beats per minute). During an interview with MD 1 on 9/16/25 at 5:00 p.m., he stated he saw and assessed Resident 1 at the facility on the afternoon of 8/19/25 and ordered the PRN Morphine Sulfate to treat Resident 1's moderate to severe pain due to her recent digestive system surgery and her current medical diagnoses. MD 1 added that Medical Doctor 2 (MD 2), who was familiar with Resident 1 then took over the care of Resident 1 on the evening of 8/19/25 and was Resident 1's attending physician for the remainder of her stay in the facility.During an interview with Resident 1 on 9/16/25 at 5:08 p.m., she stated she asked the facility nurse repeatedly for pain medication when she began experiencing pain after being admitted to the facility on [DATE], and over the next several days (from 8/18/25 through 8/21/25) she experienced severe pain that was not controlled despite her using her call light to request more pain medications multiple times, which left her feeling, scared, terrified and alone. She added that one nurse (referring to LN 1), would either not answer the call light, turn the call light off, or just come in her room and stare at her like he didn't believe me.During a concurrent interview and record review with the Director of Nursing (DON) on 9/16/25 at 11:30 a.m., Resident 1's August 2025 MAR was reviewed. The DON stated nursing staff who had cared for Resident 1 from 8/19/25 through 8/21/25 were not working during the Surveyor's visit, so they were not able to be interviewed, and she didn't know why Resident 1 was not administered the ordered Morphine Sulfate to treat her documented high pain levels and instead had only been administered Acetaminophen ordered for the treatment of mild pain. The DON stated her expectation was that nursing staff administered the pain medication that correlated with the resident's pain level, adding that if the physician order was unclear, nursing staff needed to verify the order with the physician. The DON reviewed Resident 1's MAR and confirmed Resident 1's physician ordered pain assessments indicated, Assess for Pain QS (every shift) .and chart using 1-10 Scale: 0= No pain,1-3 = Mild Pain, 4-6 = moderate pain, 7-9 = Severe Pain, 10= Excruciating (pain) every shift for pain scale. The DON confirmed there was no documentation on Resident 1's MAR of Resident 1's pain assessment on 8/19/25 for morning shift. The DON confirmed Resident 1's pain level on her MAR the evening of 8/18/25, was documented as six (6), and Resident 1's pain level was not documented on her MAR the morning shift of 8/19/25. The DON also confirmed Resident 1's MAR indicated her pain had increased in level and severity over time on the evening and night shift of 8/19/25 from level six (6) to level seven (7), after multiple administrations of Acetaminophen to treat mild pain. The DON stated she did not know if Resident 1's increasing pain level and severity was reported to the physician, as directed in one of the interventions listed in Resident 1's nursing care plan under the focus area for Pain, as the DON could not find any documentation in the chart stating the physician was notified about Resident 1's increasing pain on 8/19/25.During an interview with the facility Pharmacist, on 9/17/25 at 4:25 p.m., the Pharmacist confirmed the order for Resident 1's PRN Morphine Sulfate was entered electronically, by MD 1 on 8/19/25, at 5:52 p.m. The Pharmacist explained that due to Resident 1's listed Morphine allergy in her chart, an electronic fax was sent for clarification of the Morphine order to the ordering physician's office fax number, as was the standard practice of the pharmacy. The Pharmacist confirmed there was no follow up communication or inquiry from the ordering physician or from facility staff and if such an inquiry had occurred, it would have been documented in the electronic record in the pharmacy system. During a review of Resident 1's August 2025 MAR, from 8/29/25 through 8/31/25 indicated Resident 1 was administered Morphine Sulfate for documented pain assessment levels, of six (6), seven (7) and eight (8) after a hospitalization from 8/21/25 to 8/28/25, for which no adverse effects of Morphine Sulfate were documented. During an interview with MD 2 on 8/18/25 at 4:55 p.m., he stated there were no contraindications for Resident 1 to receive the Morphine Sulfate (ordered by MD 1on 8/19/25) for moderate to severe pain relief. MD 2 stated she did not know the reason Resident 1 was not treated for her moderate to severe pain experienced from 8/19/25 through 8/21/25 and added that Resident 1 was eventually administered Morphine Sulfate for pain relief, around the time closer to the end of her stay in the facility (8/28/25-8/31/25).A review of the facility's policy titled, Administering Medications, dated 2019, indicated, Medications are administered in a safe and timely manner, and as prescribed. The director of nursing services supervises and directs all personnel who administer medications and/or have related functions. Medications administered in accordance with provider orders. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication, will contact the prescriber, the resident's attending physician, or the facility's medical director to discuss the concerns.A review of the facility's policy titled, Pain Assessment and Management, dated 2022, indicated, The purpose of this procedure are to help staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. Pain Management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals. Pain management is a multidisciplinary care process that includes the following: a. Assessing the potential for pain; b. Recognizing the presence of pain; c. Identifying the characteristics of pain; d. Addressing the underlying causes of the pain; e. Developing and implementing approaches to pain management; f. Identifying and using specific strategies for different levels and sources of pain; g. Monitoring for the effectiveness of interventions; and h. Modifying approaches as necessary. Acute pain (or significant worsening of chronic pain) should be assessed after the onset and reassessed as indicated until relief is obtained. Contact the prescriber immediately if the resident's pain or medication side effects are not adequately controlled.A review of the facility's document titled, Job Description: Registered Nurse (RN) Prepared by: Human Resources (02-2024) indicated, The primary responsibility of your job position is to supervise the day-to-day nursing activities of the facility during your tour of duty. Such supervision must be accordance with current federal, state, and local standards, guidelines, and regulations that govern the facility and may be required by the Director of Nursing (DON) and or/Assistant Director of Nursing (ADON) when applicable, to ensure that the highest degree of quality care is maintained at all times. Monitor medication passes and treatment schedules to ensure that medications are being administered as ordered. Review medication cards for completeness of information, accuracy in the transcription of physician orders, and adherence to stop order policies. Review resident care plans for appropriate resident goals, problems, approaches, and revisions based on nursing needs. Ensure that nursing personnel refer to the resident's care plan prior to administering daily care to the resident. Review nurses notes to determine if the care plan is being followed.

Based on interviews and record reviews, the facility failed to ensure professional standards of practice were conducted for one resident (Resident 1) of four sampled residents when Resident 1 did not have: A sliding scale (a method used to manage blood sugar levels in people with diabetes, where insulin doses are adjusted based on current blood sugar readings) for use of insulin (a hormone produced by the pancreas that helps regulate blood sugar levels) and Blood sugar parameters (levels that indicate when blood sugar is considered too high or too low) ordered for insulin administration. These failures placed Resident 1 at risk for ineffective monitoring of insulin usage and worsening of Resident 1 ' s condition. Findings: Resident 1 was a [AGE] year-old male admitted to the facility on [DATE], with a medical diagnosis that included: Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness, and dysphagia (difficulty swallowing). A review of Resident 1 ' s physician order summary report dated 2/21/25, indicated the following: -Insulin glargine (a long-acting, manmade version insulin used to manage blood sugar levels in people with diabetes) solution 100 Unit/milliliters (ml, a unit of measure) Inject 16 unit subcutaneously (a layer of fatty tissue just below the skin) at bedtime for diabetes mellitus. -Insulin lispro (a short-acting, manmade version of insulin) Injection Solution 100 Unit/ml Inject 5 unit subcutaneously in the morning for diabetes mellitus. -Insulin lispro Injection Solution 100 Unit/ml Inject 8 unit subcutaneously in the afternoon for diabetes mellitus. There was no documented evidence that indicated Resident 1 had an order for a sliding scale for the administration of insulin lispro and parameters which indicated when a nurse was supposed to hold (not administer) the insulin. A review of Resident 1 ' s Medication Administration Record (MAR) dated March 2025, indicated no documented evidence blood sugar levels had been obtained prior to the administration of insulin lispro 8 units subcutaneously every day at 5 p.m. between 3/1/25 and 3/26/25. A review of Resident 1 ' s nursing note dated 3/25/25 at 1:56 p.m., indicated vital signs (measurements that indicate a person's basic biological functions and overall health status) for Resident 1 at the time of the episode were: blood pressure 99/58 (less than 120/80 is considered a normal value) millimeters of mercury (mmHg, a measurement of pressure), heart rate was 56 beats per minute (bpm, a normal resting heart rate is considered to be between 60 and 100 bpm) and oxygen saturation (the percentage of red blood cells carrying oxygen) on room air was 93% (a healthy oxygen saturation is between 95% and 100%). The paramedics arrived and checked Resident 1 ' s blood sugar level which was 69 milligrams per deciliter (mg/dl, a unit of measure). Resident 1 was sent to the hospital. A review of Resident 1 ' s Emergency Department discharge summary report dated 3/25/25, indicated [Resident 1 ' s] blood work is at baseline [a level considered normal for the person, it is used as a reference point to compare] his blood sugar did drop, he was fed and given D50 [a solution of sugar water used to increased blood sugar levels] and instructed to cut his insulin doses in half. I favor that the patient likely had a hypoglycemic [blow blood sugar level] mildly hypotensive [low blood pressure] episode. During an interview on 4/10/25 at 1:30 p.m., Licensed Staff A (LS A) stated she had not thought of checking Resident 1 ' s blood sugar level when he was showing distress on 3/25/25. LS A stated blood sugar parameters were usually ordered for residents who received insulin and would be found in the residents ' MAR. LS A stated nurses were supposed to always check blood sugar levels before giving a resident insulin. On 4/10/25 at approximately 4 p.m. a review of Resident 1 ' s MAR dated March 2025 was conducted. The review indicated Resident 1 received an order for a sliding scale for his insulin lispro on 3/26/25 at 6 p.m. and an order for hypoglycemia protocol for conscious and unconscious (in the state of not being awake and not aware of things around you) resident on 3/27/25 at 10:26 a.m. and 10:24 a.m. respectively. During an interview and concurrent record review on 4/22/25 at 11:38 a.m., LS B stated she had been assigned to Resident 1 on 3/25/25. LS B stated residents with standing orders for insulin should always have their blood sugar levels checked prior to insulin being given. LS B stated these levels would be documented in the residents ' MAR. LS B reviewed Resident 1 ' s MAR and acknowledged it did not indicate Resident 1 ' s blood sugar levels were obtained prior to the administration of insulin lispro but it should. LS B also acknowledged Resident 1 ' s food intake fluctuated based on how he was feeling, and Resident 1 had had a rough night and was unable to complete his physical therapy session on 3/25/25. LS B also stated parameters would sometimes be ordered, but regardless of the order, insulin cannot be given unless we check the blood sugar level. LS B stated she would call the physician to notify him if a resident ' s blood sugar level was below 100 mg/dl. During a telephone interview on 4/23/25 at 12:55 p.m., Consultant Pharmacist C (CP C) stated parameters should always be ordered because blood sugar levels can suddenly drop. The parameters are used to monitor the effect of the combination of insulin usage on the resident. CP C stated she usually recommends the physician to order parameters for blood sugar monitoring and a hypo/hyperglycemic protocol (orders a set of orders to manage both low and high blood sugar levels for diabetic residents). CP C stated she had not reviewed Resident 1 ' s medication orders because Resident 1 had been discharged to the hospital before she conducted her review at the facility in March. During a telephone interview on 4/25/25 at 2:55 p.m., Physician D stated his standard of practice when writing insulin orders for residents included ordering: a sliding scale for residents who had orders for long-acting insulin, hypoglycemic protocol, and parameters to notify the physician if a resident ' s blood sugar level was too high (greater than 300 mg/dl) or too low (less than 100 mg/dl). Physician D also stated he expected blood sugar levels to be checked before each meal and an hour after each meal to check the effectiveness of the insulin. Physician D stated staff usually notified him when a resident did not have parameters ordered. During a telephone interview on 5/2/25 at 2:45 p.m., the Director of Nursing (DON) stated sliding scale orders and blood sugar parameter orders usually came with a resident who was admitted from a hospital. The DON stated she expected licensed nurses to call the physician to ask for sliding scale, parameter orders, and blood sugar checks if the resident did not have them. The DON further stated the Physicians were at the facility most of the time and were very accessible. During a telephone interview on 5/7/25 at 3:30 p.m., the DON verified there was no sliding scale or blood sugar parameters listed on Resident 1's MAR prior to 3/26/25. A review of the facility ' s policy and procedure (P&P) titled Administering Medications dated revised April 2019, indicated, If .a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administrating the medication will contact the prescriber, the resident ' s attending physician or the facility ' s medical director to discuss the concerns .Each nurses ' station has a current Physician ' s Desk Reference (PDR) and/or other medication reference, as well as a copy of the surveyor guidance for .(Pharmacy Services) available. A review of the facility ' s policy and procedure titled, Insulin Administration, revised March 2025 indicated, Purpose to provide guidelines for the safe administration of insulin .The nurse will notify the provider or any discrepancies prior to administering insulin .Steps in the Procedure .Check blood glucose per physician order or facility protocol .Documentation .The resident ' s blood glucose result, as ordered .

Based on interview and record review, the facility failed to ensure one resident (Resident 1) of three sampled residents was provided a home-like environment with comfortable sound levels when Resident 4 was constantly yelling vulgar, offensive, and derogatory language. This resulted in Resident 1 being unable to get a full night of uninterrupted sleep and decreased Resident 1's potential to reach his maximum healthcare potential. Findings: A review of Resident 1 ' s admission record indicated he was admitted in 2/13/25 with diagnoses which included hemiplegia and hemiparesis (weakness and paralysis on one side of the body) following a cerebral infarction (stroke) affecting the left non-dominant side. A review of a Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 2/19/25, indicated Resident 1 had moderate memory impairment (difficulty remembering recent events, trouble with problem-solving, and changes in judgment, but it does not typically interfere with daily functioning). A review of Resident 2 ' s admission record indicated he was admitted in 12/17/24 with diagnoses which included diastolic congestive heart failure (Stiffness of the left ventricle of the heart which does not allow the heart to properly fill with blood). A review of an MDS dated [DATE], indicated Resident 2 had moderate memory impairment. A review of Resident 3 ' s admission record indicated he was admitted in 2/27/25 with diagnoses which included chronic ulcer (Open wound that persists for more than six weeks, despite appropriate treatment) of right lower leg. A review of an MDS dated [DATE], indicated Resident 3 had moderate memory impairment. A review of Resident 4 ' s admission record indicated he was admitted in 2/28/25 with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side. A review of an MDS dated [DATE], indicated Resident 4 had moderate memory impairment. A review of Resident 4's interdisciplinary team (a group of professionals from different disciplines who work together collaboratively to achieve a common goal) note dated 3/7/25 at 11:53 a.m., indicated, [Resident 4] .screaming at night and upsetting other residents. During a phone interview on 3/11/25 at 8:30 a.m., Anonymous Witness XX stated Resident 1 was gravely affected by Resident 4 ' s constant yelling throughout the day and night, which did not allow Resident 1 to rest and sleep. Anonymous Witness XX stated Resident 1 was recovering from a stroke, and this was an essential time to recover from the neurological (an area of the brain) damage caused by the stroke, therefore he required to be able to rest through the night. Anonymous Witness XX also stated Resident 4 had violently attacked staff at the facility, and police had to be called for this incident. During an interview on 3/11/25 at 9 a.m., the Director of Nursing (DON) acknowledged Resident 4 was very aggressive, confirmed police were called, and Resident 4 had been transferred to a hospital due to his aggressive behavior. The DON stated Resident 4 was back at the facility and was doing better after the physician prescribed lorazepam (an antianxiety medication) for him. During an interview on 3/11/25 at 9:40 a.m., Resident 4 acknowledged he had been aggressive at the facility and yelled frequently for help from staff because staff were not answering his call light. Resident 4 confirmed he physically hit a female Certified Nursing Assistant (CNA) during care because she was hurting him while providing services. Resident 4 stated he became, aggravated with staff and was transferred to a hospital. During an interview on 3/11/25 at 10:15 a.m., Resident 1 stated Resident 4 screamed at all hours of the day and night to the top of his lungs, using vulgar, offensive and derogatory language towards staff. Resident 1 stated he had notified the charge nurses and the DON about it, but the situation persisted. Resident 1 acknowledged Resident 4 had been moved to another wing of the facility recently, but due to his aggressive behavior, he was returned to his previous room which was right next to his. Resident 1 stated he was unable to get a restful night ' s sleep because Resident 4 ' s screams constantly woke him up. Resident 1 stated this situation was very stressful to him, since he needed to recover from neurological damage caused by a stroke. Resident 1 stated things had not gotten better with Resident 4, he was still constantly yelling. During an interview on 3/11/25 at 10:35 a.m., Resident 2 stated he had heard Resident 4 screaming at all hours of the day and night and would be very upset if Resident 4 ' s room was next to his. During an interview on 3/11/25 at 10:42 a.m., Resident 3 stated he constantly heard Resident 4 screaming in a high aggressive tone, asking for staff help. Resident 3 stated staff were very gracious with him and worked hard. Resident 3 stated he believed Resident 4's needs could be better met at a mental health facility rather than a rehabilitation center. During interviews with CNA A on 3/11/25 at 11 a.m., Licensed Staff B on 3/11/25 at 11:30 a.m., CNA C on 3/11/25 at 11:45 a.m., and CNA D on 3/11/25 at 12 p.m., they all confirmed Resident 4 constantly used loud aggressive and offensive language toward staff and stated they did not feel this facility was the right place for Resident 4's care needs to be met. Record review of the facility policy titled, Homelike Environment, last revised in February of 2021, indicated, Residents are provided with a safe, clean, comfortable and homelike environment .The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include i. comfortable sound levels.

Based on interview and record review, the facility failed to maintain an effective infection prevention and control program, for a census of approximately 90 residents, when the facility did not report an influenza outbreak to the local public health department (LPHD) for nearly three weeks. This failure had the potential to increase the transmission of influenza among all residents in the facility. Findings: During a concurrent interview and record review on 2/25/25 at 11:05 a.m., with the Infection Preventionist (IP), the facility ' s document titled, Line List Acute Respiratory Illness Outbreak In Long-Term Care Facilities (Including Influenza) (line list, a table that summarizes information about each case of an outbreak), dated 1/29/25, was reviewed. The IP stated the line list indicated, the facility had an influenza outbreak starting on 1/29/25 when two residents tested positive for influenza. The IP stated on 1/31/25 seven more residents tested positive for influenza and, during the outbreak, the facility, the facility had a total of 28 resident and [NAME] staff members who had tested positive for influenza. The IP stated, she hadn ' t notified the LPHD until 2/18/25, she had been away from work for nearly three weekly and the LPHD had not been notified while she was gone. The IP stated the local public health department should have been notified when the first case of influenza had been identified on 1/29/25. During an interview on 2/25/25 at 1:59 p.m., the Director of Nursing (DON) acknowledged she had not notified the LPHD regarding the influenza outbreak, because she thought the Administrator (ADM) was responsible for reporting the outbreak. During an interview on 2/25/25 at 2:10 p.m., the Director of Staff Development (DSD) stated she prepared the line list for the facility ' s influenza outbreak starting on 1/29/25, but had not sent the line list nor reported the outbreak to the LPHD, because she thought it was the responsibility of the ADM. During a concurrent interview and record review, on 2/25/24 at 3:30 p.m., with the ADM, the facility ' s policy and procedure (P&P) titled, Outbreak of Communicable Diseases, dated 9/2022, was reviewed. The ADM confirmed the P&P indicated, .An outbreak of influenza is defined as anything exceeding the endemic rate, or a singe case if unusual for the facility . A single case of influenza is reportable to the department of health . The administrator is responsible for: a. communicating data about reportable diseases to the health department .The ADM acknowledged he had not notified the LPHD of the influenza outbreak that started on 1/29/25, because the IP was responsible for reporting to the LPHD. The ADM acknowledged the IP was not working in the facility during the start of the influenza outbreak and the outbreak had not been reported to the LPHD until she returned nearly three weeks later. During an interview on 3/3/25 at 11:03 a.m., the LPHD ' s Infectious Disease Nurse (IDN, a specialized nurse who prevents and controls the spread of infectious diseases) stated during an influenza outbreak, it was important for the facility to notify to the LPHD on the first day of the outbreak, so the LPHD could ensure the facility had regular communications with the LPHD ' s Healthcare-Associated Infections program (HAI, a program that oversees the reporting and response to healthcare associated infections in healthcare facilities). The IDN further explained, HAI would provide education, guidance, and possible onsite support to assist the facility with keeping the spread of the outbreak to a minimum. The IDN further explained, the facility ' s influenza outbreak that started on 1/29/25, was considered a significant or bad outbreak which indicated the facility may have needed education, testing supplies, problem solving support, and close monitoring to protect the facility residents from contracting the illness. The IDN added, but in this case, due to failure to report timely, that did not happen. During a review of document Title 17. California Code of Regulations (CCR), . Reportable Diseases and Conditions, revised 8/2022, indicated, .Reporting to Local Health Authority . The administrator of each health facility .where more than one heath care provider may know of a case, a suspected case or an outbreak of a disease within the facility shall establish and be responsible for administrative procedures to assure that reports are made to the [LPHD] .The document further indicated, .OUTBREAKS of ANY DISEASE . were required to be reported to the LPHD immediately.

Based on interview and record review, the facility staff failed to recognize a cardiorespiratory arrest (a life-threatening medical emergency that occurs when the heart and lungs stop functioning properly) for one of three sampled residents (Resident 1), which resulted in a delay in performing CPR (or cardiopulmonary resuscitation, a procedure to keep the blood pumping when the heart stops or when it beats too ineffectively to circulate blood to the brain and other vital organs) on Resident 1 who was a full-code (a medical directive indicating that a patient wishes to receive all possible life-saving measures in the event of a medical emergency) after he was found unresponsive. This failure led to Resident 1 ' s death. Findings: During an interview on [DATE] at 9 a.m., Complainant 5 stated he arrived at the facility on [DATE] approximately five to seven minutes after receiving a call about an unresponsive patient who was having difficulty breathing. Complainant 5 stated he found Resident 1 on a non-rebreather mask (a mask that delivers high concentrations of oxygen), but was apneic (not breathing spontaneously), unresponsive and diaphoretic (covered with sweat), and pulseless. Complainant 5 stated he immediately started chest compressions on Resident 1. Complainant 5 stated he continued to perform CPR on Resident 1 until his time of death, about ,d+[DATE] minutes later. Complainant 5 stated there was an AED (automated external defibrillator, or a portable medical device that can analyze the heart's rhythm and, if necessary, deliver an electrical shock, or defibrillation, to help the heart re-establish an effective rhythm) at Resident 1 ' s bedside, but the machine was not on nor were the pads applied on Resident 1 ' s chest. Complainant 5 stated he was later told by the staff that Resident 1 had been unresponsive and had oxygen saturation levels (a measure of how much oxygen is in your blood) in the 60 ' s or 70 ' s approximately 40 minutes before his arrival (the normal range for oxygen saturation is typically between 95% and 100%). A review of Resident 1 ' s Face Sheet indicated he was admitted to the facility with diagnoses including acute and chronic respiratory failure (a condition where the body is not getting enough oxygen due to a failure of the lungs to properly exchange gases, which can occur suddenly or over time). A review of Resident 1 ' s Progress Notes, dated [DATE], indicated, . At around 1650 (4:50 p.m.) respiratory nurse was doing her rounds and noticed this resident was not wearing his NC (nasal cannula [a device with two prongs that deliver oxygen directly into the nostrils]). The nurse put resident back on his O2 (oxygen) via NC, states when she was with the pt (patient) he woke up but didn ' t say anything. At around 1655 (4:55 p.m.) this writer went to give resident his evening medications. Resident was asleep and unable to wake up. This LN (Licensed Nurse) did a sternum rub (to determine if a person is conscious and responsive) and resident would wake up and fall straight back to sleep. This LN then took resident V/S (vital signs) again . BP (blood pressure) ,d+[DATE], 97.5 F, 22 RPM (respirations per minute), 75 SPO2 (oxygen saturation), BG (blood glucose [blood sugar level]) 156 on 2L (2 liters of oxygen) via NC. Immediately this LN called the respiratory nurse, put his bed into high fowlers [positioned with the head elevated between ,d+[DATE] degrees], increase his 02 (oxygen) to 4L, and gave this resident his nebulizer tx [a treatment involving a device that delivers medications directly into the lungs], Resident's 02 was not increasing so this writer called 911. Respiratory nurse and Nurse Supervisor 2 was with the resident monitoring (sic). Upon completion of nebulizer tx resident's 02 was unchanged. The respiratory nurse then put a nonrebreather mask on resident and increased the 02 to 15L. Resident's 02 then went up to 97%. At around 1730 (5:30 p.m.) at the same (sic) this resident stopped breathing, and the paramedics arrived on scene. CPR was initiated by paramedics . 30 minutes of CPR was conducted. Time of death was called at 1753 (5:53 p.m.) . During an interview on [DATE] at 1:31 p.m., Licensed Staff A stated she was called into Resident 1 ' s room because of his oxygen level was low. Licensed Staff A was unable to recall the time nor how low the oxygen level was. Licensed Staff A stated she replaced Resident 1 ' s nasal cannula to a non-rebreather mask. Licensed Staff A stated Resident 1 was diaphoretic and would briefly open his eyes as she performed sternal rubs. Licensed Staff A stated she told Licensed Staff C to call 911, as she and another staff stayed at Resident 1 ' s bedside. Licensed Staff A stated she continued to monitor Resident 1 ' s breathing and performing sternal rubs. Licensed Staff A stated Resident 1 stopped breathing very suddenly, and as she was about to get the crash cart from outside the room, she almost ran straight into the paramedics. Licensed Staff A stated she never had a chance to start CPR. During an interview on [DATE] 1:40 p.m., Licensed Staff B stated she recalled Resident 1 ' s death and added she was in the room very briefly. Licensed Staff B stated Resident 1 was nonresponsive to sternal rubs. Licensed Staff B demonstrated gasping motions when asked to describe how Resident 1 ' s breathing was. Licensed Staff B stated she was checking Resident 1 ' s carotid pulse (the rhythmic pulse of the carotid arteries located on either side of the neck) while she was at the bedside, and stated Resident 1 never lost a pulse. Licensed Staff B stated there was an AED at the bedside, but it was not used. Licensed Staff B stated she had never used an AED outside of training. Licensed Staff B stated AED pads were placed on patients when CPR was started, and the AED was used when a patient became pulseless. During an interview on [DATE] at 1:58 p.m., Licensed Staff C stated she was about to give Resident 1 his medications the evening of [DATE] when he would not wake up. Licensed Staff C stated Resident 1 would briefly open his eyes as she did sternal rubs but would fall back to sleep after. Licensed Staff C stated Resident 1 ' s vital signs (temperature, blood pressure, heart rate and respiratory rate) were normal except for his low oxygen saturation. Licensed Staff C stated she started the nebulizer treatment and called for Licensed Staff A for further assistance. Licensed Staff C stated after a few minutes of the nebulizer treatment, she called 911. Licensed Staff C stated she brought the AED to Resident 1 ' s room per 911 ' s instructions. Licensed Staff C stated the AED was for Licensed Staff A and B to use, as they were at Resident 1 ' s bedside. Licensed Staff C stated CPR was not started on Resident 1 as he never lost pulse, nor had his breathing stopped. During an interview on [DATE] at 3:10 p.m., the Director of Nursing (DON) stated CPR was performed when someone was unresponsive, not breathing or has lost their pulse. The DON stated she expected staff to follow the paramedics ' instructions during emergency situations. A review of a national standard by the American Heart Association titled, Cardiac Arrest, dated 2025, indicated, Cardiac arrest can strike without warning . The signs are: Sudden loss of responsiveness - The person doesn ' t respond, even if you tap them hard on the shoulders or ask loudly if they're OK. The person doesn ' t move, speak, blink or otherwise react. No normal breathing - The person isn ' t breathing or is only gasping for air . If you think the person may be suffering cardiac arrest and you're a trained lay rescuer: Ensure scene safety. Check for response. Shout for help. Tell someone nearby to call 911 or your emergency response number. Ask that person or another bystander to bring you an AED, if there ' s one on hand. Tell them to hurry - time is critical. If you ' re alone with an adult who has signs of cardiac arrest, call 911 and get an AED (if one is available). Check for no breathing or only gasping. If the person isn ' t breathing or is only gasping, begin CPR with compressions. Administer high-quality CPR. Push down at least two inches in the center of the chest at a rate of 100 to 120 pushes a minute. Allow the chest to come back up to its normal position after each push. Use an AED. As soon as it arrives, turn it on and follow the prompts. Continue CPR. Administer it until the person starts to breathe or move, or until someone with more advanced training, such as an EMS team member, takes over . A review of the document titled, CPR Facts and Statistics by The American Red Cross Training Services, published [DATE], indicated, Out-of-Hospital Cardiac Arrest Facts: Survival chances decrease by 10% for every minute that immediate CPR and use of an AED is delayed. Immediate CPR can triple the chance of survival . Based on interview and record review, the facility staff failed to recognize a cardiorespiratory arrest (a life-threatening medical emergency that occurs when the heart and lungs stop functioning properly) for one of three sampled residents (Resident 1), which resulted in a delay in performing CPR (or cardiopulmonary resuscitation, a procedure to keep the blood pumping when the heart stops or when it beats too ineffectively to circulate blood to the brain and other vital organs) on Resident 1 who was a full-code (a medical directive indicating that a patient wishes to receive all possible life-saving measures in the event of a medical emergency) after he was found unresponsive. This failure led to Resident 1's death. Findings: During an interview on [DATE] at 9 a.m., Complainant 5 stated he arrived at the facility on [DATE] approximately five to seven minutes after receiving a call about an unresponsive patient who was having difficulty breathing. Complainant 5 stated he found Resident 1 on a non-rebreather mask (a mask that delivers high concentrations of oxygen), but was apneic (not breathing spontaneously), unresponsive and diaphoretic (covered with sweat), and pulseless. Complainant 5 stated he immediately started chest compressions on Resident 1. Complainant 5 stated he continued to perform CPR on Resident 1 until his time of death, about ,d+[DATE] minutes later. Complainant 5 stated there was an AED (automated external defibrillator, or a portable medical device that can analyze the heart's rhythm and, if necessary, deliver an electrical shock, or defibrillation, to help the heart re-establish an effective rhythm) at Resident 1's bedside, but the machine was not on nor were the pads applied on Resident 1's chest. Complainant 5 stated he was later told by the staff that Resident 1 had been unresponsive and had oxygen saturation levels (a measure of how much oxygen is in your blood) in the 60's or 70's approximately 40 minutes before his arrival (the normal range for oxygen saturation is typically between 95% and 100%). A review of Resident 1's Face Sheet indicated he was admitted to the facility with diagnoses including acute and chronic respiratory failure (a condition where the body is not getting enough oxygen due to a failure of the lungs to properly exchange gases, which can occur suddenly or over time). A review of Resident 1's Progress Notes , dated [DATE] , indicated, . At around 1650 (4:50 p.m.) respiratory nurse was doing her rounds and noticed this resident was not wearing his NC (nasal cannula [a device with two prongs that deliver oxygen directly into the nostrils]). The nurse put resident back on his O2 (oxygen) via NC, states when she was with the pt (patient) he woke up but didn't say anything. At around 1655 (4:55 p.m.) this writer went to give resident his evening medications. Resident was asleep and unable to wake up. This LN (Licensed Nurse) did a sternum rub (to determine if a person is conscious and responsive) and resident would wake up and fall straight back to sleep. This LN then took resident V/S (vital signs) again . BP (blood pressure) ,d+[DATE], 97.5 F, 22 RPM (respirations per minute), 75 SPO2 (oxygen saturation), BG (blood glucose [blood sugar level]) 156 on 2L (2 liters of oxygen) via NC. Immediately this LN called the respiratory nurse, put his bed into high fowlers [positioned with the head elevated between ,d+[DATE] degrees], increase his 02 (oxygen) to 4L, and gave this resident his nebulizer tx [a treatment involving a device that delivers medications directly into the lungs], Resident's 02 was not increasing so this writer called 911. Respiratory nurse and Nurse Supervisor 2 was with the resident monitoring (sic). Upon completion of nebulizer tx resident's 02 was unchanged. The respiratory nurse then put a nonrebreather mask on resident and increased the 02 to 15L. Resident's 02 then went up to 97%. At around 1730 (5:30 p.m.) at the same (sic) this resident stopped breathing, and the paramedics arrived on scene. CPR was initiated by paramedics . 30 minutes of CPR was conducted. Time of death was called at 1753 (5:53 p.m.) . During an interview on [DATE] at 1:31 p.m., Licensed Staff A stated she was called into Resident 1's room because of his oxygen level was low. Licensed Staff A was unable to recall the time nor how low the oxygen level was. Licensed Staff A stated she replaced Resident 1's nasal cannula to a non-rebreather mask. Licensed Staff A stated Resident 1 was diaphoretic and would briefly open his eyes as she performed sternal rubs. Licensed Staff A stated she told Licensed Staff C to call 911, as she and another staff stayed at Resident 1's bedside. Licensed Staff A stated she continued to monitor Resident 1's breathing and performing sternal rubs. Licensed Staff A stated Resident 1 stopped breathing very suddenly , and as she was about to get the crash cart from outside the room, she almost ran straight into the paramedics. Licensed Staff A stated she never had a chance to start CPR. During an interview on [DATE] 1:40 p.m., Licensed Staff B stated she recalled Resident 1's death and added she was in the room very briefly . Licensed Staff B stated Resident 1 was nonresponsive to sternal rubs. Licensed Staff B demonstrated gasping motions when asked to describe how Resident 1's breathing was. Licensed Staff B stated she was checking Resident 1's carotid pulse (the rhythmic pulse of the carotid arteries located on either side of the neck) while she was at the bedside, and stated Resident 1 never lost a pulse. Licensed Staff B stated there was an AED at the bedside, but it was not used. Licensed Staff B stated she had never used an AED outside of training. Licensed Staff B stated AED pads were placed on patients when CPR was started, and the AED was used when a patient became pulseless. During an interview on [DATE] at 1:58 p.m., Licensed Staff C stated she was about to give Resident 1 his medications the evening of [DATE] when he would not wake up. Licensed Staff C stated Resident 1 would briefly open his eyes as she did sternal rubs but would fall back to sleep after. Licensed Staff C stated Resident 1's vital signs (temperature, blood pressure, heart rate and respiratory rate) were normal except for his low oxygen saturation. Licensed Staff C stated she started the nebulizer treatment and called for Licensed Staff A for further assistance. Licensed Staff C stated after a few minutes of the nebulizer treatment, she called 911. Licensed Staff C stated she brought the AED to Resident 1's room per 911's instructions. Licensed Staff C stated the AED was for Licensed Staff A and B to use, as they were at Resident 1's bedside. Licensed Staff C stated CPR was not started on Resident 1 as he never lost pulse, nor had his breathing stopped. During an interview on [DATE] at 3:10 p.m., the Director of Nursing (DON) stated CPR was performed when someone was unresponsive, not breathing or has lost their pulse. The DON stated she expected staff to follow the paramedics' instructions during emergency situations. A review of a national standard by the American Heart Association titled, Cardiac Arrest , dated 2025 , indicated, Cardiac arrest can strike without warning . The signs are: Sudden loss of responsiveness - The person doesn't respond, even if you tap them hard on the shoulders or ask loudly if they're OK. The person doesn't move, speak, blink or otherwise react. No normal breathing - The person isn't breathing or is only gasping for air . If you think the person may be suffering cardiac arrest and you're a trained lay rescuer: Ensure scene safety. Check for response. Shout for help. Tell someone nearby to call 911 or your emergency response number. Ask that person or another bystander to bring you an AED, if there's one on hand. Tell them to hurry - time is critical. If you're alone with an adult who has signs of cardiac arrest, call 911 and get an AED (if one is available). Check for no breathing or only gasping. If the person isn't breathing or is only gasping, begin CPR with compressions. Administer high-quality CPR. Push down at least two inches in the center of the chest at a rate of 100 to 120 pushes a minute. Allow the chest to come back up to its normal position after each push. Use an AED. As soon as it arrives, turn it on and follow the prompts. Continue CPR. Administer it until the person starts to breathe or move, or until someone with more advanced training, such as an EMS team member, takes over . A review of the document titled, CPR Facts and Statistics by The American Red Cross Training Services , published [DATE] , indicated, Out-of-Hospital Cardiac Arrest Facts: Survival chances decrease by 10% for every minute that immediate CPR and use of an AED is delayed. Immediate CPR can triple the chance of survival .

Based on observation, interview and record review, the facility failed to ensure 1 of 2 sampled residents (Resident 1), who had a history of Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and amputation (surgical removal) of his right leg above the knee, received care consistent with nursing standards of practice and the resident's individualized care plan when: 1) Licensed nursing staff did not document daily skin assessments (to identify skin injury) for Resident 1, as indicated in his Nursing Care Plan (document that contains essential information about a patient's condition, diagnosis, goals, interventions, and outcomes); 2) Licensed nursing staff did not document the condition Resident 1's remaining foot (left) for a period of approximately one month prior to the identification of his necrotic (necrosis; death of body tissue; also known as necrosis) second toe. 3) Licensed nursing staff did not notify Resident 1's covering physician (via the on-call advice nurse) immediately when they identified his toe was black in color; they did not communicate Resident 1's potentially life-threatening condition during the initial phone call, they informed the physician in a subsequent phone call; and 4) Licensed nursing staff did not ensure Resident 1 was promptly transferred to the hospital once his emergent condition was discovered on the morning of 10/13/24, he was transported to the hospital hours later at 4:34 p.m.; the facility did not arrange transportation the hospital, an outside provider group (Provider Group F) called for ambulance transport. These failures: 1) Caused Resident 1's necrotic toe to go undetected until it had advanced to the wet gangrene (a type of necrosis when infection is present; can be fatal if left untreated) stage, when infection and sepsis (the body's extreme response to an infection; a life-threatening medical emergency) were already present, thereby placing him at risk of death and necessitating an emergent transfer to the hospital. 2) Prevented Resident 1's physician from knowing the declining status of his foot/toe, impairing his ability to intervene earlier in the disease process and order diagnostic testing and potential treatment to mitigate disease progression. 3) Contributed to the amputation of Resident 1's left, second toe. 4) Contributed to Resident 1 developing sepsis. 5) Delayed his arrival to the Emergency Department, thereby delaying sepsis treatment (antibiotic [medication to treat infection] administration); and 6) Contributed to Resident 1 experiencing foot pain he described as 6/10 (Pain Scale: a tool health care professionals utilize to help assess a person's pain: 0 is no pain and 10 is the worst pain imaginable). Findings: During a telephone interview with a confidential family member (CF) on 11/7/2024 at 11:54 a.m., CF stated her family member (Resident 1) called her on Sunday (10/13/2024) and told her he had pain in his left foot and his toe had been black for a while. CF stated a certified nurse assistant (CNA E) took a picture of Resident 1's foot and sent it to her; CF stated the photo showed his toe was black in color and nearly falling off. She stated the facility nurse, Licensed Nurse C (LN C), called Resident 1's provider group (Provider Group F; group of physicians covering for/working with Resident 1's physician, Physician D) and spoke to the on-call nurse. CF stated LN C told her the on-call physician had ordered Resident 1 to be given Gout (painful joint swelling) medication and have ice placed on his foot. During the same telephone interview on 11/7/24 at 11:54 a.m., CF stated she reviewed Resident 1's medical record (via computer access) after the call was made to Provider Group F and stated LN C had reported to them that Resident 1 had a painful and swollen left foot (not a black toe). CF stated she called the facility and told LN C that gout medication and ice would not help her father because he had gangrene. CF stated LN C became nervous and told her she would call Provider Group F again. During the same telephone interview on 11/7/24 at 11:54 a.m., CF stated she called Provider Group F herself (after speaking with LN C) and spoke to an on-call nurse; CF informed her that Resident 1's toe was black and nearly falling off, but LN C was not worried. CF stated the on-call nurse called a physician and told her Resident 1 needed to come by ambulance (to the hospital) right away. CF stated one hour later, Resident 1 was still at the facility (he had not been transported to the hospital). CF stated the on-call nurse (not a facility nurse) eventually called an ambulance for Resident 1. CF stated when Resident 1 arrived in the Emergency Department (ED), he was septic (sepsis; life-threatening infection) and his toe was subsequently amputated. Review of Resident 1's medical record facesheet (front page of the chart that contains a summary of basic information about the resident) indicated Resident 1 was originally admitted to the facility 5/17/21 and had diagnoses that included, but were not limited to: Diabetes Mellitus, peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs), acquired absence (amputation) of right leg above the knee, and acquired absence (amputation) of the left great toe. Review of a hospital physician note, dated 10/13/24 at 10:02 p.m. indicated Resident 1 came to the hospital with, . necrotic left toe . the patient thinks the toe has been black for some time . Review of Resident 1's medical record revealed a physician note by Physician D (Resident 1's doctor), dated 10/25/20 at 10:58 a.m., that indicated Resident 1 had been admitted to the hospital from 10/13/24 through 10/23/24. The progress note indicated Physician G (Resident 1's doctor at the hospital) documented Resident 1 , .presents (came to the hospital) with fever and necrotic left second toe . Blood culture (blood test that indicates infection) returned Strep pyogenes (bacteria was present in the blood culture; infection was present) . ID (infectious disease physician) consulted and agreed with continuing zosyn/vanco (antibiotics given to treat Resident 1's infection) . Taken to OR (operating room) on 10/15 (2024) and underwent amputation of 2nd toe . During an observation and concurrent interview on 11/8/24 at 11:30 a.m., Resident 1 was lying on his back in bed; his bed contained a foot cradle (device attached to the bed to keep blankets/sheets from touching and rubbing legs and feet). Resident 1 stated he had had four toes on his left foot but was now down to three; he stated the second toe had turned black. Resident 1 stated the second toe was getting green on Friday (10/11/24; two days prior to transport to the hospital) and on Sunday (10/13/24), an ambulance was called, and he was sent to the hospital. He stated he spent twelve days in the hospital. When asked about the wound (treatment) nurse at the facility, Resident 1 stated they take care of his heel now but, they missed the black toe. During an interview on 11/8/24 at 11:50 a.m., Certified Nursing Assistant E (CNA E) stated she had worked with Resident 1 a lot in the past and had seen him on Friday (10/11/24). She stated she had not noticed anything (unusual) Friday morning and LN B had not noticed anything, either. CNA E stated Resident 1's toe had turned black on Saturday and he was sent out (to the hospital) on Sunday. During an interview on 11/8/24 at 1:52 p.m., Licensed Nurse B (LN B) stated she was the facility's wound (treatment) nurse and had been working with Resident 1. LN B stated she had seen Resident 1 Friday and Saturday (10/11/24 and 10/12/24) prior to his hospital transfer but she did not work on Sunday (10/13/24). LN B stated Resident 1 had had back lesions (prior to 10/13/24) that were kind of infected and she had been applying ointment to them. She stated she had taken photos of his back lesions. She stated Resident 1 also had super dry skin and she had put lotion on his leg. LN B stated she had not seen a black toe when she had applied the lotion. Review of Resident 1's medical record revealed a nurse progress note from the LN B (dated 10/15/24 at 4:14 p.m.- two days after Resident 1 was sent to the hospital) that indicated, Performed wound care on patient Friday and Saturday October 11, and 12 (sic) to his lower back when turning patient and helping him roll over and take blankets down (sic). I used moisturizer lotion to patients dry left leg. Patient wasn't noted with any black discoloration to left foot. Review of Resident 1's medical record indicated LN B documented a skin assessment titled, Evaluated on [DATE] - 13:05 (1:05 p.m. - over six weeks prior to his left/second toe amputation) that indicated Resident 1 had an open lesion (tissue injury) on his right scapula (shoulder blade); she documented its size and photographed the lesion. No additional wound evaluations were located in Resident 1's medical record until 10/25/24 (after amputation of his second toe on 10/15/24),) when LN B documented and photographed a diabetic lesion located on his left heel. No photo of Resident 1's necrotic toe, reportedly taken on 10/13/24, was in his medical record. Review of Resident 1's medical record revealed a Change of Condition (An acute change of condition is a sudden clinically important deviation from a patient's baseline in physical, cognitive [mental], behavioral, or functional domains [physical ability]) evaluation, dated 10/13/24 at 2:50 p.m., that indicated, .Edema (swelling) . Change in skin color .Nursing observations, evaluation, and recommendations are: Noted swelling and discoloration on left foot. Pain level 6/10 (severe pain). Noted discoloration on 2nd toe of left foot. Called (Provider Group F) after hours and spoke to advice Nurse (name) and received orders from MD . Stat X ray (immediate timeframe; photographic or digital image of the internal composition of something, especially a body part) left foot. stat CBC (blood test) and Stat uric acid level (blood test for gout). New orders Colchicine (medication for gout) twice daily for 5 days . Apply ice on left foot three times a day for 3days (sic) . During a telephone interview on 11/18/2024 at 4:20 p.m., LN C stated she was a newly graduated registered nurse who had been working at the facility a total of four months. LN C stated she was Resident 1's nurse the day he was sent to the hospital; she stated her shift began at 6:45 a.m. and a CNA told her in the morning that Resident 1 had swelling of his left foot. LN C stated she went to Resident 1's room right away and he was complaining of foot pain that was 6/10. When asked what time the CNA notified her about Resident 1's foot and she went to the room, LN C stated she did not remember. When asked what Resident 1's foot looked like, LN C stated it was swollen with discoloration. She stated the left second toe was a little bit blackish. During the same telephone interview on 11/18/2024 at 4:20 p.m., LN C stated she called Provider Group F's after-hours advice nurse (who subsequently called the on-call physician). When asked what she told the advice nurse when she called, LN C stated she told her Resident 1's foot had, swelling and discoloration. When asked if she told the advice nurse the toe was blackish, LN C stated, no. When asked why she did not notify the nurse of the black color, LN C stated she told her in a subsequent call; she stated she called and spoke to the advice nurse two separate times. During the first call, she stated she reported Resident 1 had discoloration of the toe but did not tell the on-call nurse it was black. She stated a physician from Provider Group F ordered ice (to the foot) and gout medication. During the second call, LN C stated she told the advice nurse the toe was discolored and, I think I told it was blackish. She stated a photo had been taken of Resident 1's foot and she showed the photo (to the advice nurse) during the second call. LN C stated a stat xray was ordered after the second call and Resident 1's family member requested he be sent to the hospital. When asked what the length of time between calls to the advice nurse was, LN C stated she did not remember. When asked when 911 (emergency medical responders) was called (to transport Resident 1 to the hospital), LN C stated she did not remember. LN C stated Resident 1 was still in the facility at 2:30 p.m., when her shift ended. Review of Resident 1's medical record revealed a nurse's progress note, dated 10/13/2024 at 10:58 p.m. that indicated, Res (Resident 1) was P/U (picked up) at 1634 (4:34 p.m.) to (Hospital Name) via gurney with 2EMT's (two emergency medical technicians). During the same telephone interview on 11/18/2024 at 4:20 p.m., LN C was asked how nurses documented resident skin assessments and she stated nurses perform skin assessments after resident showers and then documented in the (nurse) progress notes. During a telephone interview on 11/18/2024 at 4:45 p.m., the Director of Nursing (DON) stated Resident 1 was a very high risk for necrosis and deep tissue injury (damage to the soft tissue beneath the skin caused by pressure). She stated he had a history peripheral vascular disease and had had an amputation of the first toe on the left foot. When asked if she knew the timeframe of events on 10/13/24, the day Resident 1 was sent to the hospital, the DON stated she did not know the conversations (that occurred). When asked if she was aware LN C did not notify the advice nurse that Resident 1's toe was blackish in the initial conversation (rather that the follow-up, second call), the DON again stated she did not know the conversations. When asked what a nurse should do when she/he discovers a resident has a black toe, the DON stated they should evaluate for pain and infection and call the doctor right away. She stated necrotic toes could have bad outcomes like amputation, bleeding, infection, sepsis and even death. Review of Resident 1's medical record document titled, Braden Scale For Predicting Pressure Sore (pressure ulcer/injury: localized, pressure-related damage/injury to the skin and/or underlying tissue) Risk, dated 8/19/24, indicated he had a score of 15 (at risk of developing pressure ulcers). [The Braden Scale is an assessment tool reflecting a person's risk of developing pressure ulcers/pressure sores]. Review of Resident 1's medical record revealed multiple nurse progress notes, prior to Resident 1's hospital transfer on 10/13/24; the nurse progress notes did not indicate nursing staff were monitoring the status of his foot. A nurse's noted dated 9/10/24 at 3:27 p.m. indicated, .monitoring for skin tear on left hand . still have rashes (sic) on his back and dressing on his wound on left upper back . On 9/12/24 at 6:39 p.m., LN C documented, .Resident has recurrent rash on back. Resident got shower . LN C's note did not indicate she conducted a skin assessment after the shower. On 9/17/24 at 8:24 p.m., nursing staff documented that Resident 1 was sent to a podiatry medical appointment but did not document any skin assessments. On 9/21/24 at 10:06 p.m., LN C documented Resident 1 was complaining of, itching; she documented he had a shower but did not document a skin assessment. On 9/25/24 at 9:10 p.m., LN C documented Resident 1 received a shower, had redness and rash around the groin area, but did not document a skin assessment of his foot. The next documented nurse's progress note was dated 10/9/24 at 10:07 p.m. (reflecting a two-week period with no documented nurse progress notes). In the 10/9/24 nurse's note, LN C indicated Resident 1 received a shower, was complaining of itching, staff applied cream to arms, leg, knee and chest and an abrasion was located on the knee; LN C did not document the status of his foot. On 10/12/24 at 10:06 p.m. (the day before he was sent to the hospital), LN C documented Resident 1 refused his shower; she did not document any skin assessment. On 10/13/24 at 3:24 p.m., LN C documented, Resident (1) is alert and oriented (not confused). Noted swelling and discoloration on left foot. Pain level 6/10. Noted discoloration on 2nd toe of left foot. Called (Provider Group F) after hours and spoke to advice Nurse (name) and received orders from MD (name). Family notified. During a follow-up interview and concurrent medical record review on 11/22/24 at 1:40 p.m., the DON was asked to review the nursing progress notes, wound nurse notes, and photos located in Resident 1's medical record. When asked about the photos of his toe, reportedly taken on the morning of 10/13/24, the DON stated they had not been uploaded (into the electronic medical record) and stated, I don't know about the photos. The DON confirmed the medical record did not contain documentation of wound nurse progress notes or foot/toe photos after August 2024 and prior to 10/13/24. The DON was asked to clarify if Resident 1's medical record contained documentation of licensed nursing staff monitoring Resident 1's toe/foot the month prior to the identification of his necrotic toe. The DON stated and confirmed she could not locate foot/toe monitoring documentation in the nurse's progress notes or the treatment administration record (TAR, location of wound care and treatment notes). When asked if nursing staff should have been monitoring Resident 1's foot daily, as indicated in the Nursing Care Plan, the DON stated, yes. Review of Resident 1's nursing care plan (date initiated 02/17/2023, revised 07/03/2024) indicated, Skin: at risk for skin breakdown . The care plan goal was, Will have no skin breakdown daily x3 (for three) months . The interventions to reach the goal indicated, Daily body assessments to monitor for any skin injury . Notify MD for any skin breakdown . During an interview on 11/22/24 at 2:30 p.m., Physician D was asked about the development and outcome of Resident 1's necrotic toe. Physician D stated LN B (treatment nurse) told him she had seen Resident 1's foot on Friday (10/11/24, two days prior to being sent to the hospital) and his foot at that time was really good. When asked if he thought the necrosis could have developed quickly (between Friday and Sunday), Physician D stated it was, conceivable, but it may have taken longer. He stated everyone (medical staff) thought it was occurring (progressing) longer than a few days. During the same interview on 11/22/24 at 2:30 p.m., Physician D stated the nurse (LN C) was concerned about the change in Resident 1's toe on Sunday (10/13/24) and at some point, reported it looked black. He stated in the first call to Provider Group F, the LN C reported swelling and treatment for gout (ice and medication) was ordered. Physician D stated there was no mention of the toe's color (being black) in the first call to his provider group. Physician D stated Resident 1's family member (CF) reached out to the facility and also made a second call to an unofficial call center (related to Provider Group F) and spoke to the on-call nurse manager; Provider Group F's on-call nurse manager then arranged ambulance transfer for Resident 1 to the hospital. During the same interview on 11/22/24 at 2:30 p.m., when Physician D was asked if the failure of nursing staff to monitor Resident 1's left foot daily and notify the physician timely of any changes contributed to his necrotic toe being found (identified) at an advanced stage, he stated, yes. He stated the necrosis was found at the wet gangrene stage and was infected. When asked if Resident 1 was septic (had sepsis) when he arrived in the emergency room , Physician D stated, he met sepsis criteria. (a combination of findings/set of criteria - such as exams, tests, etc.- that providers use to identify/confirm the presence of sepsis). He stated if the issue was found when the toe was dusky (gray color; less advanced disease), he would have ordered and performed a vascular study (to assess circulation of the foot) and monitored the foot. When asked if nursing staff should have been monitoring Resident 1's toe/foot, Physician D stated, yes. Online review of the National Library of Medicine website indicated gangrene is associated with a high incidence of mortality (death), and in patients that survive, it can have a massive impact on the quality of life. (https://www.ncbi.nlm.nih.gov/books/NBK560552/). Online review of John Hopkins website indicated, Gangrene is a dangerous and potentially deadly health problem . Gangrene can spread quickly over a large area of the body .Wet gangrene is often life-threatening . (https://www.hopkinsmedicine.org/health/conditions-and-diseases/gangrene) Online review of the Mayo Clinic website indicated diabetes increases the risk of gangrene. Symptoms include changes in skin color including pale gray to blue, purple, black and red; swelling, blisters and severe pain can be present. (https://www.mayoclinic.org/diseases-conditions/gangrene/symptoms-causes/syc-20352567). Online review of the Center for Disease Control and Prevention (CDC) website indicated, Sepsis . is a life-threatening medical emergency . almost any infection can lead to sepsis . sepsis happens when an infection you already have triggers a chain reaction throughout your body . Infections that lead to sepsis most often start in the . skin . Without timely treatment, sepsis can rapidly lead to tissue damage, organ failure and death . (https://www.cdc.gov/sepsis/about/index.html).

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) with metastatic breast cancer (The most advanced stage of breast cancer, which occurs when breast cancer cells spread from the breast to other organs) in moderate to severe pain, was discharged from the facility with her physician prescribed controlled opioid medications (Highly addictive non-synthetic medications whose use and distribution are tightly controlled by the government because of their abuse potential or risk) to manage her pain. Resident 1 was discharged without her controlled pain medications, and as a result, experienced severe pain, nausea, and vomiting, at the facility where she was discharged , prompting her to call emergency services to be taken to a General Acute Care Hospital (GACH), one day after being discharged from nursing facility. The GACH where she was transferred to, indicated Resident 1 had experienced opiate withdrawal, related to not taking her opiate medications for more than 24 hours. Findings: Record review indicated Resident 1 was admitted to the facility on [DATE] with medical diagnoses including Malignant Neoplasm of Left Female Breast (Cancer to the left breast), and Secondary Malignant Neoplasm of Bone (Cancer that had spread to the bone), according to the facility Face Sheet (Facility demographic). Record review of an e-mail sent by the Administrator to the Surveyor on 5/03/24 at 4:43 p.m., indicated Resident 1's undated BIMS (Brief Interview of Mental Status-A cognition [the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses] assessment) score was 15, which indicated her cognition was intact (A score of 1-7 indicates the cognition is severely impaired, 8-12 indicates the cognition is moderately impaired, and 13-15 indicates the cognition is intact). Record review of physician discharge orders for Resident 1 dated 3/27/24 indicated, Discharge with remaining medication supply except narcotics (Controlled medications containing opioid derivatives). Discharge with 7 days narcotics only. This form was signed by the facility physician on 3/27/24, and included the following medications, oxyCODONE/acetaminophen (A combination of Oxycodone (A narcotic opioid medication to treat severe pain) and Acetaminophen (Analgesic for mild to moderate pain) for pain control 5mg (Milligrams)/325mg Tab . Take one Tab by mouth every 4 hours as needed .morphine 12Hr-CR (12 hour-controlled release) 15mg Tab (Morphine is a controlled narcotic opioid medication to treat moderate to severe pain) .Take one Tab by mouth twice daily Morning and Night. Record review of Resident 1's Medication Administration Record for April 2024, indicated Resident 1 received 10 mg of Oxycodone for a pain level of 6 (Pain scale where 0 stands for no pain, and 10 is the worst pain experienced during a person's lifetime. A pain level of 0-3 signifies mild pain, 4-6 is moderate pain, and 7-10 is severe pain) on 4/01/24 (Day of discharge) at 8:58 a.m. Record review of a nursing note documented by Licensed Staff A on 4/01/24 at 1:42 p.m., indicated, @1235PM (At 12:35 p.m.) [Resident 1] discharge home today. Picked up by a taxi. Record review of a facility document titled, POST-DISCHARGE PLAN OF CARE 3.1, dated 4/01/24, had a section to document the medications Resident 1 was discharged with. This section inquired for each medication's purpose and special instructions, and amount sent with the resident. The section on medications was left blank, and instead, a handwritten note signed by Licensed Staff A on 4/01/24, appeared on this document indicating, PLS. (Please) SEE ATTACHED MEDICATION LIST. MEDICATION INSTRUCTIONS GIVEN & VERBALIZES UNDERSTANDING. Record review of a GACH emergency department note dated 4/02/24 at 3:57 p.m., indicated, [Resident 1] is a [AGE] year old female with metastatic breast cancer who presents from a new long-term care facility with 1 day of nausea, vomiting and diarrhea. Of note, patient was out of subacute rehabilitation center and was recently transitioned to a different long-term care facility, patient states that her opiate prescription did not follow her and she has not had any of her opiate pain medicine for her metastatic cancer for over 24 hours. Patient concerned that her symptoms may be related to her opiate withdrawal. Also with generalized nonfocal (Not specific to a certain area) abdominal pain in setting of vomiting and diarrhea .patient's symptoms improved with IV (IV-Intravenous-administered though the veins) fluids, IV antiemetics (Medications for nausea) as well as home opiate doses. Case management help set up home nursing care, patient's opiate sent to 2 different pharmacies, spoke with patient at length to ensure that the opiates can get picked up to prevent reoccurrence of opiate withdrawal. During a phone interview with Witness XX on 4/22/24 at 11:43 a.m., she stated Resident 1's discharge from the facility on 4/01/24 was, Terribly irresponsible. Witness XX stated the discharging nurse was not prepared and not aware of Resident 1's scheduled discharge, therefore she just gave Resident 1 whatever medications she could find in the medication cart, missing Resident 1's pain medications in the process. Witness XX stated Resident 1 was not discharged from the facility with her pain medication, which she needed for her hip and back pain caused by Resident 1's cancer metastasis. Witness XX stated that after 12 hours of not taking any pain medications, Resident 1 started having withdrawal symptoms such as vomiting, which triggered her to call an ambulance to be taken to a GACH. Witness XX stated staff from the GACH where Resident 1 was transferred to, as well as herself, called the nursing facility multiple times to find out what medication she was taking, but received no response. During an interview with Licensed Staff A on 5/01/24 at 10:38 a.m., with the Director of Staff Development (DSD) present, Licensed Staff A stated she was not the assigned nurse for Resident 1 on 4/01/24, on the day of the discharge, and was notified by a Social Services staff member that Resident 1 was being discharged (on 4/01/24) when the nurse assigned to Resident 1 was taking her lunch break. Licensed Staff A stated she assisted with the discharge when the taxi was already waiting for Resident 1. Licensed Staff A stated she did not believe she had provided Resident 1 with Morphine upon discharge from the facility, but she believed she had given her the Oxycodone. Licensed Staff A and the DSD were asked to provide the controlled medication reconciliation forms (A reconciliation form is a document used in nursing homes to record the amount of drugs that are received, used, and discarded. It is intended to reconcile the controlled medication use to prevent abuse or theft of controlled substances) for Resident 1's Morphine and Oxycodone, and any other evidence, to determine if Resident 1 had been discharged with these medications from the facility. Neither of the two staff members returned to speak to the Surveyor or provided the controlled reconciliation sheets or any other evidence indicating Resident 1 was discharged with her Morphine and Oxycodone from the facility. During a concurrent interview and record review with the Medical Records Director (MRD) on 5/01/24 at 1:12 p.m., with the Administrator present, the MRD was shown the handwritten note by Licensed Staff A indicating, PLS. (Please) SEE ATTACHED MEDICATION LIST. MEDICATION INSTRUCTIONS GIVEN & VERBALIZES UNDERSTANDING. The MRD was asked to provide the medication list this handwritten note referenced. The MRD was also asked to provide the last training on the discharge process or discharge planning that had been provided to Licensed Staff A at the facility. The MRD and Administrator were given until Friday 5/03/24 at the end of the day to provide these documents by e-mail. These documents requested were not provided, and instead, the Administrator sent an e-mail to the Surveyor on 5/03/24 at 4:43 p.m., indicating this requested medication list was not being provided because it had been sent to the Surveyor previously, which was not the case. The Administrator had provided the discharge signed order from the facility physician (dated 3/27/24, above) which indicated what medications Resident 1 was to be discharged with (Which included the Morphine and Oxycodone) but this document did not indicate the actual medications sent with Resident 1, and amount of each medication. During an interview with the Director of Nursing (DON) on 5/01/24 1:45 p.m., he was asked about the documentation requirements for medications provided to a resident upon discharge from the facility. The DON stated discharging staff should document what medications the resident was discharged with, and the number of pills provided of each medication. During a phone interview with Resident 1 on 5/02/24 at 1:08 p.m., she corroborated Witness XX story, and stated she was discharged from the facility without her Morphine or Oxycodone. Resident 1 stated the nurse on duty the day of discharge was not aware she was leaving, so she appeared to be in a rush gathering the medications for her when the taxi was already waiting outside. Resident 1 stated she attempted to call the facility multiple times after the discharge to let them know she had been discharged without her Oxycodone and Morphine but was unable to communicate with anybody. Resident 1 stated a few hours after her discharge from the facility she started experiencing vomiting, diarrhea, and pain of 8 of 10 (Severe pain). Resident 1 stated she called emergency services to be taken to a GACH (Refer to GACH emergency department note dated 4/02/24 at 3:57 p.m. above). Record review of the facility policy titled, Transfer or Discharge, last revised in August of 2018, indicated, Transfers or discharges may be necessary to protect the health and/or well-being of the resident(s). This policy did not indicate the process for discharging a resident non-emergently to another facility, nor did it mention medications to be provided to the resident upon discharge.

Based on interviews and records review, the facility failed to assess, monitor, and provide necessary care for one of two sampled residents (Resident 1) when: 1. The facility did not provide the necessary nursing assessment for Resident 1 ' s underlying cause of vomiting; did not provide prompt intervention to prevent Resident 1 from further vomiting when Resident 1 started vomiting in the morning of [DATE] and was given first dose of Ondansetron (a medicine used to prevent and treat nausea and vomiting) at 8:51 p.m.; and did not monitor Resident 1 for possible complications associated with vomiting, when Resident 1 vomited three times within a 12 hour period. 2. The facility did not monitor Resident 1 ' s colostomy (a stoma [opening] in the abdominal wall allows waste to leave the body) output for signs of constipation (having a condition of the bowels in which the feces are dry and hardened and evacuation is difficult and infrequent) and did not provide Milk of Magnesia (MOM - a laxative to help loosen stools and increase bowel movements) or Dulcolax Suppository (laxative suitable for the fast relief of occasional constipation) according to the doctor ' s order to relieve Resident 1 from constipation. 3. The Facility did not monitor Resident 1 ' s urostomy (a stoma in the abdomen to collect urine outside of the body) output when there was a physician ' s (doctor) order to monitor Resident 1 ' s output every shift. 4. The facility failed to monitor and ensure Resident 1 received adequate fluid intake according to his estimated fluid needs. This failure resulted in Resident 1 ' s emergent transfer to the hospital who was found to have Septic Shock (the last and most severe stage of sepsis [an overwhelming and life-threatening response to infection]); Urinary Tract Infection (UTI - condition in which bacteria invade and grow in the urinary tract (the kidneys, ureters, bladder, and urethra); Acute Kidney Failure (also known as Renal Failure - occurs when the kidneys are suddenly unable to filter wastes from the blood) with Hyperkalemia (an elevated level of potassium [a mineral and electrolyte that conducts electricity essential for all of the body ' s functions] in the blood); and Small Bowel Obstruction (SBO - a condition in which the small intestine [part of the intestine that runs between the stomach and the large intestine] becomes blocked). Resident 1 subsequently died after one day of hospitalization . Findings: 1. During a record review for Resident 1, the Face sheet (A one-page summary of important information about a resident) indicated Resident 1 was admitted on [DATE] with diagnoses including but not limited to Heart Failure (a chronic condition in which the heart doesn't pump blood as well as it should); Paraplegia (paralysis of the legs and lower body); and Spina Bifida (a congenital defect of the spine often causing paralysis of the lower limbs). During a record review for Resident 1, the MDS (Minimum Data Set - health status screening and assessment tool used for all residents) assessment dated [DATE] indicated, Resident 1 had a BIMS score of 14 out of 15 points (Brief Interview for Mental Status [current state of the patient during evaluation] - a 15-point cognitive (relating to the mental process involved in knowing, learning, and understanding things) screening measure that evaluates memory and orientation. A score of 13 to 15 is cognitively intact, 08 to 12 is moderately impaired, and 00 to 07 is severe impairment). During a record review for Resident 1, the Progress Note titled Nurse ' s Note dated [DATE] at 10:48 p.m. indicated, [Resident 1] vomited x (times) 3 within 12 hours. Vomited food contents, Zofran (also known as Ondansetron) was given at 1815 (6:15 p.m.) as per MD (Medical Doctor) order. Ineffective because [Resident 1] vomited again at 2200 (10:00 p.m.). During a record review for Resident 1, the Progress Note titled Nurse ' s Note dated [DATE] at 9:07 a.m. indicated, at around 8:45 a.m., Resident 1 appeared drowsy but arousable; had cold extremities to both arms; abdomen was hard and distended. The Nurse ' s Note indicated the physician was notified and ordered to transfer Resident 1 to the hospital. During a record review for Resident 1, the Physician ' s Progress Note dated [DATE] at 12:30 p.m. indicated, Staff report [Resident 1] had 2 episodes of vomiting yesterday. [Resident 1] this morning is confused and complaining of abdominal pain. Nurses report [Resident 1 ' s] abdomen is distended and hard. During a record review for Resident 1, the hospital document titled, ED (Emergency Department) Provider Note dated [DATE] at 9:57 a.m. indicated Resident 1 presented to the hospital for complaint of nausea and vomiting, poor urinary output and scant to no stool output. The document indicated Resident 1 had colostomy and urostomy. During a record review for Resident 1, the hospital document titled, ED Notes dated [DATE] at 10:28 a.m. indicated, [Resident 1] reports no bm (bowel movement) x (for) 4 days. During a record review for Resident 1, the hospital document titled, H & P (History and Physical - formal and complete assessment of the patient and the problem) Notes dated [DATE] at 2:11 p.m., indicated an NGT (Nasogastric tube - a thin, soft tube that goes in through the nose, down the throat, and into the stomach; typically used for decompression (relieving pressure) of the stomach in the setting of intestinal obstruction) the tube removes fluids and gas and helps relieve pain and pressure) was placed on Resident 1 with 1.4 L (liter - basic unit of liquid volume) of dark brown output. The H & P note indicated the CT (Computed Tomography scan - a medical imaging technique used to obtain detailed internal images of the body) result for Resident 1 was consistent with Small Bowel Obstruction. The H & P indicated Resident 1 was noted to be in Acute Renal Failure with Hyperkalemia. During a record review for Resident 1, the hospital document titled, Clinical Notes dated [DATE] at 5:18 a.m. indicated Resident 1 ' s primary problem was Sepsis and Urinary Tract Infection. During a record review for Resident 1, the hospital document titled, Discharge Summary Note dated [DATE] at 9:23 a.m. indicated Resident 1 ' s admitting diagnosis was Septic Shock (the last and most severe stage of sepsis). The Discharge Summary Note indicated Resident 1 died on [DATE]. During an interview with Licensed Staff F on [DATE] at 3:03 p.m., when Licensed Staff F was asked about the facility policy when a resident had vomited, Licensed Staff F stated she would complete the SBAR (Situation, Background, Assessment and Recommendation - a tool used by health care professionals to communicate with each other about critical changes in patient ' s status), initiate a care plan (contain information about a patient's diagnosis, goals of treatment, specific nursing interventions, and an evaluation plan) and give report to the incoming nurse. Licensed Staff F stated resident will be monitored and assessed every shift for seventy two (72) hours for further episode of vomiting. Licensed Staff F stated nurse ' s observation/ assessment of resident will be documented under the progress notes titled, 72 hour charting. When Licensed Staff F was asked what to assess when a resident vomited, Licensed Staff F stated she would check the color and type of the vomitus (matter that has been vomited), check resident ' s vital signs (V/S - clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure), and mental status. During a telephone interview with Family Member H on [DATE] at 5:20 p.m. Family Member H stated she received a call from Resident 1 ' s nurse on Sunday night of [DATE] to inform her that Resident 1 was throwing up. Family Member H stated when she visited Resident 1 on [DATE], Resident 1 complained of severe abdominal pain. Family Member H stated she told the nurse on that same day that Resident 1 had an infection and that the facility need to do something about it; however, Family Member H stated the nurse did not do anything. Family Member H stated Resident 1 was transferred to the hospital via ambulance after 20 hours from the time she visited Resident 1. Family Member H stated Resident 1 died on [DATE] due to sepsis from UTI. During an interview with Licensed Staff G on [DATE] at 3:25 p.m., Licensed Staff G was asked about her nurse ' s note on [DATE] at 10:48 p.m. when she indicated Resident 1 had vomited three times within a 12-hour period. Licensed Staff G stated she received a report from the morning nurse on [DATE] that Resident 1 had vomited once during day shift. Licensed Staff G stated Resident 1 vomited a couple more times on p.m. shift. Licensed staff G stated she obtained an order for Zofran from the doctor. After review of Licensed Staff G ' s nurse ' s notes on [DATE] at 10:48 p.m., Licensed Staff G verified her nurse ' s note about Resident 1 ' s vomiting did not include Licensed Staff G ' s physical assessment of Resident 1, except for checking Resident 1 ' s vital signs. When Licensed Staff G was asked what to assess when a resident vomited, Licensed Staff G stated she was a new nurse when the incident happened with Resident 1 and was not sure how to assess Resident 1. When Licensed Staff G was asked about the facility policy when a resident had vomited, Licensed Staff G stated the resident will be monitored and assessed for complications associated with resident ' s vomiting every shift for 72 hours. After review of Resident 1 ' s progress note with Licensed Staff G, Licensed Staff G verified and stated there was no nurse ' s note on [DATE] from day shift about Resident 1 ' s vomiting episode. Licensed Staff G stated there were no other notes after her [DATE] nurse ' s note about Resident 1 ' s vomiting episode until [DATE] when resident was transferred to the hospital. During a review of the [DATE] MAR for Resident 1 and concurrent interview with Licensed Staff G on [DATE] at 3:28 p.m., the MAR indicated an order written on [DATE] at 6:30 p.m. for Ondansetron 4 mg to be given every 4 hours as needed for nausea and vomiting. Licensed Staff G verified the MAR indicated that first dose of Ondansetron was given at 8:51 p.m. When Licensed Staff G was asked reason for giving the medication at 8:51 p.m. when she received the order at 6:30 p.m., Licensed Staff G stated she gave the medication to Resident 1 at 6:15 p.m.; however, Licensed Staff G stated she forgot to sign off the medication. Licensed Staff G stated she should have signed off the medication as soon as the medication was administered to Resident 1. Review of the document titled Certificate of Death issued on [DATE] for Resident 1 indicated Resident 1 died on [DATE]. The certificate indicated, Immediate Cause (Final disease or condition resulting in death) was Septic Shock and Urinary Tract Infection. The certificate indicated Small Bowel Obstruction was the underlying cause of Septic Shock. Review of the facility policy and procedure titled, Change in a Resident's Condition or Status, revised in February 2021 indicated, The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. ' Review of the facility policy and procedure titled, Documentation of Medication Administration, revised in [DATE] indicated, Administration of medication must be documented immediately after (never before), is given. 2. During a record review for Resident 1, the Colostomy Care Plan initiated on [DATE] indicated, Resident 1 had a colostomy for elimination of stool (feces). The Care Plan indicated interventions including but not limited to: Colostomy care every shift; Monitor Colostomy for patency, adherence, output every shift; During a record review for Resident 1, the document titled Order Summary Report for [DATE] indicated a physician ' s order written on [DATE] for Dulcolax Suppository to be given rectally every 72 hours as needed for constipation. During a record review for Resident 1, the document titled Order Summary Report for [DATE] indicated a physician ' s order written on [DATE] for Milk of Magnesia to be given every 24 hours as needed for constipation. During an interview and concurrent review of the document titled Documentation Survey Report for [DATE] with Licensed Staff A on [DATE] at 2:29 p.m., Licensed Staff A was asked how the nurses monitored Resident 1 to ensure he was not constipated. Licensed Staff A stated she would check Resident 1 ' s bowel record to determine if Resident 1 needed bowel care (refers to a range of activities that help maintain bowel health including but not limited to administering treatments such as enemas [the injection of liquid into the rectum and colon by way of the anus] and suppositories [relieve pain, constipation, irritation, inflammation, nausea and vomiting, fever, migraines, allergies, and sedation]). After review of the Documentation Survey Report for [DATE] for Resident 1 with Licensed Staff A, Licensed Staff A verified Resident 1 did not have colostomy output (stool from the colostomy) on [DATE], 4, 6, 7, 8, 12, 13, and 14. During a review of the [DATE] Medication Administration Record (MAR) for Resident 1, and concurrent interview with Licensed Staff A on [DATE] at 2:36 p.m., Licensed Staff A verified Resident 1 had a physician ' s order for MOM and Dulcolax suppository as needed for constipation. Licensed Staff A verified the MAR did not have licensed nurses ' initials under the MOM and Dulcolax suppository order. Licensed Staff A stated, If there was no licensed nurses initial, the medication was not given. Licensed Staff A stated physician ' s order should be followed as ordered. During an interview with Licensed Staff B on [DATE] at 3:17 p.m., Licensed Staff B was asked what to monitor when a resident had colostomy. Licensed Staff B stated she would check the bowel record if the resident had regular bowel movement. Licensed Staff B stated resident should be provided with ordered bowel care if constipated. Licensed Staff B stated unresolved constipation could result to resident ' s discomfort like vomiting; abdominal pain, abdominal distention, or even fecal impaction (a large, hard mass of stool gets stuck in your rectum or colon and causes a blockage). During an interview and concurrent record review of the document titled Documentation Survey Report for [DATE] with the Clinical Lead on [DATE] at 4:06 p.m., the Clinical Lead stated all residents had a standing order for bowel care if resident had no bowel movement for three days. After review of the of the document titled Documentation Survey Report for [DATE] for Resident 1 with the Clinical Lead, the Clinical Lead verified Resident 1 had no colostomy output on [DATE], and 14. During a review of Resident 1 ' s [DATE] MAR with the Clinical Lead on [DATE] at 4:10 p.m., the Clinical Lead verified Resident 1 had a physician ' s order for MOM and Dulcolax suppository. The Clinical Lead verified there was no licensed nurses ' initials under both medications. The Clinical Lead stated Resident 1 did not received either MOM or Dulcolax suppository when Resident 1 was constipated. Review of the Facility policy and procedure titled, Bowel Management Protocol not dated indicated, It is the policy of this facility to ensure that residents are free from complications secondary to constipation. This will be accomplished through adequate assessment, tracking and treatment as indicated. The policy indicated, The nurse will provide medication as ordered by the physician or obtain a physician's order, to residents on the bowel care list. The medication given should be recorded on the MAR and the bowel care list. 3. During a record review for Resident 1, the Urostomy Care Plan initiated on [DATE] indicated, Resident 1 had a urostomy for urine output. The Care Plan interventions indicated: Provide Urostomy care as ordered; change urostomy appliance per order . Monitor Urostomy every shift for complications; notify MD if any noted . Educate Resident as able regarding care of urostomy and signs/symptoms to look out for . Monitor skin integrity under and around the Urostomy [site] every shift and address any skin issues appropriately. During a record review for Resident 1, the document titled Order Summary Report for [DATE] indicated a physician ' s order written on [DATE] to monitor Resident 1 ' s output (the fluids that leave the body) every shift. During an interview with Unlicensed Staff C on [DATE] at 2:04 p.m. when Unlicensed Staff C was asked if she documented the amount of Resident 1 ' s urostomy output, Unlicensed Staff C stated, no. Unlicensed Staff C stated the POC (Point of Care - an electronic health care record for residents) did not have a place where she could document the amount of the urine output, however, Unlicensed Staff C stated she would document every time she emptied the urostomy bag and reported to the nurse if Resident 1 did not have urinary output. During an interview with Unlicensed Staff D on [DATE] at 2:15 p.m., when Unlicensed Staff D was asked how she documented Resident 1 ' s urostomy output, Unlicensed Staff D stated she used the urinal to measure and documented to POC. During an interview with Unlicensed Staff E on [DATE] at 2:20 p.m., when Unlicensed Staff E was asked how he documented Resident 1 ' s urostomy output, Unlicensed Staff E stated he used the urinal to measure and documented the amount on a separate binder. During an interview and concurrent review of the [DATE] MAR with Licensed Staff A on [DATE] at 2:29 p.m., when Licensed Staff A was asked how Resident 1 ' s urine output was documented, Licensed Staff A stated the CNAs (Certified Nursing Assistant) used a container to measure the urine output and the nurses would document the output in Resident 1 ' s MAR. After review of the [DATE] MAR for Resident 1 with Licensed Staff A, Licensed Staff A verified there was no documentation of Resident 1 ' s urine output in Resident 1 ' s MAR. During an interview with Licensed Staff A on [DATE] at 2:36 p.m., When Licensed Staff A was asked what should nurses monitor when a resident had urostomy, Licensed Staff A stated she would monitor for the amount of the urinary output, color, and odor of the urine. Licensed Staff A stated that decreased urinary output, strong urine odor, dark colored urine, and constipation could be an indication of dehydration (caused by not drinking enough fluid or by losing more fluid than you take in). During an interview and concurrent review of the document titled Order Summary Report with the DON (Director of Nursing) on [DATE] at 3:21 p.m., when asked about her expectations from the nurses on what to monitor when a resident had a urostomy, the DON stated she expected the nurse to monitor the resident ' s intake and output (I & O - the measurement of the fluids that enter the body [intake] and the fluids that leave the body [output]) if there was an order from the resident ' s physician. After review of the [DATE] Order Summary Report for Resident 1 with the DON, the DON verified that there was an order written on [DATE] to monitor Resident 1's intake and output every shift. During a review of the document titled, Documentation Survey Report for [DATE] and concurrent interview with the DON on [DATE] at 4:23 p.m., the DON verified the document indicated, Resident 1 ' s bladder continence (the ability to control movements of the bladder) was documented; however, the document did not indicate Resident 1 ' s urine output was measured and documented. The document indicated no data entry on the following days and shifts: AM shift: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]; NOC shift: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. When the DON was asked if the facility documented the amount of Resident 1 ' s urine output, she stated there was a physician ' s order to monitor Resident 1 ' s I & O, however, she stated the order did not indicate strict I & O where the facility had to measure and document Resident 1's urine output. When the DON was asked how would staff know if Resident 1 had adequate fluid intake or had adequate urine output, the DON stated the doctor did not want the nurses to measure Resident 1 ' s urine output, however, the DON stated, if a resident had medical condition like Congestive Heart Failure, then they would monitor the intake and measure the output of the resident. Review of the Facility policy and procedure titled, Output, Measuring and Recording revised in [DATE] indicated, The purpose of this procedure is to accurately determine the amount of urine that a resident excretes (eliminate waste matter from the body) in a 24-hour period. The policy indicated, Record the amount noted on the output side of the intake and output record. Record in mls. (milliliters - a unit of volume). 4. During a record review for Resident 1, the Nutrition Care Plan initiated on [DATE] indicated interventions to include but not limited to: Assess for dehydration and notify MD: change in LOC, poor skin turgor, dry mucous membranes, decreased and dark urine output change in vital signs. During a record review for Resident 1, the document titled, Order Summary Report for [DATE] indicated a physician ' s order written on [DATE] for Torsemide (diuretic - also called water pill, are medications designed to increase the amount of water and salt expelled from the body as urine) Tablet 20 mg. Give 40 mg by mouth one time a day for Fluid retention (buildup of fluid in the body) related to Heart Failure. During a record review for Resident 1, the document titled Nutrition assessment dated [DATE] indicated Resident 1 ' s estimated fluid needs was 2400 ml. The document indicated fluid estimate was calculated based on 25 ml per kg (kilogram - a metric unit of mass) of Resident 1 ' s body weight. During a record review for Resident 1, the document titled, Weights and Vitals Summary indicated Resident 1 had a body weight of 232.8 lbs. (pounds - unit of measurement) or 105.8 kg. (to convert pounds to kilograms, divide pounds by a factor of 2.2) on [DATE]. During an interview and concurrent review of the [DATE] MAR with Licensed Staff A on [DATE] at 2:29 p.m., when Licensed Staff A was asked how Resident 1 ' s intake and output was documented, Licensed Staff A stated the CNAs used a container to measure the urine output and the nurses would document the I & O in Resident 1 ' s MAR. After review of the [DATE] MAR for Resident 1 with Licensed Staff A, Licensed Staff A verified there was no documentation of Resident 1 ' s I & O in Resident 1 ' s MAR. During an interview with Licensed Staff A on [DATE] at 2:36 p.m., When Licensed Staff A was asked on what to monitor when a resident had urostomy, Licensed Staff A stated she would monitor for the amount of the urinary output, color, and odor of the urine. Licensed Staff A stated decreased urinary output; strong urine odor; dark colored urine; and constipation could be an indication of dehydration. During a review of the MAR for Resident 1 with Licensed Staff G on [DATE] at 3:36 p.m., the MAR indicated an order written on [DATE] for Torsemide tablet to be given to Resident 1 once a day for fluid retention. Licensed Staff G was asked about the risk for Resident 1 on diuretic. She stated Resident 1 could be at risk for dehydration and constipation due to increased urination. Licensed Staff G was asked what should the nurses monitor when Resident 1 was receiving diuretic, Licensed Staff G stated they could monitor Resident 1 ' s weight, intake, and output. During a review of the document titled Nutrition assessment dated [DATE] for Resident 1 and concurrent interview with the DON on [DATE] at 4:02 p.m., the DON verified the document indicated Resident 1 ' s estimated fluid needs was 2400 ml. During a review of the document titled Fluid Intake for Resident 1 and concurrent interview with the DON on [DATE] at 4:02 p.m., the DON verified that from [DATE] to [DATE], Resident 1 ' s documented daily total fluid intake on the following days were as follows: 1640 ml on [DATE]; 960 ml on [DATE]; 600 ml on [DATE]; 240 ml on [DATE]; 480 ml on [DATE]; 680 ml on [DATE]; 2 ml on [DATE]; 1740 ml on [DATE] and; 1440 ml on [DATE]. The DON concurred that Resident 1 ' s documented daily fluid intake was under his estimated fluid needs; however, DON stated Resident 1 had history of refusing to drink and often times did not like the food being served in the facility. The DON stated Family Member H would bring food and drinks for Resident 1; however, the DON stated facility staff were not recording Resident 1 ' s food and fluid intake when food or drink was brought in by Family Member H. The DON was asked if Resident 1 ' s refusal to drink fluid was documented, and what interventions were put in place to ensure Resident 1 was not dehydrated, considering Resident 1 was receiving a diuretic and had a colostomy and urostomy in place. After the DON reviewed Resident 1 ' s Care Plan, she stated there was a care plan initiated on [DATE] which indicated Resident 1 was non-compliant (failure or refusal to comply with something) with nursing care and nursing interventions. Care Plan interventions included: Encourage resident to verbalize concerns that is making him/her to refuse care or procedures . Inform resident of procedures and purpose prior to start . Inform resident of risk and ramifications (consequence of an action) of continued non-compliance . Monitor for significant changes in condition . Respect resident rights to refuse treatment/medications/care . When refusing care, if possible, leave resident and return later to reoffer. The DON concurred the care plan did not specifically indicate Resident 1 was refusing to drink fluid and the interventions did not indicate how the facility will ensure Resident 1 ' s hydration status was maintained to prevent Resident 1 from dehydration, constipation, and urinary tract infection. Review of the Facility policy and procedure titled, Intake, Measuring and Recording revised in [DATE] indicated, The purpose of this procedure is to accurately determine the amount of liquid a resident consumes in a 24-hour period. Under General Guidelines of the policy indicated: - Record the fluid intake as soon as possible after the resident has consumed the fluids. - At the end of your shift, total the amounts of all liquids the resident consumed. - Record all fluid intake on the intake and output record in cubic centimeters (mls).

Based on observation, interview, and record review, the facility failed to protect residents from accidents when: 1. Residents' sinks in the bathrooms between rooms two and three, six and seven, 11 and 12, 13 and 14, rooms 8, 9, 10, 18, 20, 26, 27, the showers in the Green Hall and the Yellow Hall, and a bathroom across from Station 1 accessible to residents were found to have water temperatures greater than 120 degrees Fahrenheit and as high as 138 degrees Fahrenheit. This failure could potentially have resulted in scalds [MEDICAL CONDITION] vulnerable residents with decreased safety awareness or [MEDICAL CONDITION] (damaged nerve endings that can impair the ability to feel hot or cold). On 11/6/18 at 2:22 p.m., due to the facility's failure to maintain safe water temperatures or maintain an adequate system to monitor water temperatures, Administrator and Interim Director of Nursing (IDON) were verbally notified of the Immediate Jeopardy. The Health Facilities Evaluator Nurses informed Administrator and IDON of the survey team's findings that resident sinks and showers had water temperatures greater than 120 degrees Fahrenheit. Immediate Jeopardy is a situation in which a provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident (Standard Operation Manual, Appendix Q). On 11/6/18 at 3:02 p.m., the facility presented a corrective plan of action, including but not limited to: 1) adjust the water temperature regulator, 2) service the water temperature regulator system, 3) develop a new system for monitoring water temperatures, 4) in-service staff to monitor residents' sinks and showers for safe temperatures hourly for 24 hours. On 11/7/18 at 2:15 p.m., the abatement (lifted) of Immediate Jeopardy occurred in the presence of Administrator after interviews, observations, and record review confirmed the facility implemented the corrective plan of action. On 11/13/18 at 3:30 p.m., Administrator was notified of substandard quality of care identified and that the facility was on extended survey. Substandard quality of care means one or more deficiencies related to participation requirements under 42 CFR 483.25 Quality of Care that constitute to immediate jeopardy to resident health or safety (level J, K, or L) (Standard Operation Manual, Appendix PP). 2. The facility failed to ensure resident safety when staff did not implement adequate supervision and assistance for 1 sampled residents (Resident 92) who had poor safety awareness and a history of falls, which led to harm. This failure contributed to Resident 92 falling four times in a six month period from 4/9/18 to 10/19/18. Resident 92 sustained a fractured right wrist/forearm from the fall on 10/17/18. Findings: 1. During an observation on 11/5/18 at 9:30 a.m., the temperature of the water was noted to be very hot to touch from the sink in the shared bathroom between resident rooms six and seven. During an observation on 11/6/18 at 10:31 a.m., residents' hot water from the sink faucets located in residents' bathroom were checked per surveyor thermometer. - room [ROOM NUMBER]: Hot water was at 135.4 º (degrees) F (Fahrenheit) after 15 seconds. - room [ROOM NUMBER]/12 bathroom: Hot water was at 132.8 º F. Resident 4 stated he found the hot water coming from the faucet in his bathroom a little hot. - room [ROOM NUMBER]/14 bathroom: 136.4 º F - room [ROOM NUMBER]/16 bathroom: 105.4 º F - room [ROOM NUMBER] bathroom [ROOM NUMBER] º F - room [ROOM NUMBER] bathroom: 116.4 º F - room [ROOM NUMBER]/3 bathroom: 137.8 º F - room [ROOM NUMBER]/5 bathroom: 118.5 º F - During a concurrent observation and interview, the hot water temperature in room [ROOM NUMBER]/7 bathroom sink faucet was 137.1 º F. Resident 97 stated she found the water temperature in her bathroom was not too hot, but she knew how to adjust the temperature by turning on both the cold and hot water knobs. - Yellow Hall shower: 135.9 º F - Green Hall shower: 122.9 º F - The hot water temperature in bathroom across from the Nurses Station located in the Yellow Hall (Station 1) was 136.8 º F, rose to 138 º F after 10 seconds. During a concurrent observation and interview on 11/6/18 at 12:47 p.m., the hot water temperature in the bathroom shared by the residents in room [ROOM NUMBER]/14 tempt at 136.4 º F. Unlicensed Staff Q tested the hot water and after a few seconds of washing her hands under the hot water, she stated the hot water was way too hot for her to continue washing her hands. Unlicensed staff Q stated she would normally turn on both the hot and cold faucet knobs at the same time. Unlicensed Staff Q stated she had not had residents complain to her about the hot water in their bathroom being too hot, but she could see how there could be an issue if a resident just ran the hot water. Unlicensed Staff Q stated the hot water was extremely hot. Unlicensed Staff Q shook her hands after she put her hands under the hot water and stated the hot water hurt her hands. During an observation on 11/06/2018 at 12:20 p.m., the temperature of water in the following resident rooms was noted per surveyor thermometer: -room [ROOM NUMBER], bathroom sink hot water was 134.2 º F after 29 seconds -room [ROOM NUMBER], bathroom sink hot water was 120.7 º F after 20 seconds -room [ROOM NUMBER], bathroom sink hot water was 134.5 º F after 20 seconds -room [ROOM NUMBER], bathroom sink hot water was 132.6 º F after 20 seconds. During an observation and concurrent interview on 11/6/18 at 12:37 p.m., the water temperature of the following resident room bathrooms' and yellow hall shower (which is shared by all residents) was noted per Maintenance Director thermometer: -Yellow Hall shower room, hand held shower with mixer unit turned to hot, was 126.0 º F -Joint bathroom for rooms 11/12, hot water was 129.0 º F after 20 seconds -Joint bathroom for rooms 13/14, hot water was 130.0 º F after 20 seconds -Joint bathroom for rooms 6/7 , hot water was 133.9 º F after 20 seconds. Maintenance Director stated, boy, that's hot. During an observation on 11/6/18 at 12:37 p.m., temperature of the hot water in room [ROOM NUMBER] bathroom, 124.0 º F after 20 seconds. During an interview on 11/6/18 at 12:27 a.m., Maintenance Director stated, I check temperatures daily and this is done randomly. During an interview on 11/6/18 at 12:55 p.m., Resident 87 stated the hot water in his bathroom, shared by the residents in room [ROOM NUMBER]/12, was pretty hot, but he adjusted the temperature by turning on both the cold and the hot water knobs. Resident 87 stated for those residents who were not able to adjust the water temperature, they would need assistance by a staff member. Resident 87 stated the hot water was too hot to run alone. During an interview on 11/6/18 at 1:06 p.m., Unlicensed Staff A stated she had noticed the water could be too hot. She stated the shower could be hot, but we just have to slowly adjust it. When asked how she keeps residents safe from the hot water in their bathrooms, Unlicensed Staff A stated that the residents who are alert are ok, but the ones who are confused, we make sure we are there in the bathroom with them. Unlicensed Staff A confirmed she had a resident on her hall that was confused but able to move around the facility independently, and she pointed at Resident 83 and stated the resident's room number. Unlicensed Staff A stated she had to check on Resident 83 frequently because she had found her in the bathroom alone before. Unlicensed Staff A stated Resident 83 would sometimes go in the bathroom when Resident 83 felt the urge to void. During an observation on 11/6/18 at 1:10 p.m., Resident 83 sat in her wheelchair next to the Station 1 nurses station. Resident 83 reached down with her left hand and unlocked the brake on the left wheel of her wheelchair, then reached down with her right hand and unlocked the right wheel. During an interview on 11/6/18 at 1:23 p.m., Maintenance Director stated adjustments had been made to the regulator. During an observation on 11/6/18 at 1:23 p.m., the water temperature in the room [ROOM NUMBER] bathroom sink hot water was 112.0 º F after 20 seconds, per surveyor thermometer. During an observation on 11/6/18 at 1:32 p.m., the hot water temperature in the bathroom sink faucets shared by the residents in room [ROOM NUMBER]/12 read 132.6 º F and room [ROOM NUMBER] read 127.6 º F. During a record review on 11/6/18 at 1:40 p.m., a facility document provided by Maintenance Director titled Resident Areas Hot Water Temperature Check Record for (MONTH) (YEAR) indicated the date in the first column. The second column, titled Resident Room, had Red, Yellow, Green, Blue, and Red written after the date. No room numbers were written on the log to indicate which rooms had been checked. The next two columns on the log were titled Time and Temp. The temperatures written in the Temp column were between 112 and 115. The log for (MONTH) had been completed in the same manner with the hall colors written instead of room numbers and temperatures that ranged from 111 to 113. During an observation on 11/6/18 at 1:45 p.m., the temperature of the water in the room [ROOM NUMBER] bathroom sink was 125.4 º F per surveyor thermometer. During a concurrent observation and interview on 11/6/18 at 3:07 p.m., Maintenance Director stated the hot water gauge to the regulator, which monitored the water temperature of the water flowing to the facility read 115 °F. There was a steady stream of water coming from a pipe located near temperature regulator. Maintenance Director stated the leak would not cause the high hot water temperatures. During a concurrent observation and interview on 11/6/18 at 3:15 p.m., Maintenance Director stated he made adjustments to the redundancy valve (This valve will allow water or steam to escape from the water heater if the temperature or pressure gets too high), so the hot water temperatures should have lowered. Residents' hot water from the sink faucets located in residents' bathrooms were checked per surveyor thermometer and Maintenance Director's thermometer simultaneously. Surveyor Temperature Readings Maintenance Director Temperature Readings - room [ROOM NUMBER]/3 112.8 ° F 111.7 ° F - room [ROOM NUMBER]/7 107.6 ° F 106.3 ° F - room [ROOM NUMBER]/12 110.7 ° F 109.5 ° F - room [ROOM NUMBER]/14 107.4 ° F 106.7 ° F - room [ROOM NUMBER] 110.5 ° F 109.7 ° F - room [ROOM NUMBER] 111.4 ° F 111.7 ° F - room [ROOM NUMBER] 91.9 ° F Maintenance Director stated he was going to work on room [ROOM NUMBER]'s bathroom faucet hot water temperature because it was very low. - Maintenance Director stated the redundancy valve had two parts, so he closed off one part, so the other one would override the other valve causing the hot water temperatures to decrease. Maintenance Director stated the hot water system did need to be looked at and he had a call into a plumber. - room [ROOM NUMBER] 92.1 ° F 90.3 ° F - room [ROOM NUMBER] 111 ° F 110.3 ° F - room [ROOM NUMBER] 113.9 ° F 112.9 ° F - Green Shower 103.8 ° F 105.3 ° F - Yellow Shower 105.8 ° F 105.3 ° F - Bathroom across from Nurse's Station in Yellow Hall 112.8 ° F 112.1 ° F During a concurrent observation and interview on 11/6/18 at 3:45 p.m., room [ROOM NUMBER]'s bathroom sink hot water read 129.6 ° F per surveyor's thermometer and 129.3 ° F per Maintenance Director's thermometer. Maintenance Director stated he needed to work on hot water temperature in room [ROOM NUMBER]'s bathroom because the hot water was too hot. During an observation on 11/6/18 at 4:19 p.m., the hot water temperature in the sink faucet located in the bathroom across from Station 1 was extremely hot; surveyor could not wash her hands using only the hot water knob because the hot water was extremely hot to touch. Surveyor checked hot water temperature - Thermometer read 126.8 ° F. The hot water temperature had risen 14 degrees in one hour (At 3:15 p.m. the hot water temperature was 112.8 °F). During an interview on 11/6/18 at 4:38 p.m., Maintenance Director was notified about the hot water temperature rising in the bathroom sink faucet located across from Station 1, who stated valve needed to be fixed. During an observation and interview on 11/6/18 at 4:40 p.m., Maintenance Director was observed to be working on the plumbing of the sink in the bathroom across from Station 1. Administrator stated the reason the water was still hot was that the large tanks full of hot water needed time to cool before the temperatures would even out, just like a thermos. During an interview on 11/7/18 at 9:47 a.m., Plumbing Technician M stated there were a couple of water leaks by the temperature regulator. He stated the leaks were causing a disruption in the pressure of the water which was causing the fluctuations in the temperature of the water. Review of facility maintenance policy and procedure titled Water Supply, Plumbing, and Water Heating System, dated 12/31/15, revealed, 1. Check and record water temperature daily in resident bathrooms, showers, and other rooms used by residents. This is done by taking a representative sampling. Check one or two rooms of each unit that is serviced by an individual boiler or water heater. Check different rooms daily to ensure that all hot water used by residents is checked periodically. California hot water temperatures must not exceed 120 degrees F (49 degrees C). Review of facility job description for Maintenance Director, dated 9/2018, revealed under section titled Essential Duties, Make daily rounds to assure that maintenance personnel are performing required duties and to assure that appropriate maintenance procedures are being rendered to meet the needs of the facility. Review of The Burn Foundation website, burnfoundation.org, revealed Hot water causes third [MEDICAL CONDITION]. in 5 seconds at 140 (degrees) . in 15 seconds at 133 (degrees). Hot tap water is a major cause of burn injury. As with other scald burns, young children and older adults are most at risk. 2. A review of resident 92's Admission Record, dated 6/28/16, indicated Resident 92 had a [DIAGNOSES REDACTED]. As a result, bones become weak and may break from a fall.), and muscle weakness. A review of Resident 92's Quarterly MDS (minimum data set, a clinical assessment process that provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 3/22/18, indicated Resident 92's BIMS (Brief Interview of Mental Status) of 7 (severely cognitively (memory and thinking skills) impaired) and needed one person physical assistance with: 1. transfer (how a resident moves between surfaces including to or from bed, chair, and wheelchair), 2. walking in room and hallway, and 3. toileting. Fall 1 A review of Resident 92's Nurses Progress Notes, dated 4/10/18, and Rehab-Post-Fall Review, dated 4/19/18, indicated Resident 92 had an unwitnessed fall on 4/9/18 at 9:25 p.m. Resident 92 was found sitting on the floor by the bathroom door in her room, facing the hallway. She had moderate amount of blood on her face and on her right lateral elbow. Resident 92 had sustained a 1 cm (centimeter) laceration (tear) to her right eyebrow and a 2 cm x 0.5 cm to her right elbow. Resident 92 was transferred to the local ED (Emergency Department) for evaluation. Review of Resident 92's ED (Emergency Department) Report, dated 4/9/18, indicated Resident 92 sustained a contusion (bruise) and laceration to her right forehead and her right elbow and she had a mild headache and neck pain. A review of Resident 92's Nursing-Post-Fall Review, dated 4/10/18, indicated Resident 92 was at Moderate Risk for falls. During a concurrent interview and record review on 11/9/18 at 3 p.m., Licensed Staff E stated the Annual MDS, dated [DATE], should have indicated the unwitnessed fall Resident 92 had on 4/9/18, and Resident 92's Fall Risk care plan should have been revised accordingly. Resident 92's Fall Risk care plan, initiated 6/29/16, indicated the following interventions: 1. Keep call light or personal items available and easy to reach, 2. Footwear to prevent slipping, 3. Keep environment well lit and free of clutter, 4. Observe for side effects of medication, 5. Orientation to new room and roommate, and 6. Therapy Referral. Resident 92's Fall Risk care plan and ADL (Activities of Daily Living: daily self- care activities. Common ADLs include feeding ourselves, bathing, dressing, grooming, etc.), initiated 1/4/17, indicated the following interventions: 1. Check that wander guard (tracking application designed to prevent persons at risk from leaving a facility unless they are accompanied) 2. Provide visual checks in room and while she ambulates around facility, 3. Provide extensive assist with toileting as needed, provide safety checks, and 4. Provide intermittent supervision when resident ambulates around facility. Resident 92's Fall Risk care plan was not updated after she fell on [DATE], and the care plan did not specify Resident 92 needed one person physical assistance with walking in room, corridor, with toileting, etc. at all times although Resident 92's MDS specified she needed one person physical assistance with transferring and walking. The care plan did not specify how often staff would provide visual checks and the care plan did not mention she used a walker and a wheelchair. Fall 2 Review of Resident 92's Quarterly MDS, dated [DATE], indicated Resident 92 had a BIM score of 7 (severely cognitively impaired), needed one person physical assist with transferring to and from the bed and with toilet use. Review of Resident 92's Nurse's Progress Notes, dated 10/17/18, SBAR (Situation, Background, Appearance, and Review), dated 10/17/18, and Skilled Nursing Facility to Hospital Transfer Form, dated 10/17/18, and ED Report, dated 10/17/18, and Imaging (X-Ray) Report, dated 10/17/18, indicated Resident 92 had an unwitnessed fall in her bedroom as a CNA (Certified Nursing Assistant) was tending to one of Resident 92's roommates. Resident 92's right wrist was bleeding and she was transferred to the ED. An X-Ray indicated Resident 92 had sustained a closed reduction of the distal radius and ulna fractures (wrist/forearm). The ED physician manipulated the wrist and reduced deformity; improved alignment and immobilized arm by applying a plaster splint and a sling. Review of Resident 92's Operative Report, dated 11/1/18, indicated Resident 92 had an open reduction and internal fixation of the displaced right distal radius (wrist) fracture (Open Reduction implies that broken bone is being realigned using surgery. Internal Fixation refers to the hardware used to ensure that the bone is stabilized and held in place so that it able to heal). Resident 92's Fall Risk, care plan, dated 7/20/18, indicated three new interventions: 1. bed in low position, 2. activity programming (exercises, TV programs), and 3. access for pain. and included reminding resident to ask for assistance as needed when walking or transferring. The facility did not specify how they would anticipate Resident 92's needs, who was significantly cognitively impaired, and how often staff would provide visual checks. A review of Resident 92's Nursing-Post-Fall Review, dated 10/18/18, indicated Resident 92 was at Moderate Risk for falls. During a concurrent interview and record review on 11/9/18 at 11:06 a.m., Licensed Staff H stated Resident 92 was non-compliant; she would try to get up on her own. Licensed Staff H stated the CNAs were aware Resident 92 attempted to get up on her own and the CNAs would check on her often. Licensed Staff H stated prior to Resident 92's right wrist/arm fracture, she walked with a cane. Resident 92's Fall Risk care plan did not specify Resident 92 needed a cane while walking. During a concurrent interview and record review on 11/9/18 at 3:10 p.m., Licensed Staff E stated care plans are updated by the MDS Coordinator and nurses as well. Licensed Staff E stated during her MDS review she looked at resident's therapy, RNA (Restorative Nursing Assistant: providing rehabilitative and therapeutic techniques) notes, activities of daily living (ADLs) charted by the CNA, observation of patient and CNA, correct orders, physician notes, etc. Licensed Staff E stated the term provide visual checks was vague, but the term was put on Resident 92's Fall Risk care plan to remind nursing staff to check on Resident 92 because she did not always use her call light when she needed to go to the bathroom, and she did need supervision when she walked. Licensed Staff E stated a new CNA would have to be educated on the residents who needed visual checks. Licensed Staff E stated visual checks meant for nursing staff to check on the resident on regular intervals. During an interview on 11/9/18 at 4:38 p.m., Unlicensed Staff K stated frequent monitoring of a resident meant, depended on the resident and the resident's issue. It could be every 15 minutes or even sooner or not as often. Unlicensed Staff K stated Resident 92 was forgetful. Unlicensed Staff K stated Resident 92 was mainly up in a wheelchair and not walking very much since the fall whereby she sustained a fractured right wrist/arm. Unlicensed Staff K stated Resident 92 liked to do things on her own, but she needed assistance with transferring/walking. During an interview on 11/13/18 at 10:31 a.m., Unlicensed Staff L stated he worked with Resident 92 from 5/17/18 to 7/26/18. Unlicensed Staff L stated Resident 92 was fairly independent, but she needed reminding to use her cane while up walking. Unlicensed Staff L stated Resident 92 was in the RNA program to improve her strength and endurance. During an interview on 11/13/18 at 10:46 a.m., Unlicensed Staff N stated she would get Resident 92 up and walk her to the bathroom; Resident 92 needed assistance with transferring and walking to the bathroom. During an interview on 11/14/18 at 10:30 a.m., Licensed Staff O stated she remembered Resident 92's fall on 10/17/18 due to it was at the change of shift. Licensed Staff O stated prior to Resident 92's 10/17/18 unwitnessed fall with major injury, she needed minimal assist, and she would not use her call light. Licensed Staff O stated Resident 92 always needed to be reminded to use her call light; Resident 92 was confused at times/impulsive. Licensed Staff O stated the staff tried to maintain Resident 92's independence, but she did needed to be spot checked when she walked for safety. Licensed Staff O stated frequency of checking on Resident 92 meant anytime nursing staff passed by Resident 92's room, she should have been spot checked to make sure she was not getting up on her own. Licensed Staff O stated staff really needed to check on Resident 92 often to make sure she was not getting up on her own. Licensed Staff O stated a commode (portable bedside toilet) was placed by Resident 92's bedside after her fall on 10/17/18, but she would not use it. Licensed Staff O stated Resident 92 would not use her call light and she would try to walk to the bathroom on her own. Licensed Staff O stated Resident 92 fell each time attempting to walk and use the bathroom on her own. Licensed Staff O stated a bed alarm was finally placed on Resident 92's bed after she sustained another unwitnessed fall on 10/18/18. Licensed Staff O stated when Resident 92 heard the bed alarm, the noise would remind her not to get up on her own. Fall 3 A review of Resident 92's Nurse's Progress Notes and Fall Risk, care plan, dated 10/18/18, indicated Resident 92 had an unwitnessed fall trying to get up to the bathroom on her own. Resident 92 was found near her bed lying on her back. Resident 92 had forgotten to use call light for assistance. Resident 92 sustained scattered bruising at left arm and a superficial scrape under left arm by elbow Resident 92 stated to staff she had hit her head. The physician was notified and Resident 92 was supposed to see her primary physician on Monday, 10/22/18, because of two falls in two days. A review of Resident 92's Fall Risk care plan, dated 10/18/18, did not indicate any new interventions. Resident 92's Nurse's Progress Notes, dated 10/17/18, indicated a commode was placed next to Resident 92's bed after her 10/17/18 fall with injury fall, but Resident 92's care plan did not mention a bedside commode to be placed next to Resident 92's bed. Nurse's Progress Notes, dated 10/18/18, indicated a bed alarm was placed for safety until further notice, but the bed alarm was not indicated on Resident 92's Fall Risk care plan. There was no updated care plan interventions indicating how often staff would provide visual checks to ensure Resident 92's safety and the care plan did not specify how they would anticipate Resident 92's needs, who was significantly cognitively impaired, and who continued to forget to use her call light and attempted to get up on her own and fall. Fall 4 A review of Resident 92's Nurse's Progress Notes, dated 10/19/18, indicated Resident 92 had an unwitnessed fall and was found on the floor in the bathroom; Resident 92 had hit her head on the bathroom frame door. Resident 92 stated she had a stiff neck. Resident 92's bed alarm was found under a pillow sounding very low. Resident 92 was transferred to local ED for a CT (Computed tomography is a diagnostic imaging test used to create detailed images of internal organs, bones, soft tissue and blood vessels) scan per physician's orders [REDACTED]. CT scan results were negative. During an interview on 11/14/18 at 10:30 a.m., Licensed Staff O stated Resident 92's Fall Risk care plan should have been updated every time she fell with new interventions if needed, to prevent Resident 92 from getting up on her own, which increased her risk of falling. The facility policy/procedure titled Goals and Objectives, Care Plans, revised 4/09, indicated: 1. Care plan goals and objectives are defined as the desired outcome for a specific resident problem, 2. When goals and objectives are not achieved, the resident's clinical record will be documented as to why the results were not achieved and what new goals and objectives have been established. Care plans will be modified accordingly, etc. The facility policy/procedure titled, Assessing Falls and Their Causes, revised 3/18, indicated : 1. The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall, 2. Review the resident's care plan to assess for any special needs of the resident, etc. The facility policy/procedure titled, Assessing Falls and Their Causes, revised 3/18, indicated under Treatment/Management: 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling, for such as [MEDICAL CONDITION] and dizziness, etc. and 2. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation (for example, if the individual continues to try to get up and walk without waiting for assistance).

Based on observation, interview, and record review, the facility failed to develop comprehensive, individualized care plans for four out of 19 sampled residents (Residents 1, 36, 79, and 92) when: 1. Resident 92's care plan did not include interventions appropriate to her needs, accurately reflect her mobility and cognitive status, or give specific expectations for monitoring her safety. 2. Resident 1 did not have use of an antipsychotic medication or behavior monitoring care planned. 3. Resident 36's care plan did not include the number and location of wounds or interventions ordered by the physician to treat the wounds, promote healing, and prevent future wounds. 4. Resident 79's care plan was not updated to reflect their fall status. This failure had the potential to result in insufficient information necessary to meet the needs of vulnerable residents. Findings: 1. A review of resident 92's Admission Record, dated 6/28/16, indicated Resident 92 had a [DIAGNOSES REDACTED]. As a result, bones become weak and may break from a fall), and muscle weakness. A review of Resident 92's Quarterly MDS (minimum data set, a clinical assessment process that provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 3/22/18, indicated Resident 92's BIM (Brief Interview of Mental Status) of 7 (severely cognitively (memory and thinking skills) impaired) and needed one person physical assistance with: 1. transfer (how a resident moves between surfaces including to or from bed, chair, and wheelchair, 2. walking in room and hallway, and 3. toileting. Fall 1 A review of Resident 92's Nurses Progress Notes, dated 4/10/18, and Rehab-Post-Fall Review, dated 4/19/18, indicated Resident 92 had an unwitnessed fall on 4/9/18 at 9:25 p.m. Resident 92 was found sitting on the floor by the bathroom door in her room, facing the hallway. She had moderate amount of blood on her face and on her right lateral elbow. Resident 92 had sustained a 1 cm (centimeter) laceration (tear) to her right eyebrow and a 2 cm x 0.5 cm to her right elbow. Resident 92 was transferred to the local ED (Emergency Department) for evaluation. Review of Resident 92's ED (Emergency Department) Report, dated 4/9/18, indicated Resident 92 sustained a contusion (bruise) and laceration to her right forehead and her right elbow and she had a mild headache and neck pain. A review of Resident 92's Nursing-Post-Fall Review, dated 4/10/18, indicated Resident 92 was at Moderate Risk for falls. During a concurrent interview and record review on 11/9/18 at 3 p.m., Licensed Staff E stated the Annual MDS, dated [DATE], should have indicated the unwitnessed fall Resident 92 had on 4/9/18, and Resident 92's Fall Risk care plan should have been revised accordingly. Resident 92's Fall Risk care plan, initiated 6/29/16, indicated the following interventions: 1. Keep call light or personal items available and easy to reach, 2. Footwear to prevent slipping, 3. Keep environment well lit and free of clutter, 4. Observe for side effects of medication, 5. Orientation to new room and roommate, and 6. Therapy Referral. Resident 92's Fall Risk care plan and ADL (Activities of Daily Living: daily self care activities. Common ADLs include feeding ourselves, bathing, dressing, grooming, etc.), initiated 1/4/17, indicated the following interventions: 1. Check that wander guard (tracking application designed to prevent persons at risk from leaving a facility unless they are accompanied) 2. Provide visual checks in room and while she ambulates around facility, 3. Provide extensive assist with toileting as needed, provide safety checks, and 4. Provide intermittent supervision when resident ambulates around facility. Resident 92's Fall Risk care plan was not updated after she fell on [DATE], and the care plan did not specify Resident 92 needed one person physical assistance with walking in room, corridor, with toileting, etc. at all times although Resident 92's MDS specified she needed one person physical assistance with transferring and walking. The care plan did not specify how often staff would provide visual checks and the care plan did not mention she used a walker and a wheelchair. Fall 2 Review of Resident 92's Quarterly MDS, dated [DATE], indicated Resident 92 had a BIMS score of 7 (severely cognitively impaired), needed one person physical assist with transferring to and from the bed and with toilet use. Review of Resident 92's Nurse's Progress Notes, dated 10/17/18, SBAR (Situation, Background, Appearance, and Review), dated 10/17/18, and Skilled Nursing Facility to Hospital Transfer Form, dated 10/17/18, and ED Report, dated 10/17/18, and Imaging (X-Ray) Report, dated 10/17/18, indicated Resident 92 had an unwitnessed fall in her bedroom as a CNA (Certified Nursing Assistant) was tending to one of Resident 92's roommates. Resident 92's right wrist was bleeding and she was transferred to the ED. An X-Ray indicated Resident 92 had sustained a closed reduction of the distal radius and ulna fractures (wrist/forearm). The ED physician manipulated the wrist and reduced deformity; improved alignment and immobilized arm by applying a plaster splint and a sling. Review of Resident 92's Operative Report, dated 11/1/18, indicated Resident 92 had an open reduction and internal fixation of the displaced right distal radius (wrist) fracture (Open Reduction implies that broken bone is being realigned using surgery. Internal Fixation refers to the hardware used to ensure that the bone is stabilized and held in place so that it able to heal). Resident 92's Fall Risk, care plan, dated 7/20/18, indicated three new interventions: 1. bed in low position, 2. activity programming (exercises, TV programs), and 3. access for pain. and included reminding resident to ask for assistance as needed when walking or transferring. The facility did not specify how they would anticipate Resident 92's needs, who was significantly cognitively impaired, and how often staff would provide visual checks. A review of Resident 92's Nursing-Post-Fall Review, dated 10/18/18, indicated Resident 92 was at Moderate Risk for falls. During a concurrent interview and record review on 11/9/18 at 11:06 a.m., Licensed Staff H stated Resident 92 was non-compliant; she would try to get up on her own. Licensed Staff H stated the CNAs were aware Resident 92 attempted to get up on her own and the CNAs would check on her often. Licensed Staff H stated prior to Resident 92's right wrist/arm fracture, she walked with a cane. Resident 92's Fall Risk care plan did not specify Resident 92 needed a cane while walking. During a concurrent interview and record review on 11/9/18 at 3:10 p.m., Licensed Staff E stated care plans are updated by the MDS Coordinator and nurses as well. Licensed Staff E stated during her MDS review she looked at resident's therapy, RNA (Restorative Nursing Assistant: providing rehabilitative and therapeutic techniques) notes, activities of daily living (ADLs) charted by the CNA, observation of patient and CNA, correct orders, physician notes, etc. Licensed Staff E stated the term provide visual checks was vague, but the term was put on Resident 92's Fall Risk care plan to remind nursing staff to check on Resident 92 because she did not always use her call light when she needed to go to the bathroom, and she did need supervision when she walked. Licensed Staff E stated a new CNA would have to be educated on the residents who needed visual checks. Licensed Staff E stated visual checks meant for nursing staff to check on the resident on regular intervals. During an interview on 11/9/18 at 4:38 p.m., Unlicensed Staff K stated frequent monitoring of a resident meant, depended on the resident and the resident's issue. It could be every 15 minutes or even sooner or not as often. Unlicensed Staff K stated Resident 92 was forgetful. Unlicensed Staff K stated Resident 92 was mainly up in a wheelchair and not walking very much since the fall, whereby she sustained a fractured right wrist/arm. Unlicensed Staff K stated Resident 92 liked to do things on her own, but she needed assistance with transferring/walking. During an interview on 11/13/18 at 10:31 a.m., Unlicensed Staff L stated he worked with Resident 92 from 5/17/18 to 7/26/18. Unlicensed Staff L stated Resident 92 was fairly independent, but she needed reminding to use her cane while up walking. Unlicensed Staff L stated Resident 92 was in the RNA program to improve her strength and endurance. During an interview on 11/13/18 at 10:46 a.m., Unlicensed Staff N stated she would get Resident 92 up and walk her to the bathroom; Resident 92 needed assistance with transferring and walking to the bathroom. During an interview on 11/14/18 at 10:30 a.m., Licensed Staff O stated she remembered Resident 92's fall on 10/17/18 due to it was at the change of shift. Licensed Staff O stated prior to Resident 92's 10/17/18 unwitnessed fall with major injury, she needed minimal assist, and she would not use her call light. Licensed Staff O stated Resident 92 always needed to be reminded to use her call light; Resident 92 was confused at times/impulsive. Licensed Staff O stated the staff tried to maintain Resident 92's independence, but she did needed to be spot checked when she walked for safety. Licensed Staff O stated frequency of checking on Resident 92 meant anytime nursing staff passed by Resident 92's room, she should have been spot checked to make sure she was not getting up on her own. Licensed Staff O stated staff really needed to check on Resident 92 often to make sure she was not getting up on her own. Licensed Staff O stated a commode (portable bedside toilet) was placed by Resident 92's bedside after her fall on 10/17/18, but she would not use it. Licensed Staff O stated Resident 92 would not use her call light and she would try to walk to the bathroom on her own. Licensed Staff O stated Resident 92 fell each time attempting to walk and use the bathroom on her own. Licensed Staff O stated a bed alarm was finally placed on Resident 92's bed after she sustained another unwitnessed fall on 10/18/18. Licensed Staff O stated when Resident 92 heard the bed alarm, the noise would remind her not to get up on her own. Fall 3 A review of Resident 92's Nurse's Progress Notes and Fall Risk, care plan, dated 10/18/18, indicated Resident 92 had an unwitnessed fall trying to get up to the bathroom on her own. Resident 92 was found near her bed lying on her back. Resident 92 had forgotten to use call light for assistance. Resident 92 sustained scattered bruising at left arm and a superficial scrape under left arm by elbow Resident 92 stated to staff she had hit her head. The physician was notified and Resident 92 was supposed to see her primary physician on Monday, 10/22/18, because of two falls in two days. A review of Resident 92's Fall Risk care plan, dated 10/18/18, did not indicate any new interventions. Resident 92's Nurse's Progress Notes, dated 10/17/18, indicated a commode was placed next to Resident 92's bed after her 10/17/18 fall with injury fall, but Resident 92's care plan did not mention a bedside commode to be placed next to Resident 92's bed. Nurse's Progress Notes, dated 10/18/18, indicated a bed alarm was placed for safety until further notice, but the bed alarm was not indicated on Resident 92's Fall Risk care plan. There was no updated care plan interventions indicating how often staff would provide visual checks to ensure Resident 92's safety and the care plan did not specify how they would anticipate Resident 92's needs, who was significantly cognitively impaired, and who continued to forget to use her call light and attempted to get up on her own and fall. Fall 4 A review of Resident 92's Nurse's Progress Notes, dated 10/19/18, indicated Resident 92 had an unwitnessed fall and was found on the floor in the bathroom; Resident 92 had hit her head on the bathroom frame door. Resident 92 stated she had a stiff neck. Resident 92's bed alarm was found under a pillow sounding very low. Resident 92 was transferred to the local ED for a CT (Computed tomography is a diagnostic imaging test used to create detailed images of internal organs, bones, soft tissue and blood vessels) scan per physician's order due to multiple falls in the past 3 days whereby Resident 92 hit her head. CT scan results were negative. During an interview on 11/14/18 at 10:30 a.m., Licensed Staff O stated Resident 92's Fall Risk care plan should have been updated every time she fell with new interventions if needed, to prevent Resident 92 from getting up on her own, which increased her risk of falling. A review of Resident 92's Order Summary Report, dated 7/31/18, indicated Resident 92 started on [MEDICATION NAME] (anti-depressant) 150 mg (milligrams) 1 tablet to be given in the morning, start date of 8/4/18. Resident 92's order for [MEDICATION NAME], dated 9/28/18, indicated to discontinue [MEDICATION NAME] 150 mg 1 tablet on 9/28/18, and start [MEDICATION NAME] 150 mg 2 tablets to be given in the morning, start date of 9/29/18. A review of Resident 92's Annual MDS, dated [DATE], Quarterly MDS, dated [DATE], and Significant change MDS, dated [DATE], all indicated Resident 92 had been on an anti-depressant for 7 days. A review of Resident 92's Care plan for Potential Drug Related Complications Associated With The Use of [MEDICAL CONDITION] Medications, initiated 8/5/16 and last revision 1/3/17, specified side effects for both Trazadone and [MEDICATION NAME] (anti-depressants), monitor for side effects and report to physician, but no revision of the care plan was made when [MEDICATION NAME] was started on 7/31/18. There was no interventions to monitor for side effects of [MEDICATION NAME] and report to physician accordingly. According to Mosby's Nursing Drug Reference drug handbook, 2011, Mosby Inc., an affiliate of Elsevier Inc., side effects of [MEDICATION NAME] are: headache, agitation, dizziness, akinesia (Loss or impairment of the power of voluntary movement), bradykinesia (Abnormally slow or sluggish motor activity and responses), confusion, [MEDICAL CONDITION] (Sudden, abnormal electrical activity in the brain, which could lead convulsions in which a person's body shakes rapidly and uncontrollably), sedation, blurred vision, urinary frequency, suicidal ideation (Thinking about suicide without actually making plans to commit suicide), etc. During an interview on 11/13/18 at 9:38 a.m., Licensed Staff Nurse E stated [MEDICATION NAME] should have been care planned for Potential Drug Related Complications Associated With The Use of [MEDICAL CONDITION] Medications, and the care plan should had been updated accordingly. 2. During a record review on 11/13/18 at 10:08 a.m., Resident 1's face sheet revealed an admitted [DATE], her age as [AGE] years-old, and multiple [DIAGNOSES REDACTED]. Resident 1's physician orders indicated, [MEDICATION NAME] (an antipsychotic medication) 2.5 mg (milligrams, a unit of measure) Give 1 tablet by mouth one time a day every Sun, Mon, Tue, Wed, Thu, Fri for Decreased Safety Awareness; Unrealistic fears related to MAJOR [MEDICAL CONDITION], SINGLE EPISODE, SEVERE WITH PSYCHOTIC FEATURES, dated 11/2/18. Resident 1's MDS, dated [DATE], revealed she had received an antipsychotic medication on seven of the seven previous days. Resident 1's care plan, last reviewed on 8/28/18, did not include behavior monitoring for use of [MEDICATION NAME]. During an interview on 11/14/18 at 2:52 p.m., Licensed Nurse S stated she had been caring for Resident 1 for one year. Licensed Nurse S stated Resident 1 did not have any behaviors she was monitoring for Resident 1's use of [MEDICATION NAME]. Licensed Nurse S denied Resident 1 had exibited any behaviors that were a danger to herself or others, and stated Resident 1 was a friend and advisor to other residents. Licensed Nurse S stated she is not involved in the gradual dose reduction process for [MEDICATION NAME], pharmacy does that. During an interview on 11/14/18 at 3:43 p.m., the Interim Director of Nursing confirmed Resident 1's medical record did not have any behavior monitoring documented for her use of [MEDICATION NAME]. During a concurrent interview, the Director of Nursing stated Resident 1's care plan should include the behaviors being monitored for Resident 1's use of [MEDICATION NAME]. 3. During an observation and concurrent interview on 11/6/18 at 9:11 a.m., Resident 36 was lying on a low-air loss mattress with heel protectors on his feet. Resident 36 stated he had a pressure ulcer on his left heel. During a record review on 11/14/18 at 9:04 a.m., Resident 36's face sheet revealed an admitted [DATE], age of [AGE] years-old, and multiple [DIAGNOSES REDACTED]. Resident 36's physician orders, dated 10/28/18, indicated, Turn patient every 2 hours while in bed, reposition (every) 1 hour while in chair, Pressure redistribution mattress, (Head of bed at) 30 degrees, Heels floated with prevalon boots, Apply barrier cream (diaper cream) twice a day to buttock, Left Leg Wound: Cleans (sic), apply [MEDICATION NAME] wound gel + foam foam (sic) dressing, changed twice a wee (sic), Wound Care Instructions: Coccyx Wound: Cleans (sic), remove any loose tissue. apply Barrier cream than (sic) foam dressing; change (every) 3 days and sooner for saturation. Resident 36's admission assessment of the skin, dated 10/28/18, noted a left heel pressure ulcer, left calf pressure ulcer, and a coccyx (tail bone) pressure ulcer. Resident 36's care plan for focus area Resident has chronic wounds and is currently non-weight bearing, initiated 11/5/18, did not indicate any details about Resident 36's wounds nor list any of the physician orders for wound care or prevention as interventions. The care plan for focus area SKIN: At risk for skin breakdown Decrease (sic) physical mobility, Incontinent of Bowel and Bladder, pressure ulcer, initiated 10/28/18, also did not indicate any details about Resident 36's wounds nor list as interventions any of the physician orders for wound care or prevention. During an interview on 11/14/18 at 3:43 p.m., Director of Nursing confirmed Resident 36's care plan did not include turning the resident every two hours, the pressure redistribution mattress, the prevalon boots, or any of the wound care treatments ordered. Director of Nursing stated her expectation for a care plan for a resident with pressure ulcers would be for each wound to be listed separately, because different wounds are going to require different interventions, and she would expect the physician's orders including treatments to be on the care plan. 4. During a review of the clinical record for Resident 79, the Record of Admission indicated the resident was admitted on [DATE] with a [DIAGNOSES REDACTED]. The clinical record review dated, 6/10/18 at 2:03 p.m. indicated Resident 79 was found by staff sitting on the floor next to the bed. Resident 79 was placed on alert charting and was not found to have any injuries. The clinical record review dated 6/26/18 at 3:00 p.m. indicated a Change in Condition where the Resident attempted to get into bed and slid onto the floor. The clinical record indicated Resident 79 did not sustain any injuries related this fall. During an interview with Licensed Staff Nurse E on 11/8/18 at 11:25 a.m. she stated that if Resident 79 had a fall, then the MDS would have been updated and the care plan would be updated based upon the MDS. Licensed Staff Nurse E could not answer the question as to why Resident 79's fall on 6/10/18 and 6/26/18 were not documented on the care plan as an actual fall without injury. Staff Nurse E could not answer why the MDS was not updated to reflect the falls, I just don't know why, it should be, I just can't answer that. The facility policy/procedure titled Goals and Objectives, Care Plans, revised 4/09, indicated: 1. Care plan goals and objectives are defined as the desired outcome for a specific resident problem, 2. When goals and objectives are not achieved, the resident's clinical record will be documented as to why the results were not achieved and what new goals and objectives have been established. Care plans will be modified accordingly, etc.

Based on observation, resident, family, and staff interviews, record review and document review, the facility failed to ensure three of 18 sampled residents, identified as being at risk for falls (Residents 1, 2, and 15), received adequate supervision and assistance devices to prevent recurring falls (some fall resulted in injuries), when the effectiveness of interventions were not monitored or modified following falls and new interventions to prevent further falls were not developed, with the continuation of falls. 1. Resident 2 fell twice while being transferred by staff, leading to pain and expressed fear and anxiety; 2. Resident 1 had ten unwitnessed falls in six months, some with injuries including a fracture, abrasions, and bruises; and 3. Resident 15 fell and sustained a fracture. The repeated falls caused pain and injury. Injuries had the potential to cause disability, which could diminish the level of functioning and well-being of residents. Findings: 1. Resident 2 was identified by facility documentation, received 9/9/13, as alert and oriented. Resident 2's medical record was reviewed on 9/9/13 at 3:30 p.m. Resident 2 (R2) had [DIAGNOSES REDACTED]. R2 had significant weakness of both legs. A facility occurrence report, dated 3/22/13, indicated R2 was unable to walk due to, "lower extremity paralysis." Resident 2's MDS (an assessment tool) assessments, dated 6/3/13 and 9/3/13, indicated she needed extensive assistance by two or more persons for transfers. R2 was identified as a fall risk on admission and R2's, "At risk for falls," care plan, initiated 9/22/10, indicated she needed, "extensive assist with transfers with two-person assist. Resident is transferred with sliding board" (a board used to assists with transfers). The goal was no falls or fall-related injuries. Interventions included assessing R2's wheelchair for size and safe condition, keeping R2's call light and personal items within reach, keeping the environment free of clutter, observing for medication side effects, and referring to therapy as needed. On 3/22/13, R2 was transferring from a wheeled shower chair to the bed, using a sliding board. One end of the sliding board slipped and R2 began to fall. R2 experienced pain in her left knee. An x-ray identified, "a possible fracture," and computerized tomography scan (CT Scan - a diagnostic tool) indicated, "no definite acute (new) fracture," and a, "depressed, insufficiency-type fracture" (a type of fracture/break). R2 was instructed to wear a knee brace for comfort. Resident 2's, "Left knee injury," care plan, dated 3/23/13, indicated that she slipped off a transfer board during transfer. Interventions included educating the CNAs (Certified Nurse Assistant) on safe transfers. Review of the notes regarding the, "Safe transfers using sliding board," meeting, dated March 26, 27, and 28, 2013, indicated a total of five CNAs attended the classes. Occupational Therapy (OT) notes, dated 4/8/13, indicated Resident 2 had increased, "fear with transfers due to recent fall," which resulted in an, "increased need for assistance," with transfers. OT notes, dated 6/24/13, indicated that R2s, "transfer to/from commode and shower bench can be inconsistent due to varying levels of fatigue." During an interview on 9/11/13 at 8:55 a.m., R2 stated that she had fallen the previous day while transferring from the shower chair to the bed. R2 landed on the floor, on her tailbone, which was still sore. R2 stated, "It makes me afraid. I shower every Tuesday and Friday, and I wonder what's going to happen on Friday." R2 stated that each of the falls occurred while care was being provided by a new CNA (Certified Nursing Assistant) who was unfamiliar with her care. R2 stated, "I think having two CNAs would be safer." During an interview on 9/11/13 at 9:20 a.m., CNA S stated she was assisting R2 return to bed after a shower. CNA S stated she had requested help from another CNA, during R2's transfer, but the other staff member had to leave to assist another resident. The shower chair was at an angle to the bed and facing the head of it. One end of the sliding board was between the back of R2's left thigh and the shower chair. The other end was placed on the surface of the bed. CNA S stated she was holding the end of the sliding board on the bed when the other end slid off the shower chair, and Resident 2 fell to the floor. CNA S was trapped between the bed, the adjacent wall, and R2 on the floor in front of the shower chair. R2's roommate went to get help. CNA S stated the shower chair was wet, and she usually put a towel between the board and chair. CNA S had not used a towel on 9/11/13, because R2, "didn't like it." Observation on 9/13/13 at 10 a.m., indicated the shower chair was approximately 30-inches wide with a white, tubular frame. The chair had square arms that extended to the same height as the back of the chair, and were fixed in place. The seat of the chair was a solid plastic surface with slight texturing. Observation of R2's sliding board indicated that it was approximately 30-inches long; both surfaces were made of wood, smooth and slightly shiny, except for scattered scratches and gouges. During an interview on 9/13/13 at 1:30 p.m., R2 stated she had limited getting out of bed that week because of her fall and the pain in her tailbone. "I also don't get up because I'm afraid to move back into bed." Review of R2's care plan on 9/13/13, indicated that no new interventions were added to her, "At risk for falls," care plan. A new care plan, "Witnessed fall while transferring," dated 9/10/13, included interventions for, "Therapy to evaluate for safe transfer," and, "Transfer with two CNAs." Neither intervention was added to the, "At risk for falls," care plan. 2. Resident 1's clinical records were reviewed on 9/9/13 at 3:15 p.m., and 9/13/13 at 10:30 a.m. He had a history of [REDACTED]. Resident 1's MDS assessment, dated 1/18/13, indicated his cognition (memory) was moderately impaired and he needed limited assistance by one person for transferring. Review of Resident 1's current, "physical functioning deficit (a lack of ability to funtion physically)," care plan, initiated and revised on 1/14/13, indicated he would have assistive devices, as needed, and would receive assistance with bed mobility, dressing, transfers, walking, hygiene, and toileting, as needed. There were no specifics as to how these interventions would be implemented. Resident 1's, "At risk for falls," care plan, initiated 1/1/13, indicated interventions included activity programs, assess wheelchair appropriateness, bed in low position, call light and personal belongings within reach, and therapy referral. The care plan goal was, "No Falls." Following the initiation of the risk for falls care plan, Resident 1 sustained ten (10) falls in six months, all falls were unwitnessed, and he fractured his hip during one of the falls. There was no documented evidence, and the facility was unable to provide evidence, that it developed resident-specific interventions, monitoring, and/or supervision to prevent the continuing falls. When the goal for, "No Falls," was not met, there was no documented evidence that additional pertinent approaches were considered and implemented. Fall 1 - His post fall report, dated 2/13/13, indicated that Resident 1 was attempting to transfer from bed to his wheelchair and fell . There were no injuries noted for this unwitnessed fall. A care plan was initiated to include the intervention, "Remind patient to ask for assistance when needed." This was not added to his long term, "falls risk," care plan. Physician notes, dated 2/27/13, indicated, "His intermittent impulsivity and poor judgment put him at risk for accidents." Additionally, "He may need 1 to 1 staffing due to his intermittent impulsivity. I discussed this with his staff." Interventions to address the impulsivity and poor judgment were not developed/documented. Fall 2 - Post fall report, 3/3/13, indicated Resident 1 was transferring himself without assistance and slid to the floor, sustaining an abrasion to his right arm. Review of his, "resolved," care plan, dated 3/3/13, revealed CNAs were to do routine checks on him and offer assistance to transfer or access bathroom, encourage him to ask for assistance and wait for it to arrive, therapy evaluation, and wheelchair alarm on at all times. These interventions were not added to his long-term, "At risk for falls," care plan. Nurse Practitioner notes, dated 3/14/13, indicated, "Rehab and nursing staff report a change in his personality and more tendency to fall since the end of Feb. He is not as alert. Seems more confused." Resident 1's, "Safety/judgment issues remain concern." There was no documented evidence that these factors were incorporated into interventions to prevent further falls or injuries. Fall 3 - Progress notes, dated 3/18/13, indicated Resident 1 had an unwitnessed fall, without injury, when he got up unassisted, did not put his shoe on, and fell . "Encouraged to wait for assist and use shoes." Fall 4 - Progress notes, dated 3/19/13, indicated Resident 1 had an unwitnessed fall, without apparent injuries, when he attempted to transfer from his chair to his bed. A care plan for the falls, was initiated 3/18/13, and 3/19/13. Interventions included a urology (relating to the urinary tract) consult for chronic urinary frequency and, "encourage to ask for assistance." Fall 5 - Progress notes, dated 3/30/13, indicated Resident 1 had an unwitnessed fall, without injury, when he, "slipped," out of his wheelchair, which was unlocked. His care plan, dated 3/30/13, indicated staff was to, "make sure," that Resident 1's wheelchair was, "locked for transfers and when patient is adjusting himself in it," and, "Remind patient to ask for assistance when needed." Fall 6 - Progress notes, dated 4/7/13, indicated Resident 1 had an unwitnessed fall in his room and was unable to give an understandable answer as to how the fall occurred. The bed was in a higher-than-normal position, without any facility knowledge of why or how. Fall 7 - Progress notes, dated 4/8/13, indicated Resident 1 had an unwitnessed fall and sustained an abrasion to his right hip and bruising to his right arm and leg. The bed again was elevated. His care plan, dated 4/7/13, indicated he had a black and blue area to his right upper thigh, and he was sent to an emergency department for evaluation. Review of Resident 1's x-ray report, dated 4/8/13, revealed he had a right hip fracture. Progress notes, dated 4/8/13, 4/11/13, and 4/17/13, indicated he returned to the facility, with a decrease in his cognitive ability and without surgical intervention for the fracture. Progress notes, dated 4/17/13, indicated that Resident 1, "insisted that he had to stand to toilet, which resulted in multiple falls at bedside," A Foley catheter was inserted. Fall 8 - Progress notes, dated 4/24/13, indicated Resident 1 had an unwitnessed fall, with no injuries, when he attempted to stand without assistance. There was no documented evidence of any new interventions developed, to prevent further falls. Fall 9 - Post-fall notes, dated 5/21/13, indicated Resident 1 had an unwitnessed fall in his room, with no injuries. While attempting to self transfer without assistance, he lost his grip on the transfer pole and fell on the bedside mat. Fall 10 - Progress notes, dated 6/23/13, indicated Resident 1 had an unwitnessed fall, with no injuries. Interdisciplinary Team (staff who meet to discuss residents' care plans) notes, signed on 6/26/13, indicated Resident 1 had cognitive impairment and insisted, "on doing things as he wishes. He tries to empty his own urine drainage bag even though the staff empties for him and this sometimes causes him to fall as he can not keep his balance." Resident 1 told staff that he tried to move from his bed to his chair and his leg, "gave way." The plan was to do another therapy screen, but the facility doubted, "any success as resident is not understanding and cooperative." Review of Resident 1's current, "At risk for falls," care plan, initiated 1/11/13, indicated that the only change in interventions since 1/11/13 were: a. Bed in low position, as tolerated, initiated 1/11/13, and revised on 7/28/13; and b. Transfer pole, initiated 7/28/13. There was no documented evidence of any increased supervision or additional assistive devices to prevent further falls for this, "at risk," resident. During interview, on 9/13/13 at 8:45 a.m., when asked why he did not ask for help and assistance to stand up or transfer, Resident 1 stated, it "takes too long to get here." During interview, on 9/13/13 at 11 a.m., Management Staff N stated that Resident 1 was impulsive and did not listen to staff requests to call for assistance when he stood up. When asked why there were no new interventions attempted to prevent further falls, Management Staff N stated that Resident 1 was his own responsible party and refused alarms. 3. Review of Resident 15's medical record, on 9/12/13 at 10 a.m., indicated that he had been recently admitted following a hospital stay for sepsis (bacterial infection of blood and body tissues) and a fall with a non-displaced fracture (bones in alignment) of the neck of the femur (left hip). Surgical correction of this fracture was not done due to advanced age, advanced dementia, and inability to follow physical therapy instructions. Resident 15 was allowed to weight bear, as tolerated, on the left leg following this fracture. Initial Clinical Status Tool included a potential fall risk and a care plan noted at risk for falls, fell in the past 30 days, and included interventions of bed in low position, keep environment well lit and free of clutter, orientation to room and roommate, and provide assist with toileting needs. Resident 15 was placed in the last resident room on the left side of the hall, away from the nursing station. On 9/3/13 at 3 p.m., Resident 15 was found on the floor of the activity room, no staff witnessed the fall. Nurses notes indicated no pain after the fall, and that Resident 15 stated he was trying to walk and fell . Physician examination the following day, indicated no complaints of pain or tenderness, and he appeared cheerful and in no distress. A Post Fall investigation noted that Resident 15 had impaired safety awareness, seemed unsettled, wanted to get in and out of bed frequently, was hard to re-direct, due to dementia, and had poor short-term memory, often tried to self-transfer without requesting help, and that he continued to deny pain. Recommendations included adding a wheelchair alarm and re-direct him as frequently as necessary. The Medication Administration Record (MAR) indicated that Resident 15 had no pain from 9/3/13, through 9/9/13. On the morning of 9/10/13, Resident 15 complained of severe pain, level 7 of 10 (0 = no pain, 7-10 = severe pain) and was given 20 milligrams (mg) of morphine. On 9/11/13, nurses noted Resident 15 had increasing pain in the left leg with morning care, 20 mg of morphine was given, and the physician was notified, via facsimile, that Resident 15 was crying out in severe pain when the left leg was touched. On 9/12/13, Resident 15 received 20 mg of morphine, after morning care, for a pain level of 7 and was evaluated by a nurse practitioner. The Nurse Practitioner noted that, due to the severe increase in pain, even with the morphine, Resident 15, "exhibited significant pain with any movement," and recommended sending him to a hospital, for evaluation. emergency room records indicated a new fracture of the left greater trochanter (a large projection of the femur, to which are attached various muscles) minimally displaced (not in alignment). After discussion with the family, surgery was not done, due to significant risks of surgery. The physician noted that Resident 15 should not bear weight on the left leg, to allow for healing, and that he could be out of bed in a chair. During an interview, on 9/12/13 at 1:30 p.m. Resident 15's family stated that his roommate had reported that Resident 15 had fallen a couple of days before, when trying to go to the bathroom unassisted, and that staff had not reported any falls after the fall on 9/3/13. The responsible party, stated that while in the hospital, Resident 15 had alarms on both the bed and wheelchair, to alert staff if he tried to move unassisted and did not understand why these measures were not implemented at this facility. During an interview, on 9/12/13 at 4:10 p.m., Management Staff N stated that a wheelchair alarm had not been initiated upon admission, as the noise from these alarms bothered/frightened residents with dementia, and they tried to not use them unless necessary. Review, on 9/13/13 at 11:30 a.m., of the Fall Management Clinical Guidelines, dated revised 2013, included:..."During preadmission intake, determine if the potential resident has a history of falling or if unsteady in gait (walking). Assure that the appropriate fall interventions are in place prior to the resident's admission...The Immediate Plan of Care AT Risk-Falls Risk is initiated..." The Immediate Plan of Care AT Risk-Falls Risk, was not initiated for this, "at risk," resident.