Every finding on record at West Covina Healthcare Center

Based on interview, and record review, the facility failed to implement infection (the invasion and growth of germs in the body) prevention and control practices for one of three sampled residents (Residents 1) by failing to:Ensure Resident 1 was placed on contact precautions (infection control measures used to prevent the transmission of infectious diseases) following a diagnosis of bacterial impetigo (a skin infection).Ensure Resident 1's diagnosis of bacterial impetigo was reported to the Dialysis Center (DC-a facility that provides treatments for residents with kidney failure) prior to receiving treatment on 8/4/2026.These failures had the potential to result in the transmission of disease (an illness or sickness) and infections to residents (in general) in the facility and the DC.Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 3/5/2026 and readmitted Resident 1 on 7/10/2026 with diagnoses including end stage renal disease (ESRD-irreversible kidney failure) and dependence on renal dialysis (a treatment that filters waste and excess fluid from the blood).During a review of Resident 1's History and Physical (H&P), dated 7/13/2026, the H&P indicated Resident 1 was able to make decisions.During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 5/20/2026, the MDS indicated Resident 1's cognitive (the ability to think and process information) skills for daily decision making were intact. The MDS indicated Resident 1 required setup or clean-up assistance (helper sets up or cleans up) with eating, supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with oral hygiene, substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, upper body dressing, and bathing, and was dependent on lower body dressing and personal hygiene.During a review of Resident 1's Change in Condition Evaluation (COC-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 8/3/2026 timed at 3:43 PM, the COC indicated a change in condition of, .bacterial impetigo to both arms diagnose[d] by Nurse Practitioner (NP).During a review of Resident 1's Order Summary Report (OSR), active orders as of 8/3/2026, the OSR did not indicate Resident 1 was placed on contact precautions.During a review of Resident 1's Medication Administration Records (MAR), dated 8/1/2026-8/31/2026, the MAR indicated:Resident 1 received doxycycline hyclate (a medication used to treat bacterial infections) 100 milligrams (mg-a unit of measurement) one time on 8/3/2026 and 8/10/2026 and twice a day on 8/4/2026-8/9/2026 for bacterial impetigo.Resident 1 received dialysis on Tuesday 8/4/2026 from 1:15 PM-4:45 PM at the DC.During an interview on 8/13/2026 at 12:09 PM with the Infection Prevention Nurse (IPN), the IPN stated residents (in general) with bacterial impetigo should be placed on contact precautions. The IPN stated Resident 1 was not placed on contact precautions after being diagnosed with bacterial impetigo. The IPN stated if a resident (in general) is on contact precautions the facility should communicate that to the DC so the resident could either be rescheduled or seen as the last resident for the day. The IPN stated it was important to place Resident 1 on contact precautions to protect the other residents (in general) and prevent the spread of infection.During an interview on 8/13/2026 at 12:39 PM with the Licensed Vocational Nurse (LVN), the LVN stated on 8/3/2026 the NP had diagnosed Resident 1 with bacterial impetigo. The LVN stated Resident 1 was not placed on contact precautions. The LVN stated Resident 1 went to the DC on 8/4/2026 at 12 PM. The LVN stated the DC was not informed of Resident 1's bacterial impetigo diagnosis. The LVN states it was important to let the DC know that Resident 1 had bacterial impetigo to protect the other residents by preventing the spread of infection.During a review of the facility's Policy and Procedure (P&P) titled, Isolation-Categories of Transmission-Based Precautions, revised September 2022, the P&P's policy statement indicated, Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection.and is at risk of transmitting the infection to other residents. The P&P's policy interpretation and implementation indicated, Transmission-based precautions are additional measures that protect staff, visitors and other residents from becoming infected.transmission-based precautions are contact, droplet and airborne .The Centers for Disease Control and Prevention (CDC) maintains a list of diseases, modes of transmission and recommended precautions. The P&P's contact precautions indicated, Contact precautions are implemented for residents known or suspected to be infected with microorganism that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment.During a review of the CDC's Appendix A: Type and Duration of Precautions Recommended for selected infection and condition, dated 2/7/2025, the Appendix indicated the type of precaution used for impetigo was contact and standard (minimum infection prevention measures that apply to all residents) with a duration of 24 hours after the initiation of effective therapy.

Based on interview and record review, the facility failed to provide timeliness diagnostic services to meet the needs for two of three sampled residents (Resident 7 and Resident 8) by failing to: 1. Ensure Resident 7 received a PET scan (Positron Emission Tomography imaging scans- use a radioactive tracer to check for signs of cancer, heart disease and brain disorders) as ordered on 5/21/2026.2. Ensure Resident 8 received a CT scan (A Computerized Tomography scan- is a type of imaging that uses X-ray techniques to create detailed images of the body) for abdominal pain as indicated in the physician's order dated 7/12/2026.These deficient practices resulted in delays in diagnoses services for Resident 7 and 8 and had the potential in worsening Resident 7 and 8's anxiety that could cause emotional and psychosocial distress.a. During a review of Resident 7's admission Record (AR), the AR indicated the facility admitted Resident 7 on 5/8/2026 with diagnoses which included atherosclerotic heart disease (plaque building in the blood vessels that carry oxygen and nutrients from the heart to the rest of the body and the vessels become thick and stiff), presence of cardiac pacemaker (small, battery-powered device that prevents the heart from beating too slowly), and presence of coronary angioplasty implant and graft (can open clogged blood vessels that deliver blood to heart muscles).During a review of Resident 7's History and Physical (H&P), dated 5/11/2026, the H&P indicated Resident 7 has the capacity to understand and make decisions.During a review of Resident 7's Minimum Data Set (MDS, a resident assessment tool), dated 5/15/2026, the MDS indicated Resident 7 had intact cognitive skills (ability to make daily decisions). The MDS indicated Resident 7 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with toileting hygiene, shower/bathe self, lower body dressing and putting on/taking off footwear. The MDS indicated Resident 7 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with eating, oral hygiene, upper body dressing and personal hygiene.During a review of Resident 7's Cardiovascular Consultants (CC- a medical doctor who specializes in diagnosing, treating, and managing diseases of the heart and blood vessels), dated 5/21/2026, the CC indicated PET Scan and Echocardiography Ultrasound (ECHO-uses high-frequency sound waves to create moving pictures of heart's structure and pumping function) were ordered on 5/21/2026.During a review of Resident 7's Progress Notes (PN), dated 5/21/2026, the PN indicated that the resident returned from consultation with cardiology with new orders for ECHO and PET scan.During a review of Resident 7's Progress Notes (PN), dated 6/3/2026, the PN indicated that the resident left for outside appointment to have ECHO and PET scan done.During a review of Resident 7's Progress Notes (PN), dated 6/23/2026, the PN indicated that the resident complaint of having chest pian after waking up.During a review of Resident 7's Progress Notes- Social Services Note (PNSSN), dated 7/6/2026, the PNSSN indicated the resident was unable to complete PET scan due to billing issues.During a review of Resident 7's Progress Notes (PN), dated 7/6/2026, the PN indicated that the resident's PET scan will be re-scheduled due to billing concerns and there is no re-scheduled date.During a review of Resident 7's PNSSN, dated 7/13/2026, the PNSSN indicated the resident's PET scan on 7/14/2026 was cancelled.During a review of Resident 7's Order Summary Report (OSR), dated 7/13/2026, the OSR indicated Resident 7 may have PET Scan (Positron Emission Tomography imaging scans- use a radioactive tracer to check for signs of cancer, heart disease and brain disorders) diagnosis, which was ordered on 6/17/2026. The OSR indicated Resident 7 had a scheduled appointment for PET Scan on 7/14/2026 at 2 PM.During an interview on 7/13/2026 at 10:55 AM with Resident 7, Resident 7 stated that Resident 7 had a PET scan order since 5/21/2026, which was not accomplished until currently. Resident 7 stated that the facility had scheduled Resident 7's PET scan on 6/3/2026, 7/6/2026, and 7/14/2026, and both appointments on 6/3/2026 and 7/6/2026 were cancelled. Resident 7 stated that the facility did not assist Resident 7 to accomplish the PET scan in timely manner, which could cause delayed diagnosis and treatment on Resident 7 health condition and made Resident 7 feel upset and frustrated.During a review of Resident 7's Progress Notes (PN), dated 7/14/2026, the PN indicated that the resident's PET scan will be re-scheduled and there is no re-scheduled date.During a concurrent interview and record review on 7/14/2026 at 1:38 PM with Licensed Vocational Nurse (LVN) 1, Resident 7's current progress notes were reviewed. Resident 7's progress notes indicated Resident 7 turned from consultation with cardiology with new orders for ECHO and PET scan. LVN 1 stated that Resident 7's PET scan ordered since 5/21/2026 had not been completed. The scheduled PET scan on 6/3/2026 and 7/6/2026 were cancelled. LVN 1 stated that the staff should start making a schedule and arrange for the appointment right after getting the order.During a concurrent interview and record review on 7/14/2026 at 2 PM with the Social Service Director (SSD) and Social Service Assistant (SSA), Resident 7's current progress notes and social service notes were reviewed. The SSD and SSA stated that Resident 7's scheduled PET scan on 6/3/2026, 7/6/2026, and 7/14/2026 were cancelled. The SSD and SSA stated the staff should assist scheduling and arranging an appointment right after getting the order.During an interview on 7/15/2026 at 9:38 AM with Resident 7, Resident 7 stated that the scheduled PET scan on 7/14/2026 was cancelled on 7/13/2025 afternoon. Resident 7 stated that Resident 7 had heart problems and the facility delayed the resident's PET scan several times, which could delay Resident 7's treatment.During an interview on 7/15/2026 at 11:58 AM with the administrator (ADM), the ADM stated that the facility is responsible for getting all residents' procedure done even if the procedures need to be done outside the facility.b. During a review of Resident 8's admission Record (AR), the AR indicated the facility admitted Resident 8 on 11/16/2024 with diagnoses which included history of malignant neoplasm of large intestine (commonly known as colorectal cancer- is a serious disease where abnormal cells grow out of control in the colon or rectum), anxiety disorder (involve more than occasional worry or fear, repeated episodes of sudden feelings of intense anxiety and fear or terror that reach a peak within minutes) and hypertension (high blood pressure).During a review of Resident 8's History and Physical (H&P), dated 11/24/2025, the H&P indicated Resident 8 does not have the capacity to understand and make medical decisions.During a review of Resident 8's Minimum Data Set (MDS), dated [DATE], the MDS indicated Resident 8 had severely impaired cognitive skills. The MDS indicated Resident 8 required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During a review of Resident 8's Order Summary Report (OSR), for the month of July 2026, the OSR indicated Resident 8 may have a CT scan of the abdomen and pelvis without contrast diagnosis for abdominal pain, dated 7/12/2026.During a review of Resident 8's Physician's Orders (PO), dated 7/12/2026, the PO indicated that CT abdomen and pelvis were ordered for diagnosis abdominal pain.During a review of Resident 8's Change in Condition Evaluation (CICE), dated 7/12/2026, the CICE indicated that the resident may have a CT abdomen and pelvis without contrast due to abdominal pain.During a review of Resident 8's Care Plan (CP), initiated 7/12/2026, the CP indicated that the resident complaint of abdominal pain and may have CT Abdomen and pelvis.During a review of Resident 8's Progress Notes (PN), dated 7/12/2026, the PN indicated the resident complaint of abdominal pain and may have CT abdomen and pelvis after the resident was examined by the doctor.During a review of Resident 8's current PN, the PN indicated that there is no documentation regarding scheduling CT abdomen and pelvis found after the CT was ordered on 7/12/2026.During a review of Resident 8's current Progress Notes- Social Services Note (PNSSN), the PNSSN indicated that there is no documentation regarding scheduling CT abdomen and pelvis found after the CT was ordered on 7/12/2026.During an interview on 7/15/2026 at 8:25 AM with Resident 8, Resident 8 stated that the facility had not scheduled some diagnostic procedures for several days after the diagnostic procedures were ordered. Resident 8 stated that Resident 8 wanted to get these procedures done as soon as possible and the facility should have scheduled these appointments when getting the orders.During an interview on 7/15/2026 at 11:58 AM with the administrator (ADM), the ADM stated that the facility is responsible for getting all residents' procedure done even if the procedures need to be done outside the facility.During a concurrent interview and record review on 7/15/2026 at 3:45 PM with LVN 1, Resident 8's current orders, dated 7/12/2026, were reviewed. LVN 1 stated that Resident 8 had a CT scan order, with an active order date of 7/12/2026. LVN 1 stated that the staff should start making a schedule and arrange for the appointment right after getting the order.During a concurrent interview and record review on 7/15/2026 at 4:02 PM with Social Service Assistant (SSA), Resident 8's current orders, dated 7/12/2026, were reviewed. The SSA stated the staff should assist scheduling and arranging appointments as soon as possible after notice of the orders.During a review of the facility's policy and procedure (P&P) titled, Lab and Diagnostic Test Results - Clinical Protocol, revised 11/2018, the P&P indicated, 1. The physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. 2. The staff will process test requisitions and arrange for tests. The P&P indicated, Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: Whether the physician has requested to be notified as soon as a result is received. Whether the result should be conveyed to a physician regardless of other circumstances (that is, the abnormal result is problematic regardless of any other factors). Whether the resident/patient's clinical status is unclear or he/she has signs and symptoms of acute illness or condition change and is not stable or improving, or there are no previous results for comparison.The P&P indicated, Physicians or nurses who have concerns about how test results have been handled or reported should communicate such concerns to the DON and/or Medical Director. Such concerns or disagreements should not prevent timely, clinically appropriate management of a current result or clinical situation.During a review of the facility's policy and procedure (P&P) titled, Referrals, Social Services, revised 12/2008, the P&P indicated, Social services personnel shall coordinate most resident referrals with outside agencies. The P&P indicated, 1. Social services shall coordinate most resident referrals. Exceptions might include emergency or specialized services that are arranged directly by a physician or the nursing staff.2. Referrals for medical services must be based on physician evaluation of resident needs and a related physician order.3. Social services will collaborate with the nursing staff or other pertinent disciplines to arrange for services that have been ordered by the physician.4. Social services will document the referral in the resident's medical record.During a review of the facility's policy and procedure (P&P) titled, Social Services, revised 9/2021, the P&P indicated that the social services staff are responsible for making referrals and obtaining needed services from outside entities. The P&P indicated, the facility is responsible for ensuring that all residents are provided these services whether by a staff member or through referrals to an outside agency.

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 4) was not given six medications (vitamin D3- a supplement, amlodipine- used to treat high blood pressure and chest pain [angina], atenolol- used to treat high blood pressure, angina and improve survival after a heart attack, levetiracetam- used to control partial-onset seizures, zinc- a supplement, vitamin C- a supplement) which were not ordered for Resident 4.This failure resulted in Resident 4 received normal saline (a saltwater solution) 1 liter (L, a measurement unit) intravenous bolus (IV bolus- the delivery of a concentrated dose of medication or fluid directly into a vein over a short time, typically taking from 1 to 30 minutes) for lower blood pressure of 83/50 mmHg (milliliter mercury- a measurement unit) after the medication error and was transferred to General Acute Care Hospital (GACH) 1 for evaluation on 7/1/2026. This failure also placed Resident 4 at risk for experiencing adverse consequences (causing physical and/or psychological harm from specific action or treatment) from the medications and impairing the resident's well-being.During a review of Resident 4's admission Record (AR), the AR indicated Resident 4 was originally admitted to facility on 6/10/2026 and readmitted to the facility on [DATE] with diagnoses including Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), presence of cardiac pacemaker (small, battery-powered device that prevents the heart from beating too slowly), and seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness).During a review of Resident 4's History and Physical (H&P), dated 6/11/2026, the H&P indicated Resident 4 has the capacity to understand and make decisions. During a review of Resident 4's Minimum Data Set (MDS, a resident assessment tool), dated 6/30/2026, the MDS indicated Resident 4 had intact cognitive skills (ability to make daily decisions). The MDS indicated that Resident 4 was dependent (helper does all the effort) on staff for toileting hygiene, showering/bathing, lower body dressing, and putting on/taking off footwear.During a review of Resident 4's Change in Condition Evaluation (CICE), dated 7/1/2026, the CICE indicated that wrong medications including vitamin D3 oral tablet, amlodipine oral tablet 5 milligrams (mg- a metric unit of measurement), atenolol oral tablet 25 mg, levetiracetam tablet 500mg, levetiracetam oral tablet 750 mg, zinc oral tablet 50 mg vitamin C oral tablet 500 mg were given to Resident 4 on 7/1/2026. The CICE indicated the resident received normal saline 1L IV bolus for lower blood pressure 83/50 mmHg after the medication error and was transferred to GACH 1 for evaluation on 7/1/2026.During a review of Resident 4's Order Summary Report (OSR) for the month of July 2026, the OSR indicated Resident 4 did not have orders for vitamin D3 oral tablet, amlodipine oral tablet 5 milligrams (mg- a metric unit of measurement), atenolol oral tablet 25 mg, levetiracetam tablet 500mg, levetiracetam oral tablet 750 mg, zinc oral tablet 50 mg vitamin C oral tablet 500 mg.A review of Resident 4's Nursing Progress Note, dated 7/1/2026, the note indicated on 7/1/2021 at 1 pm, basic Life Support (BLS) Ambulance transport arrived and were unable to transfer Resident 4 to GACH 1 due to low BP. The note indicated at 2:04 pm, 911 was called per Physician's order and at approximately 2:10 pm, the paramedics arrived and left the facility at 2:22 pm. Resident 4 was transferring the GACH 1's Emergency Room. During a concurrent interview and record review on 7/10/2026 at 3:10 PM with Registered Nurse (RN) 2, Resident 4's CICE, dated 7/1/2026, was reviewed. RN 2 stated that wrong medications not ordered for Resident 4 were given to Resident 4 on 7/1/2026.During an interview on 7/10/2026 at 3:38 PM with the Director of Nursing (DON), the DON stated that wrong medications were given to Resident 4 on 7/1/2026 due to not verifying the resident accurately. The DON stated it is important to follow the policy to verify the residents accurately to administer the medications and prevent medication administration error.During a review of the facility's policy and procedure (P&P) titled, Administering Medication, revised 4/2019, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed. The P&P indicated, The individual administering medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the residents include:a. checking identification band;b. checking photographs attached to medical record; andc. if necessary, verifying resident identification with other facility personnel.The P&P indicated, The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on interview and record review, the facility failed to ensure the medical record for one of three sampled residents (Resident 7) was accurately documented when the nurse documented Resident 7's PET scan (Positron Emission Tomography imaging scans- use a radioactive tracer to check for signs of cancer, heart disease and brain disorders) was done in Resident 7's Progress Notes (PN) on 6/3/2026 instead of not being done in fact.This deficient practice resulted in inaccurate documentation in Resident 7's medical record and had the potential for delaying interventions and services for Resident 7.During a review of Resident 7's admission Record (AR), the AR indicated the facility admitted Resident 7 on 5/8/2026 with diagnoses which included atherosclerotic heart disease (plaque building in the blood vessels that carry oxygen and nutrients from the heart to the rest of the body and the vessels become thick and stiff), presence of cardiac pacemaker (small, battery-powered device that prevents the heart from beating too slowly), and presence of coronary angioplasty implant and graft (can open clogged blood vessels that deliver blood to heart muscles).During a review of Resident 7's History and Physical (H&P), dated 5/11/2026, the H&P indicated Resident 7 has the capacity to understand and make decisions.During a review of Resident 7's Minimum Data Set (MDS, a resident assessment tool), dated 5/15/2026, the MDS indicated Resident 7 had intact cognitive skills (ability to make daily decisions). The MDS indicated Resident 7 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with toileting hygiene, shower/bathe self, lower body dressing and putting on/taking off footwear. The MDS indicated Resident 7 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with eating, oral hygiene, upper body dressing and personal hygiene.During a review of Resident 7's Cardiovascular Consultants (CC- a medical doctor who specializes in diagnosing, treating, and managing diseases of the heart and blood vessels), dated 5/21/2026, the CC indicated PET Scan and Echocardiography Ultrasound (ECHO-uses high-frequency sound waves to create moving pictures of heart's structure and pumping function) were ordered on 5/21/2026.During a review of Resident 7's Progress Notes (PN), dated 5/21/2026, the PN indicated that the resident returned from consultation with cardiology with new orders for ECHO and PET scan.During a review of Resident 7's Progress Notes (PN), dated 6/3/2026, the PN indicated that the resident left for outside appointment to have ECHO and PET scan done. The PN indicated that the resident returned back from having ECHO and PET scan done.During an interview on 7/13/2026 at 10:55 AM with Resident 7, Resident 7 stated that Resident 7 had a PET scan order since 5/21/2026, which was not accomplished until currently. Resident 7 stated that the facility had scheduled Resident 7's PET scan on 6/3/2026, 7/6/2026, and 7/14/2026, and both appointments on 6/3/2026 and 7/6/2026 were cancelled. Resident 7 stated that the facility did not assist Resident 7 to accomplish the PET scan in timely manner, which could cause delayed diagnosis and treatment on Resident 7 health condition and made Resident 7 feel upset and frustrated.During an interview on 7/15/2026 at 9:38 AM with Resident 7, Resident 7 stated that the scheduled PET scan on 7/14/2026 was cancelled on 7/13/2025 afternoon. Resident 7 stated that Resident 7 had heart problems and the facility delayed the resident's PET scan several times, which could delay Resident 7's treatment.During a concurrent interview and record review on 7/15/2026 at 3:45 PM with Licensed Vocational Nurse (LVN) 1, Resident 7's current progress notes were reviewed. LVN 1 stated that Resident 7's PET scan ordered since 5/21/2026 had not been completed yet and the scheduled PET scan on 6/3/2026, 7/6/2026, and 7/14/2026 were cancelled. LVN 1 stated that LVN 1 documented wrong with the ECHO and PET scan done on 6/3/2026 regardless the fact that the PET scan was cancelled on 6/3/2026. LVN 1 stated that it is important to accurately document the fact to reflect the resident still needs schedule and get the PET scan done as soon as possible.During a concurrent interview and record review on 7/15/2026 at 2:40 PM with the Director of Nursing (DON), Resident 7's current progress notes were reviewed. The DON stated that Resident 7's PET scan was not done on 6/3/2026 and Resident 7's progress notes on 6/3/2026 were inaccurately documented. The DON stated it is important to accurately document to reflect the resident health status and the services provided.During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, revised 3/2019, the P&P indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The P&P indicated, Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.During a review of the facility's policy and procedure (P&P) titled, Lab and Diagnostic Test Results - Clinical Protocol, revised 11/2018, the P&P indicated, 1. The physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. 2. The staff will process test requisitions and arrange for tests. The P&P indicated, Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: Whether the physician has requested to be notified as soon as a result is received. Whether the result should be conveyed to a physician regardless of other circumstances (that is, the abnormal result is problematic regardless of any other factors). Whether the resident/patient's clinical status is unclear or he/she has signs and symptoms of acute illness or condition change and is not stable or improving, or there are no previous results for comparison.

Based on interview and record review, the facility failed to develop and implement a care plan for Resident 1's pain in the left shoulder. This deficient practice had the potential for Resident 1 receiving delayed, inadequate and/or inappropriate care and treatment and to not maintaining Resident 1's highest practicable physical, mental, and psychosocial well-being. During a review of Resident 1's admission Record (AR), dated 5/8/2026, the AR indicated Resident 1 was originally admitted to the facility on [DATE]. The AR indicated Resident 1's diagnoses included morbid obesity (a chronic disease in which a person weighs 100 pounds or more over his/her ideal body weight), chronic pain syndrome (a condition where persistent pain lasts for more than 3 to 6 months), and spinal stenosis (the narrowing of the tunnel in a person's spine that contains the spinal cord and nerves). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 3/3/2026, the MDS indicated Resident 1's cognition (ability to make daily decisions) was intact and Resident 1 was dependent (helper does all the effort to complete the activity) on staff for toileting hygiene, to shower/bathe, for upper body dressing, and lower body dressing. During a review of Resident 1's Change of Condition (COC - a specific documentation that describes when the condition or care needs of a resident has changed), dated 9/29/2025, the COC indicated Resident 1 reported pain on Resident 1's left shoulder after Resident 1 tried to pull Resident 1's blanket over Resident 1's shoulder during the previous evening. The COC indicated Resident 1's doctor was made aware of Resident 1's left shoulder pain. During a review of Resident 1's X-ray (an imaging test that uses radiation to take pictures of the inside of a person's body) report of the left shoulder, dated 10/31/2025, the X-ray report indicated Resident 1's left shoulder had no signs of a fracture (broken bone) or dislocation (when the left upper arm bone pops out of its socket). The X-ray report indicated Resident 1 had moderate degenerative joint disease (a condition where the protective coating that cushions the ends of a person's bones gradually wears away). During an interview on 5/7/2026 at 9:31 AM with Resident 1, Resident 1 stated Resident 1 recalled injuring left shoulder approximately nine months ago while Resident 1 was at the facility but could not recall which staff member Resident 1 reported the injury to. Resident 1 stated Resident 1 received an X-ray of the left shoulder which showed severe arthritis. Resident 1 stated about 1-2 months ago, Resident 1 was hospitalized due to pain in the left shoulder, in which Resident 1 received an ultra-sound (a test where high frequency sound waves are used to take pictures of inside a person's body). During a review of Resident 1's COC, dated 3/6/2026, the COC indicated Resident 1's doctor gave an order to send Resident 1 to the emergency room at a General Acute Care Hospital (GACH) after Resident 1 reported severe left shoulder pain that was not relieved by pain medications. The COC indicated the left shoulder was noted to be swollen. During a review of Resident 1's venous duplex (VD - also known as an ultrasound test) report, dated 3/6/2026, the VD report indicated there was no blood clot found in Resident 1's left upper arm. During a review of Resident 1's Nursing Progress Note, dated 3/6/2026, Resident 1 returned to the facility from GACH 1 via ambulance. The Nursing Progress Note indicated Resident 1's doctor was made aware of Resident 1's return and did not give any new doctor's orders. During a concurrent interview and record review on 5/7/2026 at 2:33 PM with Registered Nurse 1 (RN 1), Resident 1's care plan was reviewed. RN 1 stated licensed nurses, including any nurse who was involved when a resident had a change of condition, were responsible for creating or updating a resident's care plan. RN 1 stated the purpose of a care plan was to address a resident's needs. RN 1 stated a care plan was the basis of resident care because it described the interventions (actions) that the nursing staff needed to provide to the resident. RN 1 stated if there was a change in a resident's condition, a resident's care plan must be reviewed to determine if goals and interventions needed to be created or updated. RN 1 stated Resident 1 did not have a care plan specifically addressing Resident 1's left shoulder pain. During a concurrent interview and record review on 5/7/2026 at 3:25 PM with Licensed Vocational Nurse 1 (LVN 1), Resident 1's care plan was reviewed. LVN 1 stated a care plan consisting of issues that were specific to a resident, along with the goals and interventions that addressed each specific issue. LVN 1 stated if there was a change in a resident's condition, the licensed nurses must either update the care plan or create a new care plan that addresses a specific issue. LVN 1 stated care plans were important because they directed the staff on how to provide appropriate care for the residents. LVN 1 stated Resident 1's care plan did not contain any issues, goals, or interventions specifically related to Resident 1's left shoulder pain. During an interview on 5/7/2026 at 3:44 PM with Director of Nursing (DON), DON stated a care plan identifies a specific problem for a resident and contains interventions that are designed to address the specific problem. DON stated care plans are important because they guide the approach that nursing staff take in providing resident care. DON stated care plans are also a way to measure whether a resident is improving or not. DON stated a change in condition is any new issue that affects a resident's overall health. DON stated examples of a change of condition include new pain that is reported by a resident. DON stated if a resident experiences a change in condition, a care plan should be created or updated because the nursing staff needs to be aware of the problem and how to address it. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, the P&P indicated it is the facility's policy that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The P&P indicated that the comprehensive, person-centered care plan.describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being, including.which professional services are responsible for each element of care. The P&P further indicated Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.

Based on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Release of Information, for one of four sampled residents (Resident 1). This failure violated the rights of Resident 1's responsible party (RP- a relative or friend who handles the patient's finances and helps with medical decisions) to obtain a copy of Resident 1's medical records within the time frame indicated in the facility's P&P on release of medical records. Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was re-admitted to the facility on [DATE] with diagnoses including cerebral ischemia (blood flow to the brain was blocked or reduced) and type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). The AR indicated Resident 1's daughter was Resident 1's RP. The AR indicated Resident 1 was discharged on [DATE]. During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated [DATE], the MDS indicated Resident 1 had moderately impaired cognition (ability to think). During a review of Resident 1's Record of Death (ROD) dated [DATE], the ROD indicated Resident 1 expired on [DATE]. During a review of a request for release of Resident 1's medical records from Legal Services 1 (LS1) to the facility dated [DATE], the request indicated it was received by the facility on [DATE]. During an interview on [DATE] at 12:43 pm with the Medical Records Director (MRD), the MRD stated the facility received the request from LS1 on [DATE] to release Resident 1's medical records to LS1. The MRD stated the MRD had difficulty retrieving Resident 1's medical records from the back of the facility because the medical records were in boxes and the MRD had physical limitations. The MRD stated the facility's policy indicated seven working days to send the medical records upon request, but the MRD sent Resident 1's record to LS1 after seven days of request. The MRD stated the MRD initially sent Resident 1's medical records via the link provided by LS1 on [DATE] and again on [DATE]. The MRD stated it was important for the resident's responsible party to have timely access to the resident's medical records because the medical records could be needed for court or litigation. During an interview on [DATE] at 12:20 pm with the facility's Director of Nursing (DON), the DON stated the facility could not easily locate Resident 1's chart, and when they did, the medical records were released to LS1. The DON stated it was the resident or resident's responsible party's right to request a copy of the resident's medical records and receive it timely because it may have been needed for legal purposes and for continuity of care, if the resident was alive. During a review of the facility's P&P titled, Release of Information, revised 11/2009, the P&P indicated medical records may be released by the written consent of the resident or his/her legal representative (sponsor), consistent with state laws and regulations. The P&P indicated, a resident may obtain photocopies of his or her records by providing the facility with at least a forty-eight (48) hour (excluding weekends and holidays) advance notice of such request. The P&P indicated, a resident may have access to his or her records within 24 hours (excluding weekends or holidays) of the resident's written or oral request.

Based on interview and record review, the facility failed to initiate neurological assessment (a check of how well the brain, nerves, and muscles work often performed after a suspected head injury) for two of eight sampled residents (Residents 1 and 2) after a resident-to-resident physical altercation (a fight or struggle where people used physical force, contact, or aggression against each other) that involved allegations of unwitnessed head injuries on 12/20/2025. These failures had the potential to compromise Residents 1's and Resident 2's health and safety.Findings: a. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control), and metabolic encephalopathy (brain dysfunction caused by a chemical imbalance in the body). During a review of Resident 1's History and Physical (H&P), dated 7/12/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 10/10/2025, the MDS indicated Resident 1 had severe cognitive impairment (confusion or memory loss). The MDS indicated Resident 1 required setup assistance from staff with oral hygiene. The MDS indicated Resident 1 required supervision from staff with eating, toileting hygiene, personal hygiene, bed-to-chair transferring, and using the wheelchair. The MDS indicated Resident 1 required moderate assistance (helper did less than half the effort) from staff with showering. During a review of Resident 1's Change in Condition (COC), dated 12/20/2025, the COC indicated in the morning of 12/20/2025, Certified Nurse Assistant (CNA) 1 observed Resident 1 crying and covering left eye with hand. The COC indicated Resident 1 was holding a sandal with the other hand to demonstrate that Resident 2 hit Resident 1. The COC indicated Resident 1 sustained left eye redness. The COC further indicated that the neurological assessment was not done because it was not clinically applicable to the COC. During a review of Resident 1's Post-Event Review (PER), dated 12/20/2025, the PER indicated on 12/20/2025 at 12:15 PM, Resident 1 reported that Resident 2 hit Resident 1 on the face with a sandal. During an interview with Registered Nurse (RN) 1 on 1/2/2026 at 10:49 AM, RN 1 stated a neurological assessment must be performed on a resident with an unwitnessed head injury to check alertness, cognition, pupil response, responsiveness, and reflexes to make sure the resident was cognitive stable. RN 1 stated the licensed nurse assigned to care for the resident must check vital signs (measurements of temperature, heart rate, breathing rate, blood pressure), pain level, oxygen saturation (amount of oxygen in the blood), and blood sugar if resident was diabetic. RN 1 stated neurological assessments must be started right away if the suspected head injury was unwitnessed or if there was facial redness. RN 1 stated the neurological assessment should be done every 15 minutes for the first hour, every 30 minutes for the next hour, followed by hourly, every two hours, every four hours, and then every shift for total of 72 hours. RN 1 stated all findings should be documented on the neurological assessment form in the resident's medical record. RN 1 stated that the professional standard was not met when the staff failed to initiate a neurological assessment for the residents with an unwitnessed face injury, as this could have resulted in missing any potential changes or injuries. During a concurrent record review and interview with RN 1 on 1/2/2026 at 10:49 AM, Resident 1's Vital Summary (VS) dated 12/20/2025 to 12/23/2025 was reviewed. RN 1 stated the VS indicated no neurological assessment was done for Resident 1 after the resident-to-resident physical altercation on 12/20/2025. RN 1 stated the cause of Resident 1's left eye redness was unwitnessed and the licensed nurse should have initiated the neurological assessment on 12/20/2025. During a concurrent record review and interview with RN 1 on 1/2/2026 at 10:49 AM, Resident 1's medical record, including the Nursing Progress Notes (NPN), dated 12/20/2025 to 12/23/2025 was reviewed. RN 1 stated there were no neurological assessments documented on Resident 1's medical record after the unwitnessed resident-to-resident physical altercation on 12/20/2025. b. During a review of Resident 2's AR, the AR indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia and encephalopathy. During a review of Resident 2's H&P, dated 12/11/2024, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had moderate cognitive (ability to understand) impairment. The MDS indicated Resident 2 required supervision from staff with eating. The MDS indicated Resident 2 required moderate assistance from staff with oral hygiene and personal hygiene. The MDS indicated Resident 2 required maximal assistance (helper did more than half the effort) from staff with toileting hygiene, showering, bed-to-chair transferring, and walking. During a review of Resident 2's COC, dated 12/20/2025, the COC indicated in the morning of 12/20/2025, CNA 1 observed Resident 2 in emotional distress because of a physical disagreement with Resident 1. The COC further indicated that the neurological assessment was not done because it was not clinically applicable to the COC. During a review of Resident 2's PER, dated 12/20/2025, the PER indicated on 12/20/2025 at 12:15 PM, Resident 2 reported that Resident 1 hit Resident 2 with a sandal on face when Resident 2 was sitting at the foot of the bed. The PER indicated Resident 2 hit Resident 1 on left face. During a concurrent record review and interview with RN 1 on 1/2/2026 at 10:49 AM, Resident 2's VS dated 12/20/2025 to 12/23/2025 was reviewed. RN 1 stated the VS indicated no neurological assessment was done for Resident 2 after the resident-to-resident physical altercation on 12/20/2025. RN 1 stated Resident 2's allegation of Resident 1 hitting Resident 2's face with a sandal was unwitnessed and the licensed nurse should have initiated the neurological assessment on 12/20/2025. During a concurrent record review and interview with RN 1 on 1/2/2026 at 10:49 AM, Resident 2's medical record, including the Nursing Progress Notes (NPN), dated 12/20/2025 to 12/23/2025 was reviewed. RN 1 stated there were no neurological assessments documented on Resident 2's medical record after the unwitnessed resident-to-resident physical altercation on 12/20/2025. During an interview with the Director of Nursing (DON) on 1/2/2026 at 11:28 AM, the DON stated a neurological assessment should be initiated for any unwitnessed face and head injury. The DON stated the purpose of the neurological assessment was to determine if there were changes in residents' mental status and vital signs. The DON stated that neurological assessments helped nurses decide if residents, especially those on blood thinners, needed hospital transfer to prevent blood clot in brain. The DON stated it was important for the licensed nurse to initiate the neurological assessment immediately after an incident involving allegation of unwitnessed face or head injury, even without visible injuries on residents. The DON stated it was important to document incidents and neurological assessments in residents' medical records and documentation served as evidence to support the incident and to ensure no negative outcome. The DON stated the licensed nurses should have followed the neurological assessment frequency as indicated in the facility's Policy and Procedure (P&P) titled Fall Management Program. During a concurrent record review and interview with the DON on 1/2/2026 at 12:30 PM, the facility's P&P titled Neurological Assessment, dated 10/2010, was reviewed. The P&P indicated a neurological assessment should be done following a fall or other accident or injury involving head trauma or a suspected head injury. The P&P indicated staff should always include frequent vital signs when assessing neurological status. The P&P further indicated that staff should document the neurological assessment's date and time, the names and titles of those performing it, all assessment data, the resident's tolerance or refusal with reasons and interventions, and the signature and title of the person documenting in the resident's medical record. The DON stated Residents 1 and 2's unwitnessed physical altercation on 12/20/2025 indicated the neurological assessment should have been done. During a review of the facility's P&P titled Fall Management Program, dated 3/13/2021, the P&P indicated the neurological check frequency was every 15 minutes for an hour, then every 30 minutes for an hour, then hourly for four hours, and finally every four hours for 66 hours or until discontinued by the physician, or after 72 hours if the resident was stable without neurological symptoms.

Based on interview and record review, the facility failed to develop and implement a specific and person - centered care plans for two of two sampled residents (Resident 73 and Resident 99). These deficient practices had the potential for Resident 73 and Resident 99 to not receive appropriate care, treatment, and/or services related to their needs.Findings: a. During a review of Resident 73's admission Record (AR), the AR indicated Resident 73 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 73 was readmitted with diagnoses that included Carbapenem-resistant Enterobacterales (a group of bacteria that were resistant to powerful antibiotics called carbapenems, making infections [harmful germs entered and grew in the body] hard to treat) and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) status. During a review of Resident 73's Minimum Data Set (MDS, a resident assessment and care screening tool), dated 11/14/2025, the MDS indicated Resident 73 had clear speech, had limited ability to make self-understood, and responded adequately to simple and direct communication. The MDS indicated Resident 73 had severe cognitive impairment (confusion or memory loss). The MDS indicated Resident 73 was dependent (helper did all the effort) on staff with oral hygiene, toileting hygiene, personal hygiene, and transferring. The MDS indicated Resident 73 had a feeding tube. During a review on Resident 73's Initial History and Physical (H&P), dated 2/17/2025, the H&P indicated Resident 73 did not have the capacity to understand and make decisions. During a concurrent record review and interview with Licensed Vocational Nurse 3 (LVN 3) on 12/4/2025 at 3:39 PM, Resident 73's care plan titled Risk for infection at gastrostomy-tube (GT) site, initiated on 12/17/2024, was reviewed. LVN 3 stated the care plan goals included having no infection at GT site daily. LVN 3 stated the care plan did not indicate any specific interventions to address infection control. LVN 3 stated the purpose of the care plan was to inform staff about how to provide the appropriate resident care. LVN 3 stated the care plan interventions should be patient-centered and specific because every resident was different. LVN 3 stated staff should provide proper care to residents according to their needs. LVN 3 further stated Resident 73's care plan interventions should include monitoring for signs and symptoms of infection, such as redness, discharge, and pain. LVN 3 stated it was important to have a patient-centered and specific care plan. During an interview with the Director of Nursing (DON) on 12/5/2025 at 8:43 AM, the DON stated the purposes of the care plan were to inform staff about residents' care, identify any issues, set goals, and develop interventions to provide proper care. The DON stated that the care plan should be comprehensive (full, thorough, and all-inclusive), specific, and patient-centered for the residents. The DON stated that a non-specific care plan could lead to unclear interventions and possible delays in necessary care. b. During a review of Resident 99's AR, the AR indicated Resident 99 was admitted to the facility on [DATE], with diagnoses that included spinal stenosis (a narrowing of the spine that could cause pain, numbness, or weakness) and infection on the surgical site. During a review of Resident 99's MDS, dated [DATE], the MDS indicated Resident 99 had clear speech, had the ability to understand and make self-understood. The MDS indicated Resident 99 had intact cognitive skills for daily decision making (ability to think and reason). The MDS indicated Resident 99 required partial assistance (helper did less than half the effort) with oral hygiene and personal hygiene. The MDS indicated Resident 99 required substantial assistance (helper did more than half the effort) with toilet hygiene, showering, and transferring. During a review of Resident 99's H&P, dated 9/4/2025, the H&P indicated Resident 99 had the capacity to understand and make decisions. During a concurrent record review and interview with Treatment Nurse 1 (TN 1) on 12/4/2025 at 1:40 PM, Resident 99's care plan for surgical site infection, initiated on 9/4/2025, the care plan goals included resolving the surgical site infection. TN 1 stated the care plan intervention indicated the charge nurse should document for sign and symptoms of surgical site infection for four days. TN 1 stated it was important to implement the care plan intervention. TN 1 stated that without documentation, there was no proof of action. TN 1 stated the care plan's purpose was to ensure proper patient care through interventions. During a concurrent record review and interview with TN 1 on 12/4/2025 at 1:40 PM, Resident 99's Medication Administration Record (MAR), dated 9/4/2025 - 9/8/2025, was reviewed. The MAR indicated no documentation on monitoring signs and symptoms of surgical site. TN 1 stated the licensed nurse should have documented on the MAR. During a concurrent record review and interview with TN 1 on 12/4/2025 at 1:40 PM, Resident 99's Treatments Administration Record (TAR), dated 9/4/2025 - 9/8/2025, was reviewed. The TAR indicated no documentation on monitoring signs and symptoms of surgical site. TN 1 stated the licensed nurse should have documented on the TAR. During a concurrent record review and interview with TN 1 on 12/4/2025 at 1:40 PM, Resident 99's Nursing Progress Notes (NPN), dated from 9/4/2025 - 9/8/2025, were reviewed. The NPN indicated no documentation on monitoring signs and symptoms of surgical site. TN 1 stated the licensed nurse should have documented on the NPN. TN 1 stated it delayed the necessary care and increased the risk of infection without the documentation. During an interview with the Minimum Data Set Coordinator (MDS C) on 12/4/2025 at 2:30 PM, the MDS C stated that the care plan's purpose was to help nurses determine the type of care needed for the residents. The MDS C stated it was important to implement the care plan intervention to manage the risk of infection. The MDS C stated all nursing staff providing care to the residents should have reviewed and followed the care plan. During an interview with Infection Preventionist Nurse 1 (IPN 1) on 12/4/2025 at 2:50 PM, IPN 1 stated the licensed nurse should document in the nursing progress note, daily assessment, and treatment notes every shift. IPN 1 stated the licensed nurse should document monitoring for any surgical site redness, swelling, tenderness, and pain. IPN 1 stated that documentation ensured infections didn't worsen. IPN 1 further stated the documentation facilitated communication among staff providing resident care and helped doctors determine necessary care, keeping everyone informed about the resident's condition. IPN 1 stated it was important to document for four days outlined in the care plan to avoid risks and ensure quality care. IPN 1 stated monitoring and documenting for infection signs and symptoms were parts of the nursing care. During a review of the facility's Policy and Procedure (P&P) titled Care Plans, Comprehensive Person-Centered, revised 3/2022, the P&P indicated the facility should develop and implement a comprehensive, person-centered care plan for each resident.

Based on observation, interview, and record review, the facility failed to follow proper food storage and handling practices by failing to label and discard expired food items stored in the facility's kitchen and residents' refrigerator. The facility failed to ensure:1.The kitchen staff removed expired food items from the kitchen refrigerator: a total of five [5] individually packaged peanut butter and jelly (PBJ) half sandwiches inside a white plastic container and a pack of flour tortillas.2. The facility staff removed the following expired food items from the residents' refrigerator:- A Jumbo oven roasted chicken,- A container with yellow liquid inside,- A container covered with foil paper,- A brown paper bag with multiple food items inside,- A plastic bag with three (3) ice cream bars,- A fast-food meal container with leftover food,- A bag of corn tortillas,- A bag of grated Parmesan cheese. 3. To label resident's personal food items inside the residents' refrigerator with the resident's name or room number including the date received and the expiration date. This deficient practice has the potential to result in pathogen (germ) exposure to residents and places them at risk for developing foodborne illness (food poisoning), with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever, which can lead to hospitalization.Findings:During initial observation and interview inside the kitchen's refrigerator in the presence of the Dietary Supervisor (DS) on 12/2/2025 at 8:20 AM, observed five (5) individually packaged peanut butter and jelly (PBJ) half sandwiches inside a white plastic container with label indicating use by date of 12/1/2025. DS stated the sandwiches are made by the Cook. The DS stated that if there are any expired food items, the staff should have checked and thrown them away. DS stated, We are not supposed to mix expired foods with non-expired foods. It can be given to the residents by accident and cause them stomach problems and make them sick. During concurrent observation and interview inside the facility's kitchen's refrigerator in the presence of DS on 12/2/2025 at 8:29 AM, observed a pack of flour tortillas with a Date of 11/8/2025 and a use by date of 11/20/2025. DS stated there was no way to know when the pack of tortillas was opened since the Date section did not specify if it was an open date and confirmed if they were dated with a use by date of 11/20/2025, then the tortillas were expired. DS further stated, We can't give these food items to the patients. If it is expired, it can make them sick or cause them vomiting and diarrhea. It is considered a foodborne illness. During an interview with DS in the residents' Activity Room on 12/2/2025 at 8:41 AM, the DS stated that the residents' refrigerator has food items that are used for residents' cooking activities or snacks. DS stated the residents' refrigerator contained food that was brought in for residents by their friends and family. Per DS, all the food received for residents is placed inside the refrigerator by the nurses or certified nursing assistants (CNAs). DS stated the residents' food inside the refrigerator must have a label indicating the residents name, room number, and must be dated with the day it was received or opened and must include a use by or expiration date. During an observation of the residents' refrigerator in the Activity Room in the presence of the DS and Activity Staff (AS1) on 12/2/2025 at 8:44 AM, the following was observed:-A jumbo oven roasted chicken with a date of 11/27/2025, but it did not specify whether that was the open date or the expiration date.- A plastic tumbler container with yellow liquid inside with no date or name of the liquid.- A plastic container was covered with foil and labeled Activity with the date of 11/27/2025, but it did not specify whether the food item inside was opened or expired on that date.- A large brown paper bag containing a variety of food items with the date of 11/30/25.- A plastic bag containing three (3) ice creams with no use by or expiration date.- A plastic bag dated 11/4/2025 with a fast-food Styrofoam container inside.- A bag of corn tortillas indicating Activities and dated 11/16/2025, but it did not specify whether the bag was opened on that day or if it expired on that day.- A bag of grated Parmesan cheese, labeled for Activities and dated 11/16/2025, but it did not specify whether the bag was opened on that day or if it expired on that day. During an interview with AS1 on 12/2/2025 at 8:50 AM, AS1 stated the food items in the residents' refrigerator need to be checked for an expiration date. Per AS1, if the food items only have one date, the staff will not know if the items are expired. AS1 stated that some of the food items inside the residents' refrigerator (the corn tortillas and the shredded cheese) were used for the residents' cooking class. AS1 further stated that, according to the facility's policy, in order to keep residents' food items inside the refrigerator, the items need to have a date and can not be expired. Per AS1, if the food item is expired, it should be discarded because it could make residents sick, even if stored in the refrigerator. During a concurrent interview with AS1 on 12/2/2025 at 8:56 AM, AS1 stated the DS should check the residents' refrigerator daily to make sure the residents food inside the refrigerator was not expired. Per AS1, in order to prevent having expired food inside the residents' refrigerator, the labels placed on the food items need to have the open date and the expiration date or use by date. During an interview with the Infection Prevention Nurse (IPN) on 12/2/2025 at 9:07 AM, IPN stated that once a food item is placed inside the residents' refrigerator, it is considered to be expired after 72 hours and must be discarded. Per IPN, if any of the residents eat expired food, they can have rotavirus (a highly contagious virus causing severe watery diarrhea and vomiting) which can cause the patients to experience nausea, vomiting, and diarrhea and can make them sick. Per IPN, if the food items do not have a specific date such as a use by or expiration date, it is considered to be expired and cannot be given to the residents because they need to be prevented from getting sick. A review of the facility's Policies and Procedures (P&Ps), titled Food Receiving and Storage, revised 11/2022, the P&P indicated, Foods shall be received and stored in a manner that complies with safe food handling practices. The P&P indicated:All foods stored in the refrigerator or freezer are covered, labeled, and dated ( use by date). Refrigerated foods are labeled, dated, and monitored so they are used by their use by date, frozen, or discarded. All foods belonging to residents are labeled with the resident's name, the item and the use by date. Beverages are dated when opened and discarded after twenty-four (24) hours. A review of the facility's P&P, titled Foods Brought by Family/Visitors, revised 3/2022, the P&P indicated, Food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety of residents. The P&P indicated, Food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that is clearly distinguishable from facility-prepared food. Perishable foods are stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers are labeled with the resident's name, the item and the use by date. The nursing staff will discard perishable foods on or before the use by date.

Based on observation, interview, and record review, the facility failed to implement infection (harmful germs entered and grew in the body) control measures for two of two sampled residents (Residents 73 and Resident 103) by failing to: a. Rinse off the syringe used for administering gastrostomy-tube (G-tube, a surgical opening fitted with a device to allow feedings to be administered directly into the stomach. It is commonly used for people with swallowing problems) medication for Resident 73. b. Follow Enhanced Barrier Precautions (EBP, a resident-centered and activity-based approach for preventing multidrug resistant organism [MDRO, microorganisms that are resistant to multiple antibiotics, making them difficult to treat and control]) during Resident 103's linen change when the facility staff did not wear the required Personal Protective Equipment (PPE, an equipment worn to minimize exposure to illnesses). These failures had the potential to result in cross contamination (the process by which bacteria were transferred from one surface or object to another). These deficient practices placed Resident 73 and Resident 103 at risk for infection which could increase the morbidity (the amount of disease in a population) and mortality (the state of being subject to death).Findings: a. During a review of Resident 73's admission Record (AR), the AR indicated Resident 73 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The AR indicated Resident 73's diagnoses included Carbapenem-resistant Enterobacterales (CRE, a group of bacteria that were resistant to powerful antibiotics [a substance used to kill bacteria and to treat infections] called carbapenems, making infections hard to treat), respiratory failure (a medical condition in which the lungs cannot get enough oxygen [a gas essential for humans] into the blood or remove enough carbon dioxide [a waste product] from the blood), and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach, commonly used for people with swallowing problems) status. During a review of Resident 73's Minimum Data Set (MDS, a resident assessment tool), dated 11/14/2025, the MDS indicated Resident 73 had clear speech, had limited ability to make self-understood, and responded adequately to simple and direct communication. The MDS indicated Resident 73 had severe cognitive impairment (confusion or memory loss). The MDS indicated Resident 73 was dependent (helper did all the effort) on staff with oral hygiene, toilet hygiene, personal hygiene, and transferring. The MDS indicated Resident 73 had a feeding tube. During a review on Resident 73's Initial History and Physical (H&P), dated 2/17/2025, the H&P indicated Resident 73 did not have the capacity to understand and make decisions. During a review on Resident 73's Care Plan Report for Risk for infection at gastrostomy-tube (G-tube) site, initiated on 12/17/2024, the care plan goals included having no infection (harmful germs entered and grew in the body) at G-tube site daily. The care plan indicated staff to maintain G-tube. During a concurrent medication administration observation and interview with Licensed Vocational Nurse 1 (LVN 1) on 12/4/2025 at 8:52 AM, in Resident 73's room, LVN 1 did not rinse off the syringe after the G-tube medication administration and placed it back into the pole bag (a transparent medical container designed to safely store a G-tube syringe between uses). LVN 1 stated she did not need to do anything to the syringe after flushing water to Resident 73's G-tube following the medication administration. LVN 1 stated she could just put the syringe back in the pole bag. During an interview with Infection Preventionist Nurse 1 (IPN 1) on 12/4/2025 at 10:55 AM, IPN 1 stated the licensed nurse who used the G-tube syringe should rinse it off with running water before returning it back to the pole bag because of the infection control protocol. IPN 1 stated that medication buildup in the G-tube could cause bacteria to sit and grow, leading to infection. IPN 1 stated the G-ube was reusable and changed every 24 hours. IPN 1 stated the licensed nurse must follow the infection control protocols, as improper handling could lead to stomach infection with signs and symptoms of nausea, vomiting, fever, or diarrhea among residents. IPN 1 stated it negatively affected the quality of care. During an interview with Director of Nursing (DON) on 12/5/2025 at 8:50 AM, the DON stated that it was the standard of nursing care to rinse off the G-tube syringe with water after each use. The DON stated the purpose of it was to make sure there was no medication or any kind of liquid residue in the G-tube syringe. The DON stated the medication residue in the G-tube syringe might mix with other medications and cause interaction (one medicine changed the way another medicine worked and caused unexpected side effects). The DON stated medication residue might have caused sediment that clogged the G-tube, leading to malfunction. During a review of the facility's Policy and Procedure (P&P), titled Maintaining Patency of a Feeding Tube (Flushing), revised 11/2018, the P&P indicated to clean reusable equipment according to the manufacturer's instructions. During a review of the manufacturer's instruction for the G-tube syringe used by the facility ([Brand Name] Enteral Feeding Syringe), undated, the manufacturer's instruction indicated staff should rinse syringe thoroughly with tap water greater or equal to 37 degrees Celsius (temperature scale) immediately after each use until the original content had been cleared. The manufacturer's instruction indicated that the staff should submerge the tip of syringe in water, draw up water into the barrel (clear tube portion of the syringe used to hold liquid nutrition, water, and medication), then push water through nozzle lumen using the plunger (part of the syringe used to push liquid nutrition or water into a feeding tube). The manufacturer's instruction further indicated staff should rinse the syringe including the inside surface of the barrel, the stopper, the nozzle lumen, and the outside. The manufacturer's instruction indicated that staff should thoroughly dry the syringe with non-shedding cloth prior to placing it into the pole bag. b) During a review of Resident 103's admission Record (AD), the AD indicated Resident 103 was originally admitted to the facility on [DATE] with diagnoses that included but not limited to encounter for attention to gastrostomy, candidal stomatitis (a fungal infection in the mouth), and urinary tract infection (UTI, infection in the urine). During a review of Resident 103's History and Physical Examination (H&P), dated 11/28/2025, the H&P indicated Resident 103 does not have the capacity to understand and make decisions. During a review of Resident 103's MDS, dated [DATE], the MDS indicated Resident 103 had severe cognitive impairment (never/rarely made decisions) and was dependent (helper does all of the effort, resident does none of the effort to complete the activity) on staff for eating, oral hygiene, toileting hygiene, shower/bathing, upper and lower body dressing, and personal hygiene. During a review of Resident 103's Order summary Report (OSR) for active orders as of 12/3/2025, the OSR indicated, Enhanced Barrier Precautions due to: G-tube and pressure ulcers (skin and tissue damage from prolonged pressure) with an order date of 11/26/2025. During a review of Resident 103's Care Plan Report (CP), initiated on 11/27/2025, the CP indicated, Resident requires Enhanced Barrier Precautions (EBP) related to gastrostomy tube (G-tube) and coccyx (tailbone) PU2 (pressure injury stage 2, partial thickness skin loss, like a scrape). The CP's Interventions section indicated, Provide gowns and gloves at door entry, use gowns and gloves during high contact resident care activities (dressing, bathing, transfers, hygiene, toileting, brief changes, changing lines, device care, wound care). During an observation of the facility on 12/02/2025 at 9:52 AM, EBP sign was posted outside Resident 103's room. It was observed that CNA2 was making the bed for Resident 103 while not wearing gown. During an interview with Certified Nursing Assistant (CNA2) inside Resident 103's room on 12/02/2025 at 9:54 AM, CNA2 stated Resident 103 is on EBP because Resident 103 has wounds. CNA2 stated Resident 103 had just been repositioned by CNA2 about 10 minutes ago. CNA2 stated that if there is a sign posted for EBP outside Resident 103's room, CNA2 should wear gown, gloves, and mask if coming into contact with Resident 103, Resident 103's linen, or belongings. CNA2 stated that wearing a gown is for precautions and to prevent infections or germs that can spread to staff and other residents. CNA2 stated, If I come into contact with residents that are on EBP, then I need to wear a gown for safety. If I don't wear a gown, I can spread germs to other residents. During an interview with Licensed Vocational Nurse (LVN2) on 12/02/2025 at 10:10 AM, LVN2 stated that for EBP, staff must wear gowns, and gloves if providing close contact care to residents. Per LVN2, some patients are on EBP due to having wounds or G-tubes. LVN2 stated that if staff don't wear gowns while providing care to patients on EBP, they can get infections, and can also expose other residents to germs and bacteria. LVN2 further stated, We can spread germs to other patients too, it is an infection control. We have been told we need to wear gowns, it also says so on the EBP sign posted outside the patients rooms. During an interview with Housekeeping Staff (HKP1) on 12/02/2025 at 10:20 AM, HKP1 stated that if a patient is on EBP, that means they have an infection. Per HKP1, if staff walk into a room where a resident is on EBP, the staff need to wear the reusable gowns and place them inside the dirty linen bin before they leave the room. HKP1 stated, We hardly ever get in services on infection control, they should provide us with more education to prevent any infection to myself and the patients. The patients are fragile. During an interview with Registered Nurse Supervisor (RN1) on 12/03/2025 at 3:26 PM, RN1 stated for EBP all the staff must wear gown, gloves, and mask if coming into contact with a patient who is on EBP to prevent cross contamination or spread of germs to other residents and staff. During an interview with Infection Prevention Nurse (IPN1) on 12/04/2025 at 10:18 AM, IPN1 stated EBP is just a precaution method for staff when coming into close contact with a resident. Per IPN1, there's no infection going on. IPN1 further stated, This is what I teach the staff during in-services. If staff is caring for a resident that is on EBP, the staff needs to be using the gown and gloves to provide morning care or dressing the patient because they are coming into contact with the patient. If any of the staff go in the resident's room who is on EBP and they are touching anything in the area or proximity to the resident, they must be wearing a gown and gloves. Once they are done providing care, then they can remove the gown and place it inside the bin. During a review of the facility's P&Ps, titled, Enhanced Barrier Precautions, revised 7/2022, the P&P indicated, Enhanced Barrier Precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. The P&P indicated the examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: e. Changing Linens. The P&P indicated EBPs are indicated (when contact precaution do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization.

Based on interview and record review the facility failed to obtain written informed consent for one of five sampled residents (Resident 4) for the use of psychotropic (any medication capable of affecting the mind, emotions, and behavior) medication. This deficient practice had the potential for Resident 4 not to receive adequate or sufficient information regarding psychotropic medications necessary to make an informed health care decision.Findings: During a review of Resident 4's admission Record (AR), the AR indicated Resident 4 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD- type of obstructive lung disease characterized by long-term poor airflow), depression (a feeling of severe sadness or hopelessness) and anxiety (emotion characterized by an unpleasant state of inner turmoil). During a review of Resident 4's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 1/21/2025, the MDS indicated Resident 4 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 4 was dependent (helper does all of the effort) to staff for toileting, showering, lower body dressing and putting on/off footwear. The MDS indicated Resident 4 needed maximum assistance (helper does more than half the effort) from staff for upper body dressing and personal hygiene. During a review of Resident 4's Physician's Order (PO) dated 12/1/2025, the PO indicated for licensed staff to administer Lexapro (antidepressant - a medication that change the way the brain uses certain chemicals to regulate mood and behavior) one tablet 10 milligrams (mg-unit of measurement) by mouth one time a day for depression manifested by verbalization of sadness. During an interview on 12/3/2025 at 10:23 am with Resident 4, Resident 4 stated nursing staff have not discussed with him taking Lexapro nor asking the resident for a consent to take Lexapro. During a concurrent interview on 12/3/2025 at 10:25 am with the facility's Assistant Director of Nursing (ADON) and review of Resident 4's medical record (PointClickCare - PCC, a cloud-based software), the ADON stated, Resident 4's Informed Consent Psychoactive Medication form for Lexapro was not signed by Resident 4 and Resident 4's physician. The ADON stated licensed nurses should have verified the medication upon admission with the ordering physician and ensure a consent was obtained from the resident. The ADON stated the risks and benefits of psychotropic medications should be discussed to Resident 4 upon admission to ensure Resident 4 was aware of the adverse effects (harmful effects) of the medication. During a review of the facility's Policy and Procedure (P&P) titled, Psychotherapeutic Medication Use, dated 6/2021, the P&P indicated, It is the responsibility of the attending health care practitioner to inform the resident and/or resident representative of the initiation, reason for use, and the risks associated with the use of psychotropic medications, per facility policy or applicable state regulation. The informed consent will be obtained by the Prescriber prior to initiation of the psychotropic medication. The Facility shall verify informed consent prior to the administration of a psychotropic medication for a resident.

Based on interview and record review, the facility failed to ensure the Advance Directive (AD, a written instruction, recognized under State law relating to the provision of health care when the individual is incapacitated [lacking the ability to meet essential requirements for physical health, safety, or self-care]) for one of two sampled residents (Resident 46) was readily accessible in accordance with the facility's Policy and Procedure (P&P) titled Advance Directives. This failure had the potential for facility staff to provide medical treatment and services against the resident's will. Findings: During a review of Resident 46's admission Record (AR) the AR indicated Resident 46 was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD- type of obstructive lung disease characterized by long-term poor airflow) and difficulty in walking. During a review of Resident 46's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 11/26/2025, the MDS indicated Resident 46 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 46 was dependent (helper does all of the effort) from staff for shower, lower body dressing and putting on/taking off footwear. The MDS indicated Resident 46 needed maximum assistance (helper did more than half the effort) to staff for oral hygiene, toileting hygiene, upper body dressing and personal hygiene. During an interview and concurrent record review on 12/2/2025 at 11:08 am, with Registered Nurse 1 (RN 1) of Resident 46's medical records (chart and PointClickCare [PCC, a cloud-based software]), RN 1 stated there was no AD in Resident 46's chart and PCC. RN 1 stated, RN1 could not find the existing AD of Resident 46 in the chart nor PCC. RN 1 stated, Resident 46's AD needed to be accessible in the chart for staff to identify the resident's medical wants and wishes in case of an emergency. During an interview and record review on 12/2/2025 at 11:17 am, with the Social Service Designee (SSD), the SSD stated the facility requested a copy of Resident 46's AD but the SSD was unable to find the copy in Resident 46's chart. The SSD stated, Resident 46's AD should be accessible to determine the resident's wishes in case of an emergency and in situations when the resident would not have the capacity to make decision. During an interview on 12/3/2025 at 9:19 am, with the facility's Assistant Director of Nursing (ADON), the ADON stated, the resident's AD should be uploaded in PCC and readily accessible by the staff. The ADON stated Social Service was responsible for getting a copy of the resident's AD and medical records designee will upload the AD in PCC. During a review of the facility's P&P titled, Advance Directives, dated 9/2022, the P&P indicated prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. The P&P indicated the resident, or representative is provided with written information P&P indicated, if the resident or resident's representative has executed one or more advance directive(s), or executes one upon admission, copies of these documents are obtained and maintained in the same section of the residents medical record and are readily retrievable by any facility staff.

Based on interview and record review, the facility failed to ensure Resident 4's target behavior was monitored for the use Lexapro (antidepressant - antidepressant - a medication that change the way the brain uses certain chemicals to regulate mood and behavior) for one of five sampled residents (Resident 4) as indicated in the facility's Policy and Procedure (P&P) titled Psychotropic Medication Use. This deficient practice had the potential to result in the use of unnecessary psychotropic drug, which may result in significant adverse (harmful) consequences to Resident 4. Findings: During a review of Resident 4's admission Record (AR), the AR indicated Resident 4 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD- type of obstructive lung disease characterized by long-term poor airflow), depression (a feeling of severe sadness or hopelessness) and anxiety (emotion characterized by an unpleasant state of inner turmoil). During a review of Resident 4's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 1/21/2025, the MDS indicated Resident 4 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 4 was dependent (helper does all of the effort) to staff for toileting, showering, lower body dressing and putting on/off footwear. The MDS indicated Resident 4 needed maximum assistance (helper does more than half the effort) from staff for upper body dressing and personal hygiene. During a review of Resident 4's Physician's Order (PO) dated 12/1/2025, the PO indicated for licensed staff to administer Lexapro one tablet 10 milligrams (mg-unit of measurement) by mouth one time a day for depression manifested by verbalization of sadness. During a concurrent interview and record review on 12/3/2025 at 9:40 am with the facility's Assistant Director of Nursing (ADON) of Resident 4's medical records (PointClickCare - PCC, a cloud-based software), Resident 4's Order Summary Report (OSR) for active orders as of 12/3/2025 did not indicate the specific target behavior for the use of Lexapro. The facility's ADON stated it was important for the licensed nurse to monitor the target behavior of the residents every shift to determine if the medication was effective or not. During a review of the facility's P&P titled, Psychotherapeutic Medication use, dated 6/2021, the P&P indicated, Facility staff should monitor residents' behavior pursuant to Facility policy using a behavioral monitoring chart or behavioral assessment record for residents receiving psychotropic medication for BPSD. Facility staff should monitor behavioral triggers, episodes, and symptoms. Facility staff should document the number and/or intensity of symptoms and the resident's response to staff interventions.

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool) was accurately coded for surgical wound for one of one sampled resident (Resident 99). This failure had the potential to place Resident 99 at risk of not receiving necessary care services. Findings: During a review of Resident 99's admission Record (AR), the AR indicated Resident 99 was admitted to the facility on [DATE], with diagnoses that included spinal stenosis (a narrowing of the spine that could cause pain, numbness, or weakness) and infection (harmful germs entered and grew in the body) on the surgical site. During a review of Resident 99's Minimum Data Set (MDS, a resident assessment tool), dated 9/8/2025, the MDS indicated Resident 99 had clear speech, had the ability to understand and make self-understood. The MDS indicated Resident 99 had intact cognitive skills for daily decision making (ability to think and reason). The MDS indicated Resident 99 required partial assistance (helper did less than half the effort) with oral hygiene and personal hygiene. The MDS indicated Resident 99 required substantial assistance (helper did more than half the effort) with toileting hygiene, showering, and transferring. The MDS indicated Resident 99 had no surgical wounds. During a review of Resident 99's History and Physical (H&P), dated 9/4/2025, the H&P indicated Resident 99 had the capacity to understand and make decisions. During a concurrent record review and interview with TN 1 on 12/4/2025 at 1:40 PM, Resident 99's Treatments Administration Record (TAR), dated 9/4-9/8/2025, was reviewed. TN 1 stated the TAR indicated Resident 99 had a surgical wound on mid back from 9/4-9/8/2025. TN 1 stated it was not acceptable to have an inaccurate MDS assessment because it might delay necessary care. During a concurrent record review and interview with the Minimum Data Set Coordinator (MDS C) on 12/4/2025 at 2:30 PM, Resident 99's MDS, dated [DATE], was reviewed. The MDS indicated Resident 99 had no surgical wounds. The MDS C stated that the MDS was signed and verified to have all information correct and accurate. The MDS C stated the MDS was not an accurate assessment because it should have coded Yes for surgical wound. The MDS C stated that it was important to have an accurate MDS assessment to service as a baseline for providing residents' care accordingly. The MDS C further stated it put residents at risk of not receiving proper care and risk for infection. During a review of the facility's Policy and Procedure (P&P) titled Resident Assessment, revised 10/2023, the P&P indicated All persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information. The P&P further indicated Information in the MDS assessments will consistently reflect information in the progress notes, plans of care and resident observations/interviews.

Based on observation, interview, and record review, the facility failed to ensure one of one sample resident (Resident 4) had a physician's order for the use of oxygen (a medical treatment used to help a person to breathe more easily) at two and a half liters per minute through nasal cannula (a medical device used for oxygen therapy). This failure had the potential to place Resident 4 at risk for complications associated with oxygen therapy. Findings: During a review of Resident 4's admission Record (AR), the AR indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD - a type of obstructive lung disease characterized by long-term poor airflow), depression (a feeling of severe sadness or hopelessness), anxiety (emotion characterized by an unpleasant state of inner turmoil), and gastro esophageal reflux disease (GERD, a chronic digestive disorder where stomach acid or contents leak back into the esophagus, causing symptoms like heartburn and regurgitation) without esophagitis irritation or inflammation of the esophagus (tube that carries food from throat to the stomach. During a review of Resident 4's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 1/21/2025, the MDS indicated Resident 4 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 4 was dependent (helper does all of the effort) on staff for toileting, shower, lower body dressing, and putting on/off footwear. The MDS indicated Resident 4 needed maximum assistance (helper does more than half the effort) from staff for upper body dressing and personal hygiene. During a concurrent observation and interview on 12/2/2025 at 9:36 am, observed with Infection Prevention Nurse (IPN), Resident 4 was lying in bed receiving oxygen at 2.5 liters per minute (LPM) via nasal cannula. The IPN 1 stated Resident 4 was receiving continuous oxygen at 2.5 LPM via nasal cannula. During a concurrent interview and record review on 12/3/2025 at 9:33 am with the facility's Assistant Director of Nursing (ADON), Resident 4's medical records (PointClickCare - PCC, a cloud-based software used in long-term and post-acute care facilities for resident charting and care management) were reviewed. The ADON stated that there was no physician's (doctors) order for Resident 4's oxygen therapy. The ADON stated there should be a doctors order for oxygen administration for Resident 4 to receive proper oxygen therapy. During a review of the facility's policy and procedure (P&P), titled Oxygen Administration, revised 2/2024, the P&P indicated the purpose of this procedure is to provide guidelines for safe oxygen administration. The P&P indicated: Verify that there is a physician's order for this procedure.Review the physician's orders or facility protocol for oxygen administration.

Based on observation, interview, and record review, the facility failed to implement its protocol for antibiotic (a substance used to kill bacteria and to treat infections) use for one of one sampled resident (Resident 36), who had received and was receiving antibiotics from 12/2/2025. This deficient practice had the potential for Resident 36 to develop antibiotic resistance and to receive antibiotics without justification. Findings: During a review of Resident 36's admission Record (AR), the AR indicated Resident 36 was initially admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, a type of obstructive lung disease characterized by long-term poor airflow) and depressive disorder (persistent feelings of sadness and worthlessness and a lack of desire to engage in formerly pleasurable activities). During a review of Resident 36's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 11/4/2025, the MDS indicated Resident 36 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 36 needed moderate assistance (helper does less than half the effort) from staff for toileting, shower, lower body dressing, and putting on/off footwear. During a review of Resident 36's Order Summary Report (OSR) for the active orders as of 12/4/2025, the OSR indicated to administer Azithromycin Oral Tablet (antibiotic, a substance used to kill bacteria and to treat infections) 250 milligram (mg, a unit of measurement), one tablet by mouth one (1) time a day for cough with phlegm for four days with an order date of 12/2/2025. During a concurrent interview and record review on 12/3/2025 at 10:43 AM with the facility's Assistant Director of Nursing (ADON), Resident 36's medical records (PointClickCare - PCC, a cloud-based software used in long-term and post-acute care facilities for resident charting and care management) were reviewed. ADON stated the antibiotic screening evaluation was not completed for Resident 36, who was on Azithromycin. ADON further stated that antibiotic stewardship (a coordinated program to ensure antibiotics are used correctly and appropriately to keep residents safe and prevent bacteria from becoming resistant) should have been completed prior to administering antibiotics to the resident to determine if they met the criteria for the use of antibiotics. During an interview on 12/3/2025 at 10:59 AM with the facility's Infection Preventionist Nurse (IPN, a healthcare professional who specializes in preventing the spread of infections in healthcare settings), the IPN stated Resident 36 did not meet the criteria to receive antibiotics and IPN should have notified the physician whether to continue administering antibiotics or not. The IPN stated antibiotic screening should have been done before initiating antibiotic therapy to ensure antibiotic use was appropriate and to avoid Multidrug Resistant Organisms (MDRO's refer to microorganisms, predominantly bacteria that are resistant to one or more classes of antimicrobial agents). During an interview on 12/3/2025 at 3:17 AM with Registered Nurse 1 (RN 1), RN 1 stated, I thought the Charge Nurse will complete the infection screening form. RN 1 stated that Resident 36 did not meet the criteria to receive antibiotic therapy and the physician should have been notified prior to administering antibiotics. RN 1 stated that the purpose of antibiotic screening was to identify if antibiotic therapy was appropriate and to avoid residents from becoming resistant to antibiotics. During a review of the facility's Policy and Procedure (P&P), titled Antibiotic Stewardship, dated 12/2016, the P&P indicated, Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents. When a nurse calls a physician/prescriber to communicate a suspected infection, he or she will have the following information available:a. Signs and symptoms;b. When symptoms were first observed;c. Resident's hydration status;d. Current medication list;e. Allergy information;f. Infection type;g. Any orders for warfarin and results of last INR;h. Last creatinine clearance or serum creatinine, if available; [NAME]. Time of the last antibiotic dose.

Based on interview and record review, the facility failed to ensure that a medication regimen review (MRR) irregularity identified by the facility's Pharmacy Consultant was acted upon for one of five sample resident (Resident 4). This deficient practice had the potential for harm due to the missed opportunity by the physician and the licensed staff to act upon the reported irregularities. Findings: During a review of Resident 4's admission Record (AR), the AR indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, a type of obstructive lung disease characterized by long-term poor airflow), depression (a feeling of severe sadness or hopelessness), anxiety (emotion characterized by an unpleasant state of inner turmoil), and gastro esophageal reflux disease (GERD, a chronic digestive disorder where stomach acid or contents leak back into the esophagus, causing symptoms like heartburn and regurgitation) without esophagitis irritation or inflammation of the esophagus (tube that carries food from throat to the stomach. During a review of Resident 4's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 1/21/2025, the MDS indicated Resident 4 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 4 was dependent (helper does all of the effort) on staff for toileting, showering, lower body dressing, and putting on/off footwear. The MDS indicated Resident 4 needed maximum assistance (helper does more than half the effort) from staff for upper body dressing and personal hygiene. During a review of Resident 4's Order Summary Report (OSR), for the active orders as of 12/3/2025, the OSR indicated an order to administer Linzess (a prescription medication that helps to treat chronic constipation and irritable bowel syndrome with constipation [IBS-C] by increasing the amount of fluid in the intestines) 145 microgram (mcg, a unit of measurement), one capsule by mouth one (1) time a day for bowel management. During a review of Medication Administration Record (MAR), dated 12/2025, the MAR indicated Resident 4 received Linzess oral capsule 145 mcg by mouth one (1) time a day for bowel management at 9 am on 12/1/2025, 12/2/2025, and 12/3/2025. During a review of the facility document titled, Consultant Pharmacist's Medication Regimen Review, dated 10/28/2025, completed by the facility's pharmacist consultant, the document indicated, The resident (Resident 4) has order for Linzess one (1) capsule once daily at 9 am. Manufacturer recommends administering the medication at least 30 minutes before the first meal of the day on empty stomach. During an interview on 12/3/2025 at 3:06 pm, with the facility's Assistant Director of Nursing (DON), the ADON stated the MRR was a monthly recommendation that licensed nurses supposed to carry out once received from the pharmacy. The ADON stated there was no other clinical documentation that the monthly recommendation for Resident 4 from the pharmacist, dated 10/28/2025, was carried out. The ADON stated the purpose of MRR was for the pharmacy to review if residents were receiving proper medications and to avoid unnecessary drug use. The ADON stated, I remembered it (referring to the recommendation), I thought I carried out the recommendation. During a review of the facility's Policy and Procedure (P&P), titled Consultant Pharmacist Reports, dated 6/2021, the P&P indicated, The consultant pharmacist reviews the medication regimen (MRR) of each resident at least monthly either on site or remotely. Recommendations are acted upon and documented by the facility staff and or the prescriber. Physician accepts and acts upon suggestion or rejects and provides an explanation for disagreeing by the next physician visit. The director of nursing or designated licensed nurse addresses and documents recommendations that do not require a physician intervention, e.g., monitor blood pressure.

Based on observation, interview, and record review, the facility failed to provide a minimum of 80 square feet (sq. ft., a unit of measurement) per resident area for fourteen (13) out of thirty-eight (38) resident rooms (Rooms 14, 15, 16, 17, 18, 19, 27, 28, 29, 36, 37, 38, and 39). This deficient practice had the potential to impact on the ability to provide safe nursing care and maintain the privacy of the residents.Findings: During an interview with the facility Administrator (ADM) on 12/2/2025 at 10:25 AM, the ADM stated the facility would like to request a room waiver (a document recording the waiving of a right or claim) this year for Rooms 14, 15, 16, 17, 18, 19, 27, 28, 29, 36, 37, 38, and 39. The ADM stated nothing was changed and the number of bed occupancy in the 13 rooms. During a review of the facility's letter to request for room waiver, dated 12/2/2025, the room waiver request letter indicated there was ample room to accommodate wheelchairs and other medical equipment, as well as space for mobility and movement of ambulatory residents. The letter indicated there was adequate space for nursing care, and the health and safety of residents occupying these rooms are not in jeopardy. The letter further indicated that these rooms were in accordance with the special needs of the residents, and do not have an adverse effect on the residents' health and safety or impedes the ability of any resident in the rooms to attain his or her highest practicable well-being. During a review of the Client Accommodations Analysis form, dated 12/3/2025, the analysis indicated the following: Room Sq. Ft. Beds 14 234.03 315 234.03 316 232.23 3 17 234.40 318 233.19 319 234.89 3 27 233.65 3 28 232.73 329 225.50 336 232.26 337 233.07 3 38 233.93 3 39 233.60 3 During the Health Recertification Survey, from 12/2/2025 to 12/5/2025, Rooms 14, 15, 16, 17, 18, 19, 27, 28, 29, 36, 37, 38, and 39 had adequate space, nursing care, comfort, and privacy was provided to the residents. The residents were observed to have enough space to move freely inside the rooms. There was an adequate room for the operation and use of the wheelchairs (a chair fitted with wheels for use as a means of transport by a person who is unable to walk as a result of illness, injury, or disability), walkers (is a device that gives additional support to maintain balance or stability while walking,) and Hoyer lift (a mechanical device used to lift and/or transfer a person from place to place). Each resident inside the affected rooms had beds and bedside tables with drawers. The room size did not affect the care and services provided by the staff to the residents when staff were observed providing care to the residents. During an observation and interview on 12/2/2025 at 9:23 AM with Resident 44, who was sitting in bed inside Resident 44's room. Resident 44's walker was observed next to the bed. Resident 44 stated, I don't have problem with my room space. I have enough space. I was able to walk to the restroom with my walker, and I don't have problem with it (space). During an observation and interview on 12/2/2025 at 9:41 AM with Resident 11, Resident 11 was observed lying in bed. Resident 11 stated, I have a special bed, and I do not have an issue with the room space. I am ok with the space here. During an observation and interview on 12/2/2025 at 10:06 AM with Resident 45, Resident 45 was observed sitting in her wheelchair inside Resident 45's room and was able to wheel herself from the bathroom to the bed with ease and with space. During an interview on 12/3/2025 at 11:13 AM with Certified Nurse Assistant 1 (CNA 1), the CNA 1 stated that there was enough space in the rooms to provide care to the residents. CNA 1 stated she was able to move wheelchairs and Hoyer lift inside the rooms with no issues. During an interview on 12/3/2025 at 2:14 PM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated there was enough space to provide care and treatment to the residents without issues, and that they were able to move wheelchairs, Hoyer Lifts, and walkers inside the rooms.

Based on interview and record review, the facility failed to ensure staff response/answer to Residents' call lights in a timely manor for three of three sampled Residents (Residents 1, 2, and 3).These deficient practice violated Residents 1, 2 and 3's rights, delayed in care and services and had the potential to affect Residents 1, 2, and 3's health.Findings:a) During a review Resident 1's, admission record, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included Morbid (Severe) Obesity, Hemiplegia (partial paralysis) and Hemiparesis (weakness or inability to move on one side of the body), and Neuromuscular Dysfunction (muscle weakness due to lack of nerve function) of Bladder.During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 7/1/2025, the MDS indicated Resident 1's cognition (ability to understand) was normal. Resident 1 was dependent on staff for person hygiene before and after urinating or having a bowel movement and adjusting clothing. Resident 1 required maximal assistance rolling from left to right and moving from sitting to lying. Resident 1 received scheduled pain medications for occasional pain at an intensity of 7 on a scale of 1 to 10.During a review of Resident 1's Care Plan Report, dated 4/25/2025, the Care Plan indicated staff should keep the call light within reach and answer promptly due to the following health illnesses: diabetes mellitus (a disease that results in too much sugar in the blood), bowel and bladder incontinence (unable to control flow of urine), assistance with bed mobility (able to move freely), toileting (assist with using the bathroom) needs and fall prevention. The actions listed for staff assistance, dated 7/2/2024, included to remind Resident 1 to call for a bedpan, if unable to go to toilet, and to call for assistance with self-care.b) During a review Resident 2's admission record, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included rheumatoid arthritis (a chronic disorder of redness and swelling usually affecting the hands and feet), diabetes mellitus with diabetic polyneuropathy (a disorder that affects nerve function in multiple areas) , spinal stenosis ( the spaces inside the bones of the spine get too small), morbid obesity (too much body fat), and depressive episodes.During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 has functional limitation in range of motion (full movement of a joint) of the upper and lower extremities and is always incontinent of bowel movements and is dependent on staff to maintain perineal (area of the body between the rectum and the sexual organs) hygiene, adjust clothing before and after voiding (urinating) or having a bowel movement, and getting on and off the toilet.During a review of Resident 2's Care Plan Report, dated 8/16/2025, the care plan indicated keeping the call light within reach and to answer promptly due to the following health illnesses: depression with suicidal thoughts, neuralgia/Neuritis (pain caused by damaged nerves) and migraine (intense head pain) Headaches, chronic pain syndrome, osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wears down) , contractures (shortening and hardening of muscles, tendons, or other tissue leading to deformity and rigidity of joints) of the left and right knee, and sleepiness side effects from antidepressant medications. Resident 2 is to use the call light to notify staff for any care the resident is unable to perform, for pain medications, assistance to the chair, and turning in bed.c) During a review of Resident 3's admission record, the admission record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included disease of the pancreas (a large gland, in the belly, that helps digestion and regulates blood sugar), chronic kidney disease, abnormalities of gait (manner of walking), mobility, and end stage renal disease. During a review of Resident 3's MDS, dated [DATE], indicated Resident 3 was dependent on staff for toileting (assist with using the bathroom) and repositioning.A review of the Care Plan Report for Resident 3, dated 4/30/2025, indicated that Resident 3 should have a call light within reach and staff are to answer promptly to address Resident 3's symptoms of pain, bowel incontinence, assistance with toileting, and the risk of falling due to impaired mobility. During an interview on 7/25/2025 at 1:43 p.m., Resident 1 stated, after waiting 1 and 1/2 hours for staff to answer the call light, Resident 1 used a cell phone to call for help, then staff came to help Resident 1 in 15 minutes.During an interview on 7/25/2025 at 2:39 p.m., Resident 3 stated that staff do not respond quickly to call lights. Resident 3 stated quite a few times staff took a long time to provide personal hygiene. Resident 3 stated it is very upsetting and it's uncomfortable.During an interview on 7/25/2025 at 2:47 p.m., Resident 2 stated that call lights are not answered quickly and sometimes there there is only one CNA work on the weekend.During an interview on 7/25/2025 at 3:41 p.m., Resident 2 stated staff do not answer call lights on time. Resident 2 stated I was in pain for two hours, once holding my urine, while waiting for someone to answer my call light. Resident 2 stated I have gotten UTIs in the past due to waiting for call light help. Resident 2 stated when my curtain is pulled back, I can see their (staff's) hands turning it (call light) off without asking what we want.A review of the facility's Resident Council Minutes of Meeting, dated 3/26/25, indicated the call light response needs to improve and timely call light response is a concern of the residents.A review of the facility's policy and procedure titled, Residents Call System, dated September 2022, indicated calls for assistance are answered as soon as possible, but no later than 5 minutes. Urgent requests for assistance are addressed immediately.

Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Abuse Investigation and Reporting, by failing to report an alleged verbal abuse to the facility's Abuse Coordinator, California Department of Public Health (CDPH), the Ombudsman (an official appointed to investigate individual's complaints and assists in resolution of concerns), and the local law enforcement immediately and within 2 hours on 12/19/2024 for one of five sampled residents (Resident 2) when Resident 2 allegedly called Resident 1 derogatory words. This failure had the potential to subject Resident 1 to potential further abuse from Resident 2. Findings: 1. During a review of Resident 1's Admission Record (AR), the AR indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses that included hypertension (HTN, high blood pressure) and hypothyroidism (thyroid gland does not produce enough thyroid hormones in the body). During a review of Resident 1's History and Physical (H&P, formal document of a medical provider's examination of a patient) dated 10/28/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Change in Condition (COC) Evaluation Form dated 12/23/2024 at 12:16 PM, the COC indicated on 12/19/2024 untimed, Resident 1 reported a male resident came by the door of Resident 1's room and called Resident 1 names. 2. During a review of Resident 2's AR, the AR indicated Resident 2 was originally admitted to the facility on [DATE] with diagnoses that included asthma (chronic lung disease that causes the airways to become narrow), anxiety (feelings of worry or fear), and HTN. During a review of Resident 2's H&P dated 2/22/2024, the H&P indicated Resident 2 can make needs known but cannot make medical decisions. During an interview on 12/27/2024 at 11:13 AM with Resident 1, Resident 1 stated Resident 2 was at the doorway and called Resident 1 derogatory words in Spanish. Resident 1 stated it made Resident 1 feel Real bad . During an interview on 12/27/2024 at 1:33 PM with Certified Nurse Assistant 3 (CNA 3), CNA 3 stated Resident 1 reported to CNA 3 on 12/19/2024 or 12/20/2024 that Resident 2 called Resident 1 bad words in Spanish. CNA 3 stated CNA 3 immediately reported it to LVN 4 the same day. CNA 3 stated Resident 2 allegedly called Resident 1 Venenosa. CNA 3 stated the word would be considered verbal abuse because it is very disrespectful and implying the person was not good. CNA 3 stated CNA 3 did not report the incident to the Administrator (ADM) because the charge nurse reports the incident to the ADM. CNA 3 stated CNA 3 was unsure if the charge nurse reported the incident. CNA 3 stated the risk of not reporting instances of abuse within two hours to the ADM is that the incident could get worse and could escalate to physical abuse. During an interview 12/27/2024 at 1:57 PM with the ADM, the ADM stated LVN 4 was out of the country on vacation. During an interview on 12/27/2024 at 2 PM with Registered Nurse 1 (RN 1), RN 1 stated if a staff member was made aware that a resident was called a derogatory term, the staff member should have notified the ADM because it was considered verbal abuse, contact the Ombudsman, CDPH, and local law enforcement. RN 1 stated the risk of not reporting incidents of abuse to the ADM was putting the safety of residents at risk. During an interview on 12/27/2024 at 2:30 PM with the Assistant Director of Nursing (ADON), the ADON stated staff should have reported the incident to the ADM because the incident was considered alleged verbal abuse. The ADON stated the risk of not reporting immediately was that the incident might reoccur. The ADON stated the facility must do prevention, monitor, and keep residents separated when instances of alleged abuse occur. During an interview on 12/27/2024 at 2:52 PM with the ADM, the ADM stated the ADM was made aware of the incident on 12/23/2024 by Resident 1's family member. The ADM stated staff are to notify both the ADM and the DON for incidents of alleged abuse. The ADM stated the incident on 12/19/2024 would be considered alleged verbal abuse and stated the risk of not reporting the incident was that the facility might fail to protect the resident and do the necessary interventions. During a review of the facility's P&P titled, Abuse Investigation and Reporting revised 7/2017, the P&P indicated alleged violations of abuse are to be reported immediately but no later than two hours if the alleged violation involves abuse.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from significant medication error (medication error which causes the resident discomfort or jeopardizes the resident health and safety) by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 1 administered fluticasone furoate suspension (Flonase- nasal [nose] spray medication used to treat nasal congestion, sneezing, and runny nose caused by seasonal allergies [body's reaction to normally harmless substances]) instead of Narcan nasal liquid (nasal spray medication used to rapidly reverse the effects of opioid [class of drugs used to treat moderate to severe pain] overdose) to Resident 1 on 3/14/2024 at 7:00 pm. 2. Ensure LVN 1 checked Resident 1's Narcan nasal liquid medication label three times and verified that it was the right medication, right dosage, and right time before administering the medication to Resident 1 as indicated in the facility's policy and procedure (P&P) titled, Administering Medications. As a result, on 3/17/2024 at 7:00 pm, immediately after Resident 1 received the incorrect medication, Resident 1 experienced chest pain, burning sensation of Resident 1's body, and Resident 1 felt like Resident 1 was dying. Resident 1 was transferred to General Acute Care Hospital (GACH) 1 on 3/14/2024 at 7:30 pm for further evaluation and was treated for acute opioid withdrawal (a set of symptoms from the sudden withdrawal or reduction of opioids where previous usage has been heavy and prolonged) induced (caused) by accidental Narcan administration. Cross Reference F726 and F842 Findings: During a review of Resident 1's Admission Record (AR), the AR indicated, the facility admitted Resident 1 to the facility on [DATE], with diagnoses of asthma (chronic lung disease caused by inflammation and muscle tightening around the airways), allergic rhinitis (nose irritation, sneezing, watery eyes, and nasal congestion caused by allergic reaction general to environmental factors), acquired absence of right leg above the knee and phantom limb syndrome with pain (the experience of painful sensations in a limb that did not exist). During a review of Resident 1's Physician Order (PO), dated 8/16/2022, the PO indicated, Resident 1 had an order for fluticasone furoate suspension, 27.5 micrograms (mcg- unit of measurement), spray one (1) spray in both nostrils, (nose) two times a day related to adverse (unwanted and harmful) effect of anti-asthmatics (medications that reduced the swelling and tightening in the airways). During a review of Resident 1's Minimum Data Set (MDS- a standardized resident assessment and care screening tool), dated 2/13/2024, the MDS indicated, Resident 1 had intact cognition (ability to think, remember, and reason). The MDS indicated, Resident 1 required supervision or touching assistance (helper provided verbal cues and/or touching/steadying and/or contact guard assistance as resident completed the activity) with oral hygiene, toileting hygiene, showering/bathing self, upper and lower body dressing, putting/taking off footwear, and personal hygiene. During a review of Resident 1's PO, dated 2/20/2024, the PO indicated, Resident 1 had an order for Percocet (a combination medication containing oxycodone [an opioid pain medication] and acetaminophen [medication used to treat mild to moderate pain and fever] oral (by mouth) tablet 5-325 milligrams (mg, unit of measurement), give one (1) tablet by mouth every six (6) hours as needed for moderate to severe pain. During a review of Resident 1's PO, dated 2/14/2024, the PO indicated, Resident 1 had an order for Narcan nasal liquid (Naloxone Hydrochloride [HCl]), one (1) spray in nostril as needed for opioid overdose. During a review of Resident 1's Progress Notes (PN), dated 3/14/2024 at 7:38 pm, the PN indicated, at approximately 7:00 pm, LVN 1 administered nasal spray (unidentified) to Resident 1. The PN indicated, LVN 1 retrieved a box containing nasal spray (naloxone HCl nasal spray) labeled with Resident's 1 name. The PN indicated, immediately after administration of the nasal spray, Resident 1 began to shout and complain of chest pain, burning sensation of Resident 1's body, and felt like Resident 1 was dying. The PN indicated, Resident 1 complained that Resident 1's body was on fire and Resident 1's nose was burning. The PN indicated, Resident 1's blood pressure (BP- the pressure of blood pushing against the walls of the arteries) was 142/94 millimeters of mercury (mmHg- unit of measurement) (Normal BP was 120/80). The PN indicated, the facility called paramedics (healthcare professional trained to give emergency medical care to people who were injured or ill, typically in a setting outside of a hospital). During a review of Resident 1's PO, dated 3/14/2024, the PO indicated an order to transfer Resident 1 to GACH 1 via 911 (emergency medical services) on 3/14/2024 (no time and indication specified). During a review of Resident 1's GACH 1 Emergency Department Exam Narrative (ED Exam), dated 3/14/2024 at 7:47 pm, the ED Exam indicated, Resident 1 was brought in for accidental medication administration of Narcan, eight (8) mg. The ED Exam indicated, Resident 1 was normally on Percocet and occasionally on Morphine (opioid pain medication used to treat moderate to severe pain) for chronic pain. The ED Exam indicated, Resident 1 was very anxious and restless and was in acute withdrawal due to Narcan. The ED Exam indicated, Resident 1's blood pressure was 170/80 mmHg. The ED Exam indicated, Resident 1 was treated with buprenorphine (medication used to treat opioid use disorder), clonidine HCI (medication used to lower blood pressure and heart rate), and intravenous (into a vein) fluids. During an interview on 3/28/2024 at 9:05 am with Resident 1, Resident 1 stated LVN 1 was Resident 1's medication nurse in the afternoon (on 3/14/2024). Resident 1 stated LVN 1 handed Resident 1 a nasal spray medication that did not look familiar to Resident 1. Resident 1 stated Resident 1 explained to LVN 1 that it was not Resident 1's medication, but LVN 1 insisted it was the correct nasal spray medication for Resident 1. Resident 1 stated Resident 1 explained to LVN 1 that Resident 1 normally took Flonase and not Naloxona. Resident 1 stated LVN 1 told Resident 1 to take the medication because it was prescribed to Resident 1 and was due to be taken. Resident 1 stated LVN 1 made Resident 1 take the Narcan. Resident 1 stated immediately after LVN 1 sprayed the Narcan into Resident 1's nostril, Resident 1's body felt like it was burning. Resident 1 stated Resident 1 wanted to remove all of Resident 1's clothes because Resident 1's body felt like it was on fire. Resident 1 stated Resident 1 felt different in Resident 1's head like Resident 1's head was going to explode. Resident 1 stated Resident 1 urinated and vomited on Resident 1's self. Resident 1 stated Resident 1 started to scream and ask for help because Resident 1 felt like Resident 1 was going to die. Resident 1 stated after Resident 1 returned to the facility from GACH 1, Resident 1 still experienced some chest pain and body tingling. Resident 1 stated Resident 1 had never been more scared in Resident 1's entire life than in that moment when Resident 1 received the wrong medication. During an interview on 3/28/2024 at 12:02 pm with LVN 1, LVN 1 stated when giving medications, LVN 1 did not check the medication label on the nasal spray before administering the medication to Resident 1 (on 3/14/2024 at 7 pm). LVN 1 stated LVN 1 normally checked the resident's name, medication order, and matched the information against the medication label to ensure LVN 1 had the right dose of medication, right time, right patient, right medication, and right route of administering the medication. LVN 1 stated on 3/14/2024 at approximately 7 pm, LVN 1 thought LVN 1 was giving Resident 1 Flonase nasal spray. LVN 1 stated LVN 1 had trouble finding the Flonase in the medication cart. LVN 1 stated LVN 1 found a box of nasal spray with Resident 1's name on it but did not look at the name/label of the medication or the bottle of the medication. LVN 1 stated after giving the nasal spray to Resident 1, LVN 1 left Resident 1's room to get Resident 1's prescribed narcotic (medication used to treat moderate to severe pain). LVN 1 stated Resident 1 then wheeled himself into the hallway screaming, My body is on fire. I'm going to die. My chest, my chest! LVN 1 stated Resident 1 vomited. LVN 1 stated at that time, LVN 1 did not know what was happening to Resident 1. LVN 1 stated the desk nurse called 911 (a phone number used to contact the emergency services). LVN 1 stated when the paramedics arrived, the paramedics asked for the medications administered to Resident 1. LVN 1 stated LVN 1 showed the paramedics the box of nasal spray LVN 1 thought was Flonase and administered to Resident 1. LVN 1 stated the paramedics told LVN 1 that LVN 1 gave Resident 1 the Narcan. LVN 1 stated LVN 1 accidentally gave Resident 1 the Narcan. LVN 1 stated it was important to check medication label and bottle to ensure the medication being given was the correct medication. LVN 1 stated not checking the medication bottle/label before giving the medication to Resident 1 caused Resident 1 harm and could have led to Resident 1's death. LVN 1 stated if LVN 1 checked the bottle/label of nasal spray before administering it to Resident 1, the medication error could have been avoided. During a telephone interview on 3/28/2024 at 1:36 pm with Pharmacist Consultant (PC) 1, PC 1 stated Narcan was administered only in the event of a suspected or confirmed opioid overdose situation. PC 1 stated Narcan would be administered if a resident was experiencing respiratory depression (decrease in breathing), lethargy (extreme exhaustion) or unresponsiveness. PC 1 stated Narcan diminished the effects of opioids. PC 1 stated Resident 1 had an adverse response to Narcan because it caused vomiting and hypertension (high blood pressure). PC 1 stated LVN 1 made a medication error because Resident 1 was not experiencing opioid overdose when LVN 1 administered the Narcan to Resident 1. PC 1 stated LVN 1 could have avoided the medication error if LVN 1 followed the five rights of medication administration (right medication, right dose, right time, right route, right patient). During an interview on 3/28/2024 at 4:44 pm with the Director of Nursing (DON), the DON stated the five rights of medication administration needed to be followed during medication pass to ensure mistakes or medication errors were not made. The DON stated if the licensed nurses did not follow the five medication rights, medication errors could be made. The DON stated giving a resident Narcan when not indicated could cause a resident to experience increased heart rate, hypertension, anxiety, agitation, and acute opioid withdrawal. The DON stated LVN 1 did not follow the five rights of medication administration before administering the Narcan to Resident 1. The DON stated the medication error and Resident 1's adverse reaction could have been avoided had LVN 1 followed the five medication rights. During a review of the facility's P&P titled, Administering Medications, revised in 4/2019, the P&P indicated, medications were administered in a safe and timely manner, and as prescribed. The P&P indicated, medications were administered in accordance with prescriber orders, including any required timeframe. The P&P indicated, individuals administering medications checked the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication.

Based on observation, interview, and record review, the facility failed to implement a resident-centered comprehensive care plan to prevent a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) for one of five sampled residents (Resident 1) by failing to: Ensure Certified Nursing Assistant (CNA) 1 provided two-person physical assistance (help from two person) when CNA 1 turned Resident 1 to one side while bathing Resident 1 on the bed as indicated in Resident 1's Care Plan titled, Activities of Daily Living (ADL)/Self-Care Deficits, initiated on 10/6/2023, and the facility's policies and procedures titled, Fall and Fall Risk, Managing, and Care Plans, Comprehensive Person-Centered. As a result, on 12/12/2023 at 10:30 AM, Resident 1 fell from Resident 1's bed to the floor. Resident 1 sustained a displaced fracture (bone breaks into two or more pieces and move out of alignment) at the neck of the right subcapital femur (neck of the thighbone). Resident 1 was transferred and admitted to the General Acute Care Hospital (GACH) 1 on 12/12/2023 at 8:15 PM for further evaluation, had a right hip hemiarthroplasty (a type of partial hip replacement surgery that involved replacing half of the hip joint) on 12/14/2023, and remained in GACH 1 for five days. Cross Reference F689 Findings: During a review of Resident 1's Admission Record (AR), the AR indicated the facility admitted Resident 1 on 10/3/2023 and readmitted Resident 1 on 12/19/2023, with diagnoses that included morbid obesity (more than 80 to 100 pounds over ideal body weight), muscle weakness, dementia (memory loss which interferes with daily functioning), lack of coordination, and osteoporosis (a condition in which the bones become weak and brittle). During a review of Resident 1's Initial History and Physical (H&P), dated 10/3/2023, the H & P indicated Resident 1 did not have the capacity to understand or make decisions. During a review of Resident 1's Care Plan titled, ADL/Self Care Deficits (ADL CP), initiated on 10/6/2023, the ADL CP indicated Resident 1 required physical assistance from two persons (two staff) for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed). During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 10/7/2023, the MDS indicated Resident 1 had severely impaired cognition (ability to think and process information). The MDS indicated Resident 1 required substantial/maximal assistance (helper lifted or held trunk or limbs and provided more than half the effort) for showering/bathing and personal hygiene. The MDS indicated Resident 1 depended (helper provided all the effort or the assistance of two or more helpers was required for the resident to complete the activity) on staff (any nursing staff in general) for rolling left and right (the ability to roll from lying on back to left and right side and return to lying on back on the bed). During a review of Resident 1's Progress Notes (PN), dated 12/12/2023, timed at 10:45 AM, the PN indicated at 10:30 AM, CNA 1 notified Licensed Vocational Nurse (LVN) 1 that Resident 1 fell on the floor during Resident 1's care. The PN indicated, CNA 1 instructed Resident 1 to turn to Resident 1's right side, but instead Resident 1 turned to Resident 1's left side and rolled down from the bed to the floor. The PN indicated, Resident 1 complained of pain (unrated) on Resident 1's right hip. The PN indicated, LVN 1 notified Resident 1's Primary Physician (PP) and the PP ordered for Resident 1 to have a stat (immediately) X-ray (pictures of the inside of the body) of the right hip. During a review of Resident 1's Change in Condition Evaluation (COC, a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains), dated 12/12/2023, timed at 11:15 AM, the COC indicated on 12/12/2023, Resident 1 fell from the bed to the floor on Resident 1's right side while CNA 1 was providing care to Resident 1. During a review of Resident 1's PN dated 12/12/2023, timed at 7:41 PM, the PN indicated X-ray Company 1 (X-ray Co. 1) had not arrived and Resident 1 continued to complain of pain (unrated) on Resident 1's right hip. The PN indicated the facility transferred Resident 1 to GACH 1 via non-emergency transport. During a review of Resident 1's Skilled Nursing Facilities to Hospital Transfer Form (SNF to Hosp Form), dated 12/12/2023, the SNF to Hosp Form indicated the facility transferred Resident 1 to GACH 1 at 8:15 PM. During a review of Resident 1's GACH 1 Emergency Department Provider Note (ED PN), dated 12/12/2023, timed at 8:20 PM, the ED PN indicated Resident 1 arrived to GACH 1 for evaluation of right hip pain status post (s/p, condition after) fall. The ED PN indicated Resident 1 would be admitted to GACH 1 for further evaluation and care. During a review of Resident 1's GACH 1 Computed Tomography scan (CT scan, medical imaging technique used to obtain detailed internal images of the body) of the right hip report, dated 12/12/2023, timed at 8:22 PM, the CT scan report indicated Resident 1 had a subcapital fracture of the right femur. During a review of Resident 1's GACH 1 Orthopedist (a doctor who specialized on injuries and diseases affecting the bones, muscles, and joints) Consultation (OC), dated 12/14/2023, timed at 2:06 PM, the OC indicated the plan was to proceed with a right hip hemiarthroplasty on 12/14/2023. During a concurrent observation and interview on 1/29/2024 at 3:30 PM with Resident 1 in Resident 1's room, Resident 1 was lying in bed. Resident 1 had an intact, clean, dry, and clear surgical incision on the right hip. Resident 1 was calm and had no signs of facial grimacing. Resident 1 stated Hi, but did not respond to any questions. During an interview on 1/30/2024, at 9:15 AM with Registered Nurse Supervisor (RNS) 1 who worked the night shift from 11 PM to 7 AM on 12/12/2023 (the date Resident 1 fell ), RNS 1 stated Resident 1 required total care, but was able to follow simple commands. RNS 1 stated Resident 1 was a heavy resident and required two-person physical assistance for repositioning, cleaning, and changing. RNS 1 stated before RNS 1 ended RNS 1's shift on 12/12/2023, RNS 1 specifically instructed CNA 1 that Resident 1 always needed assistance from two persons for repositioning, changing, and cleaning because Resident 1 was totally dependent on staff (any nursing staff in general) for care. RNS 1 stated Resident 1's fall could have been prevented if CNA 1 asked another staff (any CNA) to assist when providing care to Resident 1. During a telephone interview on 1/30/2024 at 11:25 AM with CNA 1, CNA 1 stated CNA 1 provided Resident 1 a bed bath on 12/12/2023 at around10:30 AM. CNA 1 stated after CNA 1 washed Resident 1's back, CNA 1 asked Resident 1 to turn to Resident 1's right side towards CNA 1 but Resident 1 turned to Resident 1's left side away from CNA 1, and Resident 1 fell from Resident 1's bed to the floor. CNA 1 stated she did not ask for another staff to assist in turning Resident 1 because she had taken care of Resident 1 without assistance several times in the past. CNA 1 stated Resident 1 was able to understand simple commands and could turn with assistance. CNA 1 stated CNA 1 received training on safe resident handling and caring for heavyset (plump/thick) residents upon hire. CNA 1 stated the safest way to change, clean, or reposition Resident 1 was with two staff. CNA 1 stated Resident 1's fall could have been prevented by having another staff to assist when repositioning, cleaning, or changing Resident 1. During a phone interview on 1/30/2024 at 11:45 AM with LVN 1, LVN 1 stated on 12/12/2023, CNA 1 called LVN 1 into Resident 1's room. LVN 1 stated when LVN 1 entered Resident 1's room, LVN 1 saw Resident 1 lying on the floor on Resident 1's right side. LVN 1 stated Resident 1 was lying on the left side of Resident 1's bed facing Resident 1's room door. LVN 1 stated Resident 1 was totally dependent on staff for care and required full assistance for cleaning, eating, and turning. LVN 1 stated Resident 1 could follow simple commands at times. LVN 1 stated Resident 1 had a heavyset body, was unable to move much, and needed two-person assistance for bathing, repositioning, and changing. LVN 1 stated the safest way to turn or clean Resident 1 and prevent a fall was to have another staff help when providing care to Resident 1. During an interview on 1/30/2024 at 2:34 PM with the Director of Rehabilitation (DOR) in the facility's conference room, the DOR stated Resident 1 was heavily built, weighed 183 pounds (lbs., unit of measurement for weight), had poor trunk control, and required two-person total assistance for transfer, repositioning, and changing. The DOR stated CNAs (all CNAs) were informed at the huddles (brief staff meeting) at the beginning of the shift which residents required two-person assistance when providing care. The DOR stated Resident 1 was one of the residents who needed two-person assistance. The DOR stated CNA 1 could have prevented Resident 1's fall if CNA 1 asked for another staff's assistance when CNA 1 turned Resident 1. During an interview on 1/31/2024 at 10 AM with the Director of Nursing (DON) in the facility's conference room, the DON stated Resident 1 fell from Resident 1's bed to the floor on 12/12/2023, at 10:30 AM when CNA 1 asked Resident 1 to turn to Resident 1's right side towards CNA 1, but Resident 1 turned to Resident 1's left side away from CNA 1. The DON stated CNA 1 thought CNA 1 could manage Resident 1 by herself. The DON stated CNA 1 knew Resident 1 needed two-person assistance, but CNA 1 told the DON that CNA 1 had been providing care to Resident 1 without another staff in the past and did not have any issue. The DON stated CNA 1 could have prevented Resident 1's fall if CNA 1 had asked for another staff to assist before providing care to Resident 1. During an interview on 1/31/2024 at 10:30 AM with the Director of Staff Development (DSD), the DSD stated CNAs (in general) were instructed to have another staff to work with when providing care to Resident 1 who needed assistance or were dependent on CNAs for care. The DSD stated the expectation was to have CNA 1 team up with another CNA (any CNA) when providing care to Resident 1. The DSD stated Resident 1 was dependent on staff for care, turning, and repositioning in bed because Resident 1 had lack of coordination, muscle weakness, and was unable to move. The DSD stated Resident 1 needed to be assisted by two staff. The DSD stated CNA 1 needed to ask for assistance from another staff before CNA 1 turned Resident 1 on the bed to prevent the fall. During a review of the facility's policy and procedure (P&P) titled, Fall and Fall Risk, Managing, revised in 3/2018, the P&P indicated based on previous evaluations and current data, staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling. The P&P indicated staff will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, revised in 3/2022, the P&P indicated facility's staff in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.

Based on observation, interview, and record review, the facility failed to provide care and services to prevent the development of pressure ulcers/pressure injuries (PU/PI- refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) for one of two sampled residents (Resident 22), who was assessed as high risk for developing pressure ulcers, by failing to: 1. Assess Resident 22's skin condition on the buttocks (bottom), coccyx (tail bone), sacral (a triangular shape bone at the bottom of the spine) area, and feet for redness or open sores (injuries that involve a break in the skin and leave the internal tissue exposed) during resident care as indicated in Resident 22's care plan on prevention of pressure ulcer/pressure injury, and the facility's Policy and Procedures titled, Prevention of Pressure Injuries. 2. Float (raise) Resident 22's bilateral (both) heels with pillow while the resident was in bed and during turning and repositioning, as indicated in Resident 22's Care Plan titled, Pressure Ulcer. 3. Apply heel protectors to Resident 22's both heels while in bed, every day shift (7 am to 7 pm) as ordered by the physician on 10/2/23. These deficient practices resulted in Resident 22 developing an avoidable (able to be avoided/prevented) Stage 3 pressure ulcer (full thickness tissue loss, fat tissues may be visible, but bone, tendon, or muscle was not exposed) on the left posterior heel (back of heel) on 10/1/23, and an avoidable deep tissue pressure injury (DTPI- intact skin with localized area of persistent non-blanchable deep red maroon, purple discoloration due to damage of underlying soft tissue) of the buttocks and sacral coccyx area on 10/13/23. Findings: During a review of Resident 22's Admission Record, the Admission Record indicated Resident 22 was self-responsible (holding oneself accountable). The Admission Record indicated the facility admitted Resident 22 on 9/2/23, with diagnoses that included diabetes mellitus (a medical condition characterized by the body's inability to regulate blood sugar levels) and hypertension (high blood pressure). During a review of Resident 22's Admission Skin assessment dated [DATE], the Admission Skin Assessment indicated Resident 22 was admitted to the facility without pressure ulcer/pressure injury. During a review of Resident 22's Braden Scale for Predicting Pressure Sore Risk (a tool which uses a scoring system to evaluate resident's risk of developing a pressure ulcer), dated 9/2/23, the scale indicated Resident 22 was high risk for developing pressure ulcer. Resident 22 had a Braden Scale score of 11 (a score of 10-12 indicated high risk for developing pressure ulcer). Resident 22 was at high risk for developing pressure ulcer due to very limited sensory perception (ability to respond meaningfully to pressure related discomfort), skin was often moist, confinement to bed, very limited mobility (ability to change and control body position), probable inadequate nutrition (usual food pattern) and potential for friction (mechanical force exerted on the skin that is dragged across any surface) and shear (force on the skin in a direction parallel to the body) problem. During a review of Resident 22's initial care plan for prevention of pressure ulcer/pressure injury, dated 9/2/23, the care plan indicated Resident 22 was at risk for skin breakdown due to needing assistance in bed mobility (ability to move around in bed), diabetes mellitus and low back pain. The care plan interventions included for nursing staff to assess Resident 22's skin condition during care and to report to the physician if redness and/or open area was noted. The care plan interventions also included for nursing staff to ensure no open sores/areas on the resident's feet/toes and to notify the physician promptly for any change in sensation, color, or temperature of resident's lower extremities (legs and feet). During a review of Resident 22's Minimum Data Set (MDS- a standardized assessment and care planning tool) dated 9/6/23, the MDS indicated Resident 22 was assessed with good short and long-term memory recall (process of retrieving information from the past). The MDS indicated Resident 22 required extensive assistance (staff provide weight- bearing support) in bed mobility with one-person physical support and was always incontinent of bowel and bladder (lack of voluntary control over defecation and urination). During a review of Resident 22's Physician's Progress Notes dated 10/1/23, the Physician Notes indicated on 10/1/23, Medical Doctor 1 (MD1) conducted a physical examination of Resident 22's both heels. MD1's assessment of Resident 22's left posterior heel indicated Stage 3 pressure ulcer with surrounding purpura (redness) and no purulent discharge (a thick and milky discharge from the wound). MD1's assessment of Resident 22's Stage 3 pressure ulcer of the left posterior heel did not indicate the size of the pressure ulcer. During a review of Resident 22's Physician's Order dated 10/2/23, the Physician Order indicated for staff to apply heel protectors to Resident 22's both lower extremities (feet) while in bed every day shift. During a review of Resident 22's Care Plan titled, Pressure Ulcer, dated 10/2/23, the care plan indicated Resident 22 had altered skin integrity (health of the skin) related to Stage 3 pressure ulcer of the left posterior heel. The care plan interventions included to float Resident 22's heels with pillow while in bed, apply heel protector to Resident 22's both heels, and to turn and reposition Resident 22 every two hours in bed, and whenever necessary. During observations on 10/10/23 at 10 a.m., 11:15 a.m., 12:25 p.m., and 2:20 p.m., Resident 22 was lying on Resident 22's back while in bed and the residents' both heels were resting directly on the pillow (heels were not floated). Resident 22 was not wearing heel protector until 2:20 p.m. when Resident 22's heel protector was observed only on the left foot. During a concurrent observation and interview on 10/10/23 at 2:20 p.m., Resident 22 was lying on Resident 22's back while in bed, alert and coherent. Certified Nursing Assistant 1 (CNA 1) stated she was the caregiver of Resident 22. Resident 22's heels were observed resting directly on the pillow (heels not floated). Resident 22 was wearing a heel protector only on the left foot. Resident 22 stated, Today (10/10/23) was the third day that the heel protector was applied on Resident 22's left foot. Resident 22's both heels had dry and intact wound dressing. CNA 1 stated she did not know why Resident 22 had wound dressing on both heels. Resident 22 stated, Resident 22 was always lying on his back in bed and was not turned and repositioned every two hours while in bed. Resident 22 stated, Resident 22 did not refuse to be turned or repositioned while in bed. CNA 1 stated she was not made aware by licensed nursing staff (Licensed Vocational Nurses [LVNs] and Registered Nurses [RNs], in general) that Resident 22 needed to be turned and repositioned every two hours while in bed. CNA 1 stated Resident 22's heels should be floated on the pillow to prevent more pressure on the wounds (PU/PI). CNA 1 stated pressure on the PU/PI could worsen the condition of Resident 22's PU/PI due to further skin breakdown for Resident 22. CNA 1 did not turn and reposition Resident 22 to side lying position in bed and the resident's heels were not floated on the pillow before CNA 1 left Resident 22's room after the interview. During observations on 10/11/23 at 9:17 a.m., 10:21 a.m. and 11:45 a.m., 10/12/23 at 11:28 a.m. and 3:15 p.m. and on 10/13/23 at 11:30 a.m., Resident 22 was lying on Resident 22's back while in bed. Resident 22 had bilateral (both) heel protectors, and both heels were resting directly on the mattress (heels were not floated on the pillow). During Resident 22's treatment observation on 10/12/23, at 11:28 a.m., in the presence of Director of Nursing (DON), CNA 1, Treatment Nurse 1 (TN 1) Resident 22 was lying on his back in bed with bilateral heel protectors and the heels were resting directly on the mattress. The DON assessed Resident 22's left posterior heel as unstageable pressure ulcer (UTD- full thickness tissue loss when the stage of PU/PI was not clear due to the PU/PI covered by dead tissue and the base of the PU/PI cannot be seen to determine the stage) with moderate amount of yellow green slough and black color slough in the center of the wound base and the surrounding area of the wound edge was red in color. The DON stated, Resident 22's pressure ulcer had progressed from Stage 3 to UTD. TN 1 measured Resident 22's left posterior heel UTD pressure ulcer as 1.5-centimeter (cm) in length (L) x (by) 1.3 cm in width (W), no depth, no undermining (damage underneath the wound edge in multiple directions) and no tunneling (wound damage in one direction deeply underneath the skin). Resident 22's right heel skin was clear and intact. Resident 22's buttocks and sacral coccyx were observed with deep red colored with intact skin, not moist or shiny. TN 1 measured the reddened skin on Resident 22's buttocks and sacral coccyx area as 9 cm (L) x 16.5 cm (W). During a review of Resident 22's Physician's Order dated 10/12/23 at 12:35 p.m., the Physician's Order indicated for Resident 22 to use low air loss mattress (LAL-a mattress that provides a flow of air to assist in managing the heat and humidity of the skin) for preventative use. During an observation on 10/12/23 at 3:15 p.m., with CNA 2 and TN 1, Resident 22 was lying on his back on a low air loss mattress with bilateral heel protectors and the heels were resting directly on the mattress. TN 1 stated Resident 22 had the LAL mattress to help with the healing of the redness on the buttocks and sacral coccyx while Resident 22 was lying on his back while in bed. During a concurrent interview and record review of Resident 22's clinical record on 10/12/23, at 4:48 p.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated LVN 1 was doing rounds in the hallway on 10/1/23 at 2 p.m., when Resident 22's granddaughter notified LVN 1 of Resident 22's complaint of pain on the left heel. LVN 1 stated, when LVN 1 entered Resident 22's room, MD 1 was assessing Resident 22's roommate (Resident 23). LVN 1 stated LVN 1 informed MD 1 of Resident 22's left heel pain. LVN 1 stated LVN 1 did not assess Resident 22's skin condition or size of Resident 22's pressure ulcer of the left posterior heel because MD 1 was holding Resident 22's left heel while assessing Resident PI/PU. LVN 1 stated she was not notified by any staff of any changes in Resident 22's skin condition on the resident's buttocks and heels. During observation of Resident 22's buttocks area on 10/13/23 at 11:30 a.m., in the presence of the DON, TN 1, Resident 22 was lying on the right side. Resident 22's buttocks and sacral coccyx areas were purple with skin intact. TN 1 measured Resident 22's purple skin on the buttocks and sacral coccyx areas as 12 cm (L) x 13 cm (W). The DON and TN 1 did not stage the PI on Resident 22's buttocks and sacral coccyx area during the interview. During a concurrent interview and record review of Resident 22's clinical record on 10/13/23 at 1:35 p.m., the DON stated the facility had turning and repositioning schedules every two hours for residents (in general) who were at high risk for skin breakdown, to prevent the development of pressure ulcer/pressure injury. The DON stated, the Charge Nurses LVNs and RNs, in general) were responsible for notifying the CNAs of residents who were assessed as high risks for skin breakdown and needed to be turned and repositioned every two hours while in bed. Resident 22's repositioning schedule did not contain information indicating Resident 22 was turned and repositioned every two hours while in bed, on all shifts from 9/2/23 to 10/12/23. During a concurrent interview and review of the facility's Resident Repositioning Schedule with the DON on 10/13/23 at 5:07 p.m., the DON stated, the written copy of the Resident Repositioning Schedule was placed on the back of each CNA's identification card. The Resident Repositioning Schedule indicated to reposition the resident every two hours as follows: 7-9 am-Back 7-9 pm-Door 9-11 am-Window 9-11 pm-Back 11 am-1pm-Back 11 pm-1 am -Window 1-3 pm-Door 1-3 am-Back 3-5 pm-Window 3-5 am -Door 5-7 pm-Back 5-7 am-Window During a phone interview with MD 1 on 10/13/23, at 6:32 p.m., MD 1 stated he was the physician who assessed Resident 22's left heel on 10/1/23, after MD 1 was made aware by LVN 1 of Resident 22's complaint of pain on the left heel. MD 1 stated Resident 22's wound on the left posterior heel was a pressure ulcer and not a diabetic ulcer. MD 1 stated, I was the first one to discover it (pressure ulcer). During a review of the facility's undated Policy and Procedures (P&P) titled, Prevention of Pressure Injuries, the P&P indicated to inspect the resident's skin daily when performing or assisting with personal care or activities of daily living to identify any signs of pressure injuries, inspect pressure points such as sacrum, heels, buttocks, coccyx, elbows, and to reposition the resident as indicated on the care plan.

Based on observation, interview, and record review, the facility failed to provide range of motion exercises (activities aimed at improving movement of a specific joint, a point where two bones make contact) for one of five sampled residents (Resident 1) as indicated in the physician ' s order and the facility's policy for Resident Mobility (ability to move) and Range of Motion (ROM, full movement potential of a joint). This deficient practice resulted for Resident 1 to experience pain and decline in ROM, that caused stiffness (inability to move easily and without pain) and contractures (deformity and joint stiffness) of Resident 1 ' s right hand and right arm. (Cross Reference F725). Findings: A review of Resident 1 ' s Admission Record indicated the facility admitted the resident on 6/12/22, with diagnoses that included cerebral infarction (brain damage due to a loss of oxygen to the area, also known as a stroke) and difficulty in walking. A review of Resident 1 ' s Occupational Therapy (OT, profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) Admission Evaluation & Plan of Treatment, dated 6/13/22, indicated Resident 1 ' s right and left upper extremity (arm) ROM were within functional limits (WFL, sufficient joint movement) and no contracture. The OT evaluation indicated Resident 1 had no pain. A review of Resident 1 ' s Occupational Therapy Notes with dates of service from 6/13/22 to 7/15/22, indicated the resident ' s right and left upper extremity ROM were within functional limits (WFL). A review of Resident 1 ' s Plan of Care for Risk for decline in ROM initiated on 8/9/22, indicated for Restorative Nursing Aide Program (RNA, nursing aid program that helps residents to maintain their function and joint mobility) to provide passive range of motion (PROM, therapist or equipment moves the joint through the range of motion with no effort from the resident) to both arms and both legs. A review of Resident 1 ' s Physician Order dated 8/9/22, indicated for RNA to initiate PROM to both arms for the Resident 1 ' s five times a week or as tolerated. A review of Resident 1 ' s RNA Flow Sheet (record of RNA treatment sessions) from 8/9/22 to 11/18/22, indicated ROM exercises to both arms was not provided five times a week according to physician ' s order. Resident 1 ' s RNA Flow Sheet for September 2022 was blank for the following dates: 9/2/22, 9/4/22, 9/9/22, 9/11/22, 9/12/22, 9/18/22, 9/21/22, 9/25/22 and 9/26/22. Resident 1 ' s RNA flow sheet for October and November 2022 were blank from 10/17/22 to 11/18/22. The Flow Sheets were blank and unsigned. A review of Resident 1 ' s Minimum Data set (MDS, a standardized assessment and care planning tool) dated 9/16/22, indicated the resident usually understands and able to make herself understood. The MDS indicated Resident 1 required extensive assistance (the individual would not be able to perform or complete the activity of daily living without another person to aid in performing the complete task, by providing weight-bearing assistance) with bed mobility, transfers between surfaces, dressing, toilet use and personal hygiene and was totally dependent with eating. During an observation of Resident 1 in Resident 1 ' s room and a concurrent interview, on 11/18/22 at 11:16 am, Resident 1 stated she has no therapy here, and she wanted therapy. Resident 1 ' s right side of the body had limited movement and the right hand appeared contracted (limited movement, decrease in size and or range). During an observation of Resident 1 in Resident 1 ' s room and interview on 11/18/22 at 1:53 pm, Resident 1 was awake, lying-in bed. Resident 1 was unable to lift her right arm and right hand. Resident 1 stated, no nurse exercises with me, they have not come to do exercises with me in a long time. Resident 1 was unable to specify how many days she did not receive ROM exercises. During an interview on 11/18/22 at 4:02 pm, the Director of Rehabilitation Services (DOR) stated, Resident 1 was last seen by the OT in July 22 (7/15/22). During an observation of Resident 1 ' s Therapy Screening by the DOR and a concurrent interview on 11/18/22 at 4:50 pm, the DOR assessed Resident 1 ' s arms and legs. Resident 1 ' s right hand was in closed position (like a fist). The DOR attempted to open Resident 1 ' s right hand but was unable to extend the fingers due to stiffness. Resident 1 complained of pain while the DOR attempted to open her right hand. The DOR stated Resident 1 ' s right arm could not raise above 80 degrees (approximately shoulder height) due to Resident 1 ' s complaints of pain. The DOR stated Resident 1 ' s right arm had 80 degrees of shoulder flexion (raising the arm in front of the body and overhead, normal range is 0-180 degrees) and 80 degrees of shoulder abduction (raising the arm to the side and overhead, normal range is 180 degrees). A review of Resident 1 ' s Therapy Screening Form dated 11/18/22, indicated the resident had stiffness on right hand and fingers, painful right shoulder on flexion 0-80 degrees and abduction 0-80 degrees. There was a recommendation for an OT evaluation to determine appropriate splint (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) and to continue with RNA program. During an interview on 11/18/22 at 5:25 pm and a review of Resident 1 ' s OT Admission Evaluation and Treatment (OT Evaluation) dated 6/13/22, the DOR stated during the initial OT evaluation (6/13/22), the ROM in Resident 1 ' s right arm was WFLs. The DOR defined WFLs as having no limitations in ROM, even when performing PROM. During an interview on 11/18/22 at 5:45 pm, and a review of Resident 1 ' s OT Discharge Summary, dated 7/15/22, the DOR stated Resident 1 did not receive PROM exercise after the resident was discharged from OT services (7/15/22). The DOR stated, Resident 1 should be screened for ROM quarterly. The DOR reviewed Resident 1 ' s clinical record and stated there was no quarterly ROM screening completed for Resident 1 since 7/15/22. During an interview on 11/18/22 at 6:21 pm and a review of Resident 1 ' s OT Evaluations (in general), the Medical Records Director (MRD) and the DOR stated Resident 1 did not have any quarterly screening for ROM since Resident 1 was discharged from OT services on 7/15/22. During an interview on 11/18/22 at 6:30 pm, the DOR stated, Resident 1 ' s right arm ' s ROM could have been maintained had PROM exercise been provided consistently (in every case or on every occasion). The DOR stated PROM exercise were not provided as ordered after the OT Department discharged the resident from OT services on 7/15/22. The DOR stated Resident 1 had decreased ROM on right shoulder, right hand, right fingers and right thumb and the resident complained of pain when performing PROM exercises to the resident ' s right arm. The DOR stated Resident 1 would not have right arm pain if ROM exercises were consistently provided. The DOR stated, Resident 1 ' s decline in ROM to the right arm was avoidable and preventable. During an interview on 11/18/22 at 7:28 pm and a review of Resident 1 ' s RNA Flow Sheet dated from 8/9/22 to 11/18/22, the Director of Nursing (DON) stated when the RNA Flow Sheet was blank, unsigned, and not documented, then it was not done. During an interview on 12/8/22 at 1:39 pm, Restorative Nursing Aide 1 (RNA 1) stated, she was the only RNA at the facility. RNA 1 stated, when she could not provide PROM exercise for some residents that she was assigned to perform RNA exercises, she gave them (the residents) off days. During an interview with the facility ' s Administrator on 1/10/23 at 4:15 pm, the facility did not have a policy for monitoring the residents ' ROM and mobility. The Administrator stated the facility monitored the residents ' ROM and mobility using the quarterly MDS. A review of the facility ' s contracted Rehabilitation Agency ' s Policy and Procedure updated 9/5/17, indicated all residents identified needing an assessment of functional status and potential to benefit from rehabilitation services be evaluated in order to determine an appropriate plan of care. Therapeutic goals must meet at least one of the following characteristics to prevent deterioration and sustain function; provide interventions that enable the resident to live at their highest level of independence in the case of a chronic or progressive disability. A review of the facility ' s Policy and Procedure tiled Resident Mobility and Range of Motion, revised July 2017, indicated residents with limited mobility will receive appropriate services, equipment, and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. The policy indicated the residents will not experience an avoidable reduction in range of motion.

Based on observation, interview and record review, the facility failed to provide treatment and care in accordance with professional standards and its policies and procedures for the application of a new left knee brace (an external device to support, align, or correct a movable part of the body) for one of three sampled residents (Resident 1) by failing to ensure: a) Physical Therapist 1 (PT 1) assessed and monitored Resident 1's tolerance to wear a new left knee brace at 20 degrees of knee flexion (knee bend) for two hours. b) Restorative Nurse Assistants 1 and 2 (RNAs 1 and 2, Nurse Aides that help residents to maintain their function and joint mobility) discontinued the application the left knee brace on 3/17/22, 3/18/22, and 3/21/22 after Resident 1 complained of severe pain due to the application of the new left knee brace on 3/16/22. These deficient practices resulted in Resident 1 experiencing increased pain, swelling in the left knee and a new left knee dislocation (when the bones in a joint are not in their usual positions). On 3/24/22, Resident 1 was transferred to a General Acute Care Hospital (GACH) for further evaluation of the left knee. (Cross Reference F697) (Cross Reference F842) Findings: A review of Resident 1's Admission Record indicated the resident initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Order Summary Report, dated 1/7/22, indicated for the resident to have a DynaPro Flex Knee (a type of knee splint, rigid material or apparatus used to support and immobilize a broken bone or impaired joint). A review of Resident 1's Restorative Nurse Assistants Meeting Follow Up Notes, dated 1/12/22, indicated PT staff (unidentified) recommended a left knee splint for Resident 1 due to left knee contracture (loss of motion of a joint) and pain. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 1/27/22, indicated Resident 1 had moderately impaired cognition (mental processes involved in thinking, knowing, remembering, judging, problem-solving). Resident 1 required extensive assistance (requires significant amount of assistance from another person to perform task) from staff to complete dressing, eating, toileting, and personal hygiene. The MDS indicated Resident 1 had impairment in range of motion (ROM, full movement potential of a joint) of both legs and the resident did not ambulate. A review of Resident 1's Physician's Progress Note dated 2/3/22, signed by Nurse Practitioner 1 (NP 1), indicated Resident 1 was doing well and had no complaints of pain or discomfort. The note indicated Resident 1 did not have any swelling in the resident's arms or legs. A review of Resident 1's Radiology (X-ray) Report of the left knee, dated 2/18/22, indicated the artificial parts of the left knee were intact. The x-ray indicated Resident 1 did not have a fracture (broken bone) or an acute (new) dislocation. A review of Resident 1's Physician's Progress Note, dated 3/10/22, signed by NP 1, indicated Resident 1 had no complaints of pain or discomfort. The note indicated there was no swelling in Resident 1's arms or legs. A review of Resident 1's Inservice Meeting Minutes, dated 3/15/22, indicated PT 1 provided an in-service for 15 minutes, from 1:30 p.m. to 1:45 p.m., on the topic of left knee brace application, duration, angles and RNA responsibilities. Attendance in the in-service included PT 1, RNA 1, and RNA 2. A review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Brace set at 20 degrees knee flexion. A review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Brace set at 20 degrees knee flexion. A review of Resident 1's Restorative Therapy Referral Form, dated 3/16/22, indicated Resident 1 had a potential for left knee contracture to worsen and the goal of the RNA program was to maintain or improve the left knee contracture. The form indicated for RNAs (RNA 1 and RNA 2) to apply a left knee brace to Resident 1 for two hours a day, seven days a week, as tolerated at 20 degrees. A review of Resident 1's Change in Condition (COC) Evaluation, dated 3/16/22, time stamped at 12:36 p.m., indicated Resident 1 had uncontrolled pain that started on 3/16/22 in the morning. Resident 1 complained of new pain of 10/10 on a pain scale of 0 to 10 (0 means no pain and 10 means the worst possible pain). The evaluation indicated Resident 1 complained of a horrible pain in the left knee when the left knee brace was applied, and that Resident 1 stated she feel better when the left knee brace was removed. The evaluation indicated Resident 1 was pre-medicated for pain before the left knee brace was applied and the pain increased when the resident wore the brace. A review of Resident 1's Nursing Progress Notes, dated 3/16/22, indicated Resident 1 did not tolerate the brace on the left knee for two hours and staff would apply the brace again tomorrow. A review of Resident 1's Order Summary Report, dated 3/16/22 at 1:59 p.m., indicated to administer [MEDICATION(S)] (medication used to treat moderate to severe pain), one tablet, 5-325 milligram (mg), by mouth as needed for breakthrough pain (exacerbation of pain even when taking pain medicine regularly) above 6/10 pain scale for 10 days after application of the left knee brace. A review of Resident 1's Restorative Nursing Flow Sheet, dated from 3/16/22 to 3/23/22, indicated that RNA 1 and RNA 2 applied Resident 1's left knee brace on 3/17/22, 3/18/22, and 3/21/22. There was no brace application for 3/19/22 (Saturday) and 3/20/22 (Sunday). On 3/21/22, RNA 1 wrote she applied the left knee brace, but Resident 1 did not tolerate it and charge nurse (unidentified) was notified. On 3/22/22, RNA 1 wrote Resident 1 refused the application of the left knee brace, and the charge nurse (unidentified) was notified. On 3/23/22, RNA 1 wrote Resident 1's left knee brace was not applied while waiting for the results of the x-ray of the knees. A review of Resident 1's COC Evaluation dated 3/22/22 time stamped at 2:39 p.m., indicated Resident 1 had an abrupt onset of swelling on both knees that started on 3/22/22 in the afternoon. A review of Resident 1's Physician Order, dated 3/22/22, indicated for the resident to have the x-ray of both knees. A review of Resident 1's Radiology Report of the left knee, dated 3/22/22, indicated there was an acute (new) posterior (towards the back of the body) dislocation of the left knee arthroplasty (surgical reconstruction or replacement of a joint) and that the knee joint was not in proper alignment. A review of Resident 1's COC Evaluation, dated on 3/24/22, indicated the resident had 8/10 pain on the front left knee. The evaluation indicated Resident 1's x-ray result showed posterior dislocation of the left knee arthroplasty. A review of Resident 1's Physician's Progress Note, dated 3/24/22, signed by NP 1, indicated NP 1 performed a follow up visit due to Resident 1's x-ray finding of a left knee dislocation. The note indicated Resident 1 had tenderness and swelling in the left knee compared to the right knee. NP 1's Note indicated to transfer the resident to GACH for further evaluation. A review of Resident 1's Order Summary Report, dated 3/24/22, indicated to transfer Resident 1 to GACH for further evaluation of the left knee. A review of Resident 1's GACH Radiology Report of the left knee, dated 3/24/22, indicated there was an abnormal positioning of the left knee joint and a partial posterior subluxation (partial dislocation of a joint). The report indicated an extensive valgus deformity (condition in which the joint is angled outward) of the knee joint and a recommendation for surgical consultation. A review of Resident 1's Emergency Department (ED) Records, dated 3/24/22, indicated Resident 1 complained of left knee pain with movement and the left knee was deformed. The ED records indicated facility staff (unidentified) reported Resident 1 complained of left knee pain when the knee brace was applied and that the resident did not walk. Resident 1 was discharged from the ED on 3/24/22 and returned to the facility. A review of Resident 1's Order Summary Report, dated 3/25/22, indicated for the resident to receive an orthopedic (branch of medicine dealing with the corrections of deformities of bones and muscles) consultation for potential surgical intervention. A review of Resident 1's Physician's Progress Note, dated 3/28/22, signed by Nurse Practitioner 1, indicated NP 1 performed a follow up visit due to Resident 1's left knee dislocation and NP 1 communicated with nursing staff (unidentified) regarding an orthopedic follow up as soon as possible. The note indicated Resident 1's left knee was more prominent (sticking out) than the right knee. Resident 1's pain medication was made routine and increased in frequency while waiting for orthopedic consult. During an interview and record review of the March RNA Flowsheet, on 5/18/22, at 11:20 a.m., RNA 1 stated PT 1 provided an in-service to show RNA 1 and RNA 2 on how to apply the left knee brace for Resident 1 on 3/15/22 (the same day the new left knee brace arrived at the facility). RNA 1 stated that Resident 1's knee brace was a different type of brace and that it was not a typical brace that she used at the facility. RNA 1 stated on 3/15/22 PT 1 applied the new brace on Resident 1's left knee and RNA 1 removed the left knee brace at the end of two hours. RNA 1 stated she applied the brace the next day on 3/16/22, but Resident 1 could not tolerate the brace for one hour and the resident complained of pain on the left knee even after she received pain medications. RNA 1 stated she knew Resident 1 could not tolerate the brace because the resident said, it hurts. RNA 1 stated on the first and the second day (3/15/22 and 3/16/22) of applying the new brace, she did not notice swelling or deformity on Resident 1's knee. RNA 1 stated on 3/21/22, when she applied the brace again Resident 1 did not tolerate it and she reported the incident to the Director of Nursing (DON). During an interview on 5/18/22 at 11:50 a.m., RNA 2 stated on 3/15/22, Resident 1 received a new left knee brace and PT 1 provided an in-service to RNA 1 and RNA 2 and demonstrated how to apply the left knee brace to Resident 1. RNA 2 stated it was a new type of brace and she had not worked with this brace prior to the in-service. RNA 2 stated PT 1 demonstrated how to put on the brace, but he did not demonstrate how to remove the brace. RNA 2 stated she assumed how she applied the brace on was how she would remove the brace. RNA 2 stated she applied the brace on 3/18/22 for two hours and Resident 1 complained of pain on both legs. RNA 2 stated Resident 1 wore the left knee brace for two to three days and she received an instruction to hold the brace application because the resident's knee was dislocated. During an interview on 5/18/22 at 12:50 p.m., Occupational Therapist 1 (OT 1) stated a splint/brace was for proper positioning of a joint and to prevent further contractures. OT 1 stated the standard of practice in therapy for a resident requiring a new splint or brace included an initial evaluation of the resident's joint range of motion. OT 1 stated once a new brace was received, the therapist had to work with the resident over multiple treatment sessions to adjust the brace to the resident's specific joint range of motion to ensure the fit was correct. The therapist needed to monitor and slowly increase the resident's tolerance in wearing the brace starting from 30 minutes, then to one hour and gradually increase wearing tolerance for the brace. OT 1 stated after adjustments and the brace still did not fit well, then the resident may require a different brace. OT 1 stated Only trained therapists would know how to do this, nurses cannot do it. OT 1 stated once the therapist established the proper fit, adjustment, and wearing time of a brace, then the therapist would train the RNAs on how to apply and remove the brace over two to three sessions. During the RNA trainings, the therapist needed to show the RNAs how to apply and remove the brace, then watched the RNAs applying and removing the brace and provided the RNAs opportunities to ask questions. During an interview on 5/18/22 at 2:01 p.m., PT 1 stated that physical therapy was the profession that had the training and knowledge to assess if a resident required a knee brace. PT 1 stated that once a brace was received, the therapist needed to assess whether the brace was appropriate for the resident by assessing for pain, whether the fit was comfortable and adjust the brace as needed. PT 1 stated if there was presence of pain or the brace was not comfortable, then a therapist would have to adjust the brace to determine if the brace was appropriate. A therapist would assess through checking in with the resident for about a week or two. PT 1 stated a therapist needed to apply the brace first and would not transition to an RNA program to apply and remove the brace right away due to a therapist needed to make sure the brace fit properly, the resident was comfortable, and that the brace was working. In the same interview on 5/18/22 at 2:01 p.m., PT 1 stated on 3/15/22 (the same day the left knee brace arrived at the facility), he provided in-services to the RNA 1 and RNA 2 on how to apply the brace on Resident 1. PT 1 stated on the first day (3/15/22), he applied the left knee brace to Resident 1 and RNA 1 took the brace off on the two hours mark. PT 1 stated he was not present when RNA 1 removed the brace on 3/15/22 to assess Resident 1's tolerance of the new brace after two hours mark. PT 1 stated on 3/15/22, about 30 minutes after the brace was applied, he checked on Resident 1. PT 1 stated Resident 1 was talkative, but he did not directly assess the resident or the brace because Resident 1 was not receiving formal therapy services. PT 1 stated Nursing Staff (in general) did not notify him or the therapy department that Resident 1 did not tolerate the brace until a week or two later when he was informed that Resident 1 had a dislocation or a subluxation of the left knee. PT 1 stated PT 1 assumed Resident 1 tolerated the brace well so there was no reason to change the degrees of knee flexion of the brace or adjust the wear time. PT 1 stated Resident 1 needed to receive a physical therapy evaluation to monitor and assess the application of the new left knee brace to ensure the appropriate fit at 20 degrees of knee flexion and if Resident 1 could tolerate wearing the brace for two hours. PT 1 stated it required the professional knowledge and training of a therapist to properly assess the knee brace, especially because Resident 1's left knee brace was not a typical brace used in the facility and was more complicated. PT 1 stated in retrospect, it would have been beneficial to have a resident on skilled therapy to monitor and assess the knee brace, how to fit it for degrees and time. During an observation on 5/18/22 at 2:35 p.m., in Resident 1's room, the resident was lying in bed and there was a pillow in between the resident's legs and under the left knee. Both knees had a vertical old scar over the middle of both knees. The left knee was deformed and larger in size compared to the right knee. The lower part of the left leg appeared to be shifted lower than the knee. The right leg was straight, and the right knee did not have any swelling or deformity. During an interview and record review on 5/19/22 at 12:50 p.m., the DON stated the facility received the left knee brace on 3/15/22 and on the same day PT 1 provided an in-service to RNA 1 and RNA 2 on how to apply the brace for Resident 1. The DON stated since the brace was new, staff (in general) needed to continue to monitor Resident 1 for the whole time during the initial application of the brace. The DON stated on the next day (3/16/22), Resident 1 could not tolerate the left knee brace and the resident had a lot of pain, so a change of condition report was completed. The DON stated, It was really hurting her. Oh yea, the brace was hurting her. The DON stated on 3/16/22, NP 1 ordered additional pain medication for breakthrough pain after application of the left knee brace. During an interview on 5/19/22 at 1:41 p.m., RNA 1 stated on 3/15/22, after the in-service for application of the left knee brace for Resident 1, RNA 1 stayed with the resident for 15 to 20 minutes and left. RNA 1 stated she went back to Resident 1 after two hours and the resident was okay. RNA 1 stated she removed the brace and applied it again on 3/16/22 and 3/17/22. During an observation and interview on 5/19/22 at 2:11 p.m., in Resident 1's room, Resident 1 was sitting up in bed wearing a hospital gown. PT 1 assessed Resident 1's legs and stated the left knee anatomy (body structures) did not look normal. PT 1 stated Resident 1's left knee had a deformity. PT 1 stated Resident 1's left knee did not have a deformity before the application of the left knee brace. PT 1 assessed the resident's knee brace (that was stored in Resident 1's closet) and stated this type of brace was not typically used in the facility. PT 1 stated the brace had dials on both sides which had to be adjusted manually to the correct angle and locked into place. PT 1 stated there a dial to adjust extension/flexion for the knee portion. During an interview on 5/19/22 at 2:45 p.m., the DON stated on 3/21/22, Resident 1 could not tolerate the brace so RNA 1 took the brace off. The DON stated on 3/22/22, she and RNA 1 went into Resident 1's room and the resident got upset. The DON stated, the resident did not want the brace. The DON stated she noticed Resident 1 had swelling in the left knee and the knee was protruding. The DON stated a change of condition was completed and an x-ray was ordered for both knees. The DON stated the resident was not responding to pain medications and the DON told RNA 1 and RNA 2 not to put the brace on Resident 1 until further orders. The DON stated Resident 1 did not have left knee swelling and the left knee was not protruding before the start of the application of the brace on 3/15/22. During a telephone interview with OT 1 on 5/19/22, at 3:53 p.m., she stated as a therapist she would never give a brace to nursing staff to apply on the resident right away because they were not trained to do it. OT 1 stated it takes a while to evaluate and make sure the resident tolerates the new brace. OT 1 stated she was not at the facility on 3/15/22 and PT 1 took over and trained RNA 1 and RNA 2. OT 1 stated if she was at the facility on 3/15/22, she would wait for an authorization for PT evaluation before putting the new brace on Resident 1. During a phone interview on 5/23/22 at 9:33 a.m., Orthotist 1 (a professional that specializes in provision of orthotics) stated a measurement for a left knee brace was completed on 3/7/22 for Resident 1. Orthotist 1 stated that orthotists do not determine how long a resident could wear a brace or the degrees of knee flexion. Orthotist 1 stated that these decisions would be up to a resident's therapist or physician. Orthotist 1 stated she did not prescribe the degree of motion of the knee brace or the wearing schedule for Resident 1. The Orthotist 1 stated Resident 1's brace is a little more complicated, it needs to be adjusted more, like the straps, it needs to be trimmed down to the resident size. During a phone interview on 5/24/22 at 3:50 p.m., Family Member 1 (FM 1) stated on 3/16/22, Resident 1 used the resident's cellular phone to call FM 1 and stated, this brace is hurting me. FM 1 stated on 3/18/22 facility's staff (unidentified) told her that Resident 1 tolerated the left knee brace for one hour. FM 1 stated on 3/22/22, Resident 1 called FM 1 and stated her left knee was burning and she was in pain. FM 1 stated she spoke with a therapist (unidentified) at the facility and the therapist told her facility staff (unidentified) did not do what they were supposed to do to adjust Resident 1 to the new brace. A review of a textbook, titled The Guide to Physical Therapist Practice, second edition, pages 76 and 77, revised 2003 by the American Therapy Association, indicated a physical therapist used tests and measures to assess the need for orthotic devices in patients and evaluated the appropriateness and fit of the device. The Guide to Physical Therapy Practice indicated physical therapists performed assessments to determine a patient's alignment and fit of the orthotic device, components of orthotic device, level of safety with device, and functional benefit of the device. A review of the facility's policy and procedure, dated 9/5/17, titled Splinting and Orthotics, indicated the following procedures must be followed by clinicians when providing splinting and/or orthotics, while the [resident] is receiving therapy services. Adhere to precautions and contraindications listed below: · Monitor extremity for function, and sensation throughout fabrication and/or application process. · Eliminate rough or sharp edges that could cause skin integrity issues. · Modify splints/orthotics and strapping as required to ensure proper fit. · Discontinue use of device, if modifications do not resolve issues or if [resident] is unable to tolerate wearing device. · Document [resident's] wearing tolerance when establishing wearing schedule. A review of the facility's policy and procedure, updated 9/6/17, titled Therapy's Role in Care Planning, indicated, when a decline is noted, the following substantiates a need for skilled intervention: i. an accurate and complete assessment. ii. a care plan which is implemented consistently and based on information from the assessment iii. evaluation of the results of the intervention and revising the interventions as necessary.

Based on observation, interview, and record review, the facility failed to implement interventions to prevent and control the spread of COVID-19 (Coronavirus disease, a severe respiratory illness caused by virus and spread from person to person) in accordance with the local Department of Public Health's (DPH) guidelines, facility's policy and Mitigation Plan (MP, a plan to reduce loss of life and impact of COVID-19 in the facility) for 7 of 19 sampled residents (Residents 1, 2, 3, 4, 5, 6 and 7) by failing to: 1. Ensure Certified Nursing Assistants 1 and 2 (CNAs 1 & 2) don (put on) Personal Protective Equipment (PPE, gowns, gloves, N95 masks, and face shields worn to minimize exposure to hazards that cause serious workplace injuries and illnesses). CNA 1 did not don a gown when providing care to Resident 1 in the Yellow Zone (area for residents who have been in close contact with known cases of COVID-19, newly admitted or readmitted residents, residents who have symptoms of possible COVID-19 pending test results and for residents with indeterminate tests). CNA 2 did not use eye protection when feeding Resident 2 in the Yellow Zone. 2. Ensure Licensed Vocational Nurse 1 (LVN 1) did not work in both Yellow and Red Zone (area for residents who tested positive for COVID-19) during the same shift. LVN 1 was assigned to care for Residents 4, 5, 6 and 7 in the Red Zone and Residents 1, 2, 3, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, and 19 in the Yellow Zone. 3. Ensure five of five staff (Housekeeping 1 (HK 1), LVN 1, CNA 1, CNA 2 and CNA 3) were fit tested (a test to determine how effectively a mask will protect health care workers) for N95 masks (mask designed to achieve a very close facial fit and efficient filtration of airborne particles). These deficient practices had the potential to result in the spread of COVID 19 from Residents 4, 5, 6 and 7 in the Red Zone to Residents 1, 2, 3, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, and 19 in the Yellow Zone and staff that could lead to severe respiratory illness, hospitalization and/or death. Findings: On 2/22/21 at 6:56 p.m., an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's Director of Nursing (DON) and Administrator regarding the facility's staff failure to implement infection control practices according to the local DPH's guidelines, the facility's policy, and MP for COVID-19. On 2/23/21 at 5:52 p.m., the IJ was lifted after the DON and Administrator submitted an acceptable Plan of Action (POA, interventions to correct the deficient practices). The surveyor verified and confirmed the implementations of the POA while onsite by observation, interview and record review. The IJ was removed in the presence of the DON and the Administrator. The acceptable POA indicated, as follows: A. Registered Nurse Supervisor (RNS) assessed Residents 1 and 2 on 2/23/21. Director of Staff Development and Clinical Nurse Resource conducted a PPE competency validation on 2/22/21 for all nursing staff. B. Facility's Administrative Staff designated Licensed Vocational Nurses (in general) to work in the Red Zone on 2/23/21. C. The DON conducted N95 masks fit testing for staff on 2/23/21. 1. During an observation of the Yellow Zone with an Infection Prevention Nurse (IPN, a nurse who helps prevent and identify the spread of infectious disease in the healthcare environment) on 2/22/21 at 12:20 p.m., CNA 1 went inside Resident 1's room and did not don an isolation gown (gown that protect residents and health care workers from germs and body fluids). CNA 1 donned (put on) gloves and repositioned Resident 1 by pulling the sheet under the resident. CNA 1's clothes touched Resident 1's bed. On 2/22/21 at 12:25 p.m., CNA 1 stated he did not don an isolation gown when he repositioned Resident 1. CNA 1 stated he needed to don an isolation gown when providing care to Resident 1 in the Yellow Zone. CNA 1 stated his clothes were contaminated. CNA 1 stated wearing an isolation gown could protect his clothes from being contaminated and prevent the spread of COVID-19 to other staff and residents. During an observation in the Yellow Zone with the IPN on 2/22/21 at 12:30 p.m., CNA 2 went inside Resident 2's room without wearing a face shield. CNA 2 was within six feet of Resident 2 while feeding the resident's lunch. During an interview with CNA 2 on 2/22/21 at 12:40 p.m., while in the Yellow Zone, she stated she could not find her face shield. CNA 2 stated she needed to wear face shield in the Yellow Zone for infection control. During an interview with the IPN on 2/22/21 at 12:45 p.m., she stated, CNA 1 and CNA 2 in the Yellow Zone needed to don full PPE when they enter the residents' rooms to prevent the spread of COVID-19. The IPN stated residents in the Yellow Zone could have been exposed to COVID 19. A review of Resident 1's Admission Record indicated the resident was newly admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 2's Admission Record indicated the resident was newly admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the facility's Mitigation Plan dated 5/22/20, indicated the IPN would monitor and collect guidance from the local DPH, California Department of Public Health (CDPH), Center for Disease Control and Prevention (CDC) and counsel staff on best practices to ensure consistent application of safe infection prevention practices. A review of the local DPH's guideline titled Guidelines for Preventing and Managing COVID-19, updated 2/22/21, indicated gowns should be worn in the Yellow Zone. A review of the local DPH's guideline, titled Guidelines for Preventing and Managing COVID-19, dated 11/24/20 and updated on 2/22/21, indicated for staff in the Yellow Zone to wear eye protection such as face shields or goggles when within six feet with the residents. 2. During an interview on 2/22/21 at 12:47 p.m., the IPN stated LVN 1 was assigned to work in both Yellow and Red Zones due to LVN 3 called in sick. The IPN stated sharing LVN 1 in the Yellow Zone and Red Zone could spread COVID-19 from residents in the Red Zone to residents in the Yellow Zone. During an observation in the Yellow Zone on 2/22/21 at 1:05 p.m., LVN 1 went inside Resident 3's room to administer [MEDICATION NAME] suspension (medication to treat fungal infection) for oral thrush (white spots and ulcers inside the mouth) and artificial tear (solution to treat dry eyes) to the resident. During an observation in the Yellow Zone on 2/22/21 at 1:14 p.m., LVN 1 went inside Resident 1's room to administer [MEDICATION NAME] (medication to treat high blood pressure) to the resident. During an interview with LVN 1 on 2/22/21 at 1:21 p.m., she stated she was in the Red Zone this morning at 10:00 a.m. to administer medication to Residents 4, 5, 6, and 7. LVN 1 stated after she gave medications in the Red Zone, she returned to the Yellow Zone to administer medications to Residents 1, 2, 3, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, and Resident 19. A review of Residents 4's, 5's, 6's and 7's Medication Administration Record (MAR), dated 2/22/21, indicated the following: a. LVN 1 signed Resident 4's MAR and administered 12 medications by mouth to the resident as scheduled for 9 a.m. b. LVN 1 signed Resident 5's MAR and administered six medications (five by mouth and one injection) to the resident as scheduled for 9 a.m. c. LVN 1 signed Resident 6's MAR and administered six medications by mouth to the resident as scheduled for 9 a.m. LVN 1 checked Resident 6's blood sugar at 12 p.m. d. LVN 1 signed Resident 7's MAR and administered ten medications by mouth to the resident as scheduled for 9 a.m. LVN 1 checked Resident 7's blood sugar at 11:30 a.m. During an interview with the DON and a concurrent review of the Staffing Assignment on 2/22/21 at 4:15 p.m., she stated LVN 3 called off sick on today and there was no replacement for LVN 3. The DON stated LVN 1 was assigned to work in both Yellow and Red Zones to cover for LVN3. The Staffing Assignment dated 2/22/21, indicated LVN 3 was scheduled to work on 2/22/21 but called off sick. The DON stated she called one staffing registry (company that provide staff to work at the facility in case of staffing shortage) with no response and she did not attempt to call other staffing registries. A review of the facility's MP, dated 5/22/20, indicated when staff worked in the Red Zone, they could not work at the Yellow or Green Zones on the same shift. A review of Resident 1's Admission Record indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 3's Admission Record indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 4's Admission Record indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 5's Admission Record indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 6's Admission Record indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 7's Admission Record indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 3. During an observation in the Yellow Zone on 2/22/21 at 12:09 p.m., HK 1 was cleaning Resident 8's room. HK 1 was wearing a 3M 8210 mask (a type of N95 masks). During an observation in the Yellow Zone, on 2/22/21 at 1:05 p.m., LVN 1 was wearing a 3M 8210 mask. LVN 1 went inside Resident 3's room to administer medications to the resident. During an observation in the Yellow Zone on 2/22/21 at 2:05 p.m., CNA 1 was walking in the hallways while wearing a 3M 8210 mask. During an observation in the Yellow Zone on 2/22/21 at 2:05 p.m., CNA 2 was standing in the hallway while wearing a Honeywell DC365 (a type of N95 mask). During an observation in the Red Zone on 2/22/21 at 5 p.m. CNA 3 was in the hallway wearing a 3M 8210 N95 mask. During a review of the facility's undated Mask Fitting Log, on 2/22/21 at 1:35 p.m., indicated the following: a. HK 1 was not fit tested for N95 mask. b. LVN 1 was fit tested for size small 3M 1860 mask (a type of N95 mask). c. CNA 1 was not fit tested for N95 mask. d. CNA 2 was not fit tested for N95 mask. e. CNA 3 was not fit tested for N95 mask. During an interview with the IPN on 2/22/21 at 1:40 p.m., she stated, LVN 1 was not wearing the fit tested mask. IPN stated LVN 1 was fit tested for 3M 1860 mask but the facility did not have 3M 1860 masks since October 2020. The IPN stated CNA 1 was not fit tested for the N95 mask because CNA 1 worked part-time. The IPN stated CNA 2 was not fit tested for the N95 because she was hired on 9/22/20. The IPN did not state a reason why HK 1 and CNA 3 were not fit tested for N95 Masks. The IPN stated employees' fit tests were initiated on April 2020. The IPN stated facility's staff were fit tested for 3M 1860 masks but the facility did not have supplies for 3M 1860 masks since October 2020. During an interview with the DON on 2/22/21 at 4:08 p.m., she stated staff were wearing 3M 8210 masks and Honeywell DC365 masks which were considered by the facility as one size fits all N95 masks. A review of the facility's undated policy, titled Infection Control COVID-19 Policy and Procedure, indicated for staff to be fit tested for N95 masks for protection before entering isolation rooms. A review of the local DPH's Guideline, titled Guidelines for Preventing and Managing COVID-19, dated 11/24/20 and updated 2/22/21, indicated an initial and annual N95 fit testing were required for all staff per California Division of Occupational Safety and Health (Cal-OSHA). A review of the Cal/OSHA Interim Guidance on COVID-19 for Healthcare Facilities-Severe Respirator Supply Shortages, dated 8/6/20, indicated initial fitted tests and re-fitted tests for N95 masks were required before using N95 masks when changing in the masks' model, make, or size. The Cal/OSHA guidance indicated an annual fit testing for N95 masks was also required.

Based on observation, interview, and record review, the facility failed to provide a safe and sanitary environment to avoid flies in the residents' living areas to help prevent infections and medical complications [REDACTED]. Resident 1, who was totally dependent on staff for care and was unable to communicate needs, developed growth of maggots (the larva, an immature, wingless and wormlike form of the fly, which hatches from the egg, before developing into its adult form) in her right ear. As a result, Resident 1 required transfer to General Acute Care Hospital 1 (GACH 1) for removal of maggots and antibiotics treatment. GACH 1's physicians diagnosed Resident 1 with a rupture of the right ear tympanic membrane (is a hole or tear in the thin tissue that separates the ear canal from the middle ear or eardrum caused by, among other sources, foreign objects in the ear canal). Findings: A review of Resident 1's Admission Record (Face Sheet) indicated the facility readmitted Resident 1 on 2/16/18 with [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS - standardized assessment and care-screening tool) dated 7/12/18, indicated Resident 1's cognition (mental processes involved in gaining knowledge and comprehension) was severely impaired and could not communicate needs. Resident 1 was totally dependent on staff for all activities of daily living (ADLs such as, transferring, eating, bathing, and personal hygiene). A review of Resident 1's Ear, Nose, and Throat (ENT) consultation dated 7/12/19, indicated Resident 1's tympanic membranes were intact (not damaged). The ENT physician removed ear wax (yellowish waxy material) from both ears. Resident 1 did not have an infection on both ears. A review of Resident 1's Change of Condition form dated 7/15/19, timed at 4:02 a.m., by Registered Nurse 2 (RN 2) indicated Resident 1 had bleeding and had, white moving objects coming from her right ear. RN 2 cleansed Resident 1's right ear with Normal Saline Solution (NSS - salt solution, adjusted to the normal salinity of the body) and applied a dry dressing. RN 2 called the physician and left a message. A review of Resident 1's physician's orders [REDACTED]. A review of Resident 1's Emergency Transfer Communication form dated 7/15/19, timed at 9:51 a.m. by Licensed Vocational Nurse 1 (LVN 1), indicated the resident was noted with bleeding and possible moving objects inside her right ear. Resident 1 left the facility at 9:51 a.m. A review of Resident 1's GACH 1 Emergency Department (ED) note dated 7/15/19, timed at 10:20 a.m., indicated Resident 1 presented to ED for atraumatic (not caused by trauma) right ear bleeding. Resident 1 was treated with a first dose of antibiotics in ED. GACH 1 discharged the resident with a [DIAGNOSES REDACTED]. A review of Resident 1's nursing Progress Notes dated 7/15/19 at 5:34 p.m., indicated Resident 1 returned to the facility the same day, 7/15/19, at 11:30 a.m. The note also indicate Resident 1's right ear had, a little more blood and two small clear white and moving foreign objects which were removed with a cotton swab. Resident 1's attending physician, when notified, ordered to send Resident 1 back to GACH 1 for possible infestation of foreign body. A review of Resident 1's nursing Progress Notes form dated 7/15/19 and timed at 9:24 p.m., indicated the facility transferred Resident 1 to GACH 1 at 9:15 p.m. A review of Resident 1's GACH 1 ED notes dated 7/15/19, timed at 10:26 p.m., indicated Resident 1 was referred back to ED due to multiple foreign bodies in the right ear. The ED physician documented Resident 1's right ear had obvious hemorrhage (bleeding) with worms noted, suggesting maggots. Resident 1 was admitted for monitoring of her right ear myiasis (ear infestation by maggots). Resident 1 was admitted in an isolation room and on antibiotics (eardrops and intravenous (within the vein)) for three to five days depending on the resolution of the ear infection. On 7/18/19 at 7:40 a.m., during an observation of the main Dining/Activity Room, the sliding door was partially open to a patio, and there were flies inside the Dining Room. During an interview, on 7/18/19 at 8:22 a.m., Certified Nursing Assistant 1 (CNA 1) stated that in the early morning of her night shift (11 p.m. to 7 a.m.), she saw dried blood on Resident 1's right outer ear with some fresh blood coming out. CNA 1 stated she immediately notified the licensed nurse. During an interview, on 7/18/19 at 8:51 a.m., Treatment Nurse 1 (TN 1) stated that he with LVN 1, observed, on 7/15/19 at 7 a.m., more dry blood and a white moving like-worm objects on Resident's 1 right ear. During an interview, on 7/18/19 at 9:31 a.m., LVN 1 stated she observed on 7/15/19 at 7 a.m., with TN 1, Resident's 1 right ear with two small moving whitish worms. LVN 1 stated the facility had an ongoing flooring renovation and doors leading outside the facility were often open. LVN 1 stated, at times, she had seen flies inside the facility. On 8/1/19 at 3:30 p.m., the north section hallway floor was observed being in process of replacement. A contracted worker was propping the north exit door open for about five minutes and there was a portable air blower by the door. Resident 1's room was 13 steps away from the north exit door. There were two open trash bins at the corner of the north exit door and there were flies in the area. During an observation, on 8/1/19 at 3:57 p.m., Resident 1 was in bed and did not respond to questions. Resident 1 was clean and properly dressed. During an interview, on 8/1/19 at 3:35 p.m., Maintenance Supervisor (MS) stated the gardener, who was mowing the lawn at the time of the interview, must had left the trash bins open. During an interview, on 8/8/19 at 8:49 a.m., Resident 3 stated she had seen flies in the dining area once in a while. Resident 3 also stated the dining room sliding door was open at times. During an observation at the central Nursing Station, on 8/15/19 at 3:45 p.m., LVN 4 was observed driving away a fly. On 8/15/18 at 4:20 p.m., during a concurrent observation and interview, in the Dining Room next to the kitchen, Resident 5 was driving away a fly with her arms.

Based on observation, interview and record review, the facility failed to: 1. Provide adequate supervision and intervention to prevent recurrence of falls for one of 9 sampled residents (Resident 17) who was at high risk for fall, in a total sample of 18 residents. This deficient practice resulted in three incidents of falls with injuries to Resident 17 during the month of September 2017. 2. Implement fall interventions for four of 9 sampled residents (Residents 8, 16, 1, and 12) who were at high risk for falls in a total sample of 18 residents. This deficient practice had the potential to result in injuries related to falls. 3. Provide training to certified nursing assistants (CNAs) on the fall precaution protocol that was started in October 2015 which included checking the Kardex in the I-pad computer (summary of resident's plan of care) to ensure all precaution measures identified were implemented. 4. Implement a system of preventing fall incidents to residents who were at high risk for falls. As a result there were 23 incidents of falls for the month of September 2017. On 10/6/17 at 10:35 p.m., the administrator and director of nursing were notified of an immediate jeopardy (IJ) due to facility's failure to: -Establish a system to prevent falls and prevent its recurrence. -Provide adequate supervision to prevent falls, hourly monitoring as indicated on the care plan for residents that are high risk for falls, ensure care plan measures were reflected on the Kardex in the I-pad computer, and identify and categorize severity of resident's risk of falls. -Provide training to all certified nurse assistants (CNAs) on the fall protocol, CNAs to check the resident's record to be able to implement fall interventions. On 10/7/17 at 11:30 p.m., the facility submitted an acceptable plan of correction as follows: - Residents who have been affected will be reassessed to determine their fall risk level using the criteria. - Residents identified to be high risk for falls will be placed on the falling star program (designed to be an alert to all staff that the resident is a high risk for fall). - IDT will review current care plan interventions for affected residents and revise care plan or interventions as needed. - The facility fall prevention program will be reviewed and revised to include the falling star program. - Policies and procedures will be reviewed and revised. - The Facility will implement and train staff on the falling star program to provide visual identification for care staff. -All departments will be in-serviced on the falling star program. -Nursing staff will be in-serviced regarding the Kardex and identifying safety interventions on a quarterly basis. - Competency skills checklist will be conducted by Director of Staff Development (DSD) upon hire, orientation, annually and as needed with return demonstration. - CNAs will receive the I-Pad at the start of shift or as soon as possible and will check the Kardex for safety plans as they are doing their rounds. - After a fall incident, IDT will review to determine cause of fall, review care plans for interventions to prevent any further falls. Resident will be reviewed weekly for one month in IDT. - Residents who are on the falling star program will have a log in place in the fall management binder for visual checks every hour. Alternating staff will conduct visual checks and maintain the log. - Revised fall prevention program and falling star program will be reviewed with medical director and pharmacy consultant for input and recommendations. - DON or designee will audit falling star placement daily for one month, if no issues are identified the audit will continue weekly. - Fall prevention plan will be re-evaluated and revised as needed at monthly Quality Improvement meeting for three months then quarterly. On 10/7/17 at 11:30 p.m., the IJ was abated. The administrator and the DON were notified. Findings: 1. A review of Resident 17's Admission Record indicated Resident 17 was admitted to the facility on [DATE], and was readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 17's Minimum Data Set (MDS), a comprehensive assessment and care-planning tool dated 6/19/17, (prior to re-admission to the facility) indicated that Resident 17 had a Brief interview for Mental Status (BIMS - screens for cognitive impairment) score of 15 (a score of 13-15 indicates intact cognition; required extensive assistance with two-person assist for ADL that included bed mobility (how resident moves to and from lying position, turn side to side), transfer (how resident moves between surfaces including to and from bed, chair, wheelchair or standing position) and toilet use. MDS document also indicated that Resident 17's balance during transfer was not steady and only able to stabilize with staff assistance. MDS also indicated Resident 17 had fall incidents in the last 2-6 months prior to readmission on 6/22/17. A review of Resident 17's Admission assessment dated [DATE] indicated that Resident 17 required one person physical assistance with bed mobility, required two person physical assistance with transfer. The fall risk assessment indicated at risk for falls. A review of Resident 17's Care Plan initiated on 8/7/16 indicated that Resident 17 was high risk for falls. Staff interventions included were to perform frequent visual checks and safety reminders. It also indicated Resident 17 had a decline in bed mobility, transfer, gait and balance, however there were no interventions indicated. During an interview with the DON on 10/5/17, at 4:10 p.m., verified that frequent visual checks indicates hourly monitoring for high risk residents. A review of Resident 17's Weekly Nursing Progress Note dated 9/9/17 indicated Resident 17 required assistance with activities of daily living that included bed mobility, transfer, toilet use and personal hygiene, care plan strengths, problems, goals and interventions reviewed and remain appropriate. A review of Resident 17's Change in Condition Evaluation dated 9/15/17, 5 p.m., indicated that Resident 17 had a fall incident (first fall incident), was found face down in her room with epistaxis (nose bleeding) and 2 skin tears, noted to be extremely weak, bilateral handgrips weak, appears sleepy but able to answer questions correctly and stated she was fine, refused hospital transfer when asked by facility staff 3 times. On 9/15/17 at 5:30 p.m., the attending physician was notified and ordered x-ray, apply pressure to nose, and apply dressing on skin tear and visual monitoring. A review of Resident 17's Care Plan dated 9/15/17 indicated that Resident 17 was found lying on the floor, interventions included to continue frequent safety reminder, frequent visual checks and remind resident to ask for help when in need of assistance. A review of the facility's Fall Prevention Program for High Risk Residents that was conducted with the DSD and Medical Records Director did not indicate that there was a documented evidence of hourly monitoring done for Resident 17 on 9/15/17. During an interview with LVN 7 on 10/7/17 at 10:32 a.m., LVN 7 stated Resident 17 went out for dialysis on 9/15/17. LVN 7 also stated she was not aware how Resident 17 fell . During an interview with the CNA 12 on 10/7/17 at 12:10 p.m., CNA 12 stated when she was passing dinner trays to other residents, she saw Resident 17 who came back from dialysis on 9/15/17. CNA 12 also stated she was not aware how Resident 17 fell . A review of Resident 17's Weekly Nursing Progress Note dated 9/17/17 at 3:46 a.m. indicated Resident 17's care plan, problems, goals and interventions were reviewed and remained appropriate. Weekly nursing progress note also indicated Resident 17's interventions were to monitor for s/p (status [REDACTED]. A review of Resident 17's Change in Condition Evaluation dated 9/17/17 indicated Resident 17 had a fall incident at around 7 p.m., (second fall incident) the resident was found lying on her back on the floor near the head on the left side of the bed, her head next to foot of side table, sustained ½ (half inch) cut on the left temple (left forehead). During an interview with LVN 9 on 10/7/17 at 2:55 p.m., LVN 9 stated that on 9/17/17, she looked at Resident 17's room from outside and saw Resident 17's family member in the room. LVN 9 also stated that she heard Resident 17's family member saying You have to wait for help before going out of bed. LVN 9 also stated that she did not do anything at that time because she thought that Resident 17 and the family member were just having an argument. LVN 9 also stated that Resident 17's family member went out of Resident 17's room, talked to her and asked for updates regarding Resident 17. LVN 9 also stated that Resident 17 was found on the floor when both LVN 9 and family member went back to Resident 17's room at around 7 p.m. A review of the facility's Fall Prevention Program for High Risk Residents that was conducted with the DSD and Medical Records Director did not indicate that there was a documented evidence of hourly monitoring done for Resident 17 on 9/17/17. A review of Resident 17's Transfer Form dated 9/17/17 indicated that Resident 17 was transferred to General Acute Care Hospital (GACH). A review of Resident 17's Orthopedic Consultation GACH notes dated 9/18/17 indicated the following: - Acute fracture of left superior pubic ramus (hip bone), may begin physical therapy with WBAT (weight bearing as tolerated) on the left leg as pain permits and follow-up X-Ray in 3 weeks to assess healing. - Acute fracture of the scaphoid (one of the bones of the wrist) of left wrist, no specific treatment/splinting (secure the broken bone with a splint) is needed. A review of Resident 17's Progress Notes-IDT (Interdisciplinary Team) Review dated 9/18/17 indicated that previous interventions for fall prevention included: - Frequent visual checks and safety reminders - Call light within easy reach and reminded resident to call for assistance with toileting and transfers - Re-educate resident on safety precautions r/t fall risk and importance of calling for staff assistance with toileting and transfers for safety - Non-skid strip on the floor IDT recommendations include to re-evaluate resident upon re-admission. A review of Resident 17's Admission Record indicated that Resident 17 was readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 17's Care Plan initiated on 9/22/17 indicated that Resident 17 was at risk for falls and related injuries; does not ask/use call light for assistance; history of falls at home/prior to admission; impaired cognition and safety awareness; involuntary tremors/movements; need assist in transfer and toileting; non-compliant to instructions; possible side-effects of hypnotics/psychotropic, tries to be independent beyond ability; unsteady gait/poor balance. Interventions included the following: - Do not leave resident unattended in the room. Initiated on 9/23/17. - Keep resident in frequently monitored areas. Initiated on 9/23/17. - Observe resident frequently when in bed or up in w/c (wheelchair) for any behavior changes/impulsiveness. During a concurrent record review an interview with the MDS Coordinator on 10/7/17 at 10:15 a.m., the MDS Coordinator stated Resident 17's care plan should have indicated high risk for falls. MDS coordinator also stated that all residents who were at high risk for falls will be monitored hourly using the facility form titled Fall Prevention Program High Risk Residents. A review of Resident 17's Change in Condition Evaluation - Fall dated 9/30/17 (third fall) at 3 p.m. indicated that Resident 17 was noted lying on supine (flat on one's back, face upward) position on the floor with severe right hip pain of 10/10 and was unable to move right leg and right hip due to severe pain. A review of the facility's Fall Prevention Program for High Risk Residents that was conducted with the DSD and Medical Records Director did not indicate that there was a documented evidence of hourly monitoring done for Resident 17 on 9/30/17. A review of Resident 17's GACH notes dated 9/30/17 indicated that Resident 17 had a non-displaced right intertrochanteric fracture (broken thigh bone), underwent open reduction internal fixation (ORIF - surgery to repair broken bone) on 10/2/17. During an interview with the MDS Coordinator on 10/7/17 at 10:15 a.m., the MDS coordinator stated that charge nurses initiate a care plan upon admission or revise the care plan after an incident of fall and IDT reviews and revises the care plan as needed. MDS coordinator also stated that if a fall happened on a weekend, the nurse reviews and revises a care plan depending on the resident's need. The MDS coordinator further stated that the IDT reviews the care plan on the next working day. During an interview with RN 1 on 10/7/17 at 8:30 a.m., RN 1 stated that Resident 17 was insistent on doing things by herself. RN 1 stated that the facility could have tried the use of alarms if Resident 17 would agree with it. RN 1 further stated that the facility could have provided a one-on-one sitter or companion for safety because they did not know when Resident 17 would transfer to-and-from bed-to-wheelchair. During an interview with the DON on 10/5/17 at 6:30 p.m., the DON stated that the facility stopped the use of side rails, bed and wheelchair alarms two months ago in preparation for the new regulation by November 2017. DON also stated that it was the corporate office decision to remove these interventions. DON further stated that the facility will continue to use existing interventions to prevent fall. During an interview with the administrator on 10/6/17 at 12:35 p.m., the administrator stated that the facility stopped the use of bed alarms and wheelchair alarms 8 months ago. The administrator also stated that if an alarm is indicated the facility could still use it. A review of the facility's policy and procedure titled Falls and Fall Risk, Managing dated 12/2007 indicated that staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. Approaches to managing falls and fall risk include: - If falling despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. - If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. 2 (a). A review of Resident 8's Admission Record indicated that Resident 8 was admitted to the facility on [DATE], readmitted on [DATE] with [DIAGNOSES REDACTED]. functioning) and hypertension (chronic elevated blood pressure). A review of Resident 8's history and physical examination [REDACTED]. A review of Resident 8's Minimum Data Set (MDS), a comprehensive assessment and care-planning tool dated 6/20/17 indicated that Resident 8 had a brief interview for mental status (BIMS - screens for cognitive impairment) score of 13, required limited assistance with one-person assist with transfer, required supervision with ambulation. Fall risk assessment indicated at risk for falls. A review of Resident 8's clinical record with the Medical Records Director (MRD) indicated that Resident 8 had unwitnessed fall incidents on the following dates: 10/29/16, 11/19/16 and 2/3/17. A review of the progress note dated 10/29/16 indicated that Resident 8 was found on the floor at 2 p.m. Resident 8 stated that he fell off the bed while sleeping and sustained right forehead redness, a right knee skin tear. On 11/19/2016, Resident was found sitting on the floor. Resident 8 stated he was getting something from the closet and lost his balance and fell on the floor and sustained an abrasion on the forehead. On 2/3/17, Resident 17 was noted lying on the floor in front of the bed with no injuries noted. A review of Resident 8's Care Plan initiated on 10/29/16 and was revised on 8/6/17 indicated that Resident 8 is at risk for falls with interventions that included bed in the lowest position and non-skid socks when in bed. During an interview with the MDS coordinator on 10/6/17 at 12:35 p.m., the MDS coordinator stated that residents who had a fall incident were considered high risk for falls and were added to the list of hourly monitoring. During an observation of Resident 8 with the MRD on 10/4/17 at 4:30 p.m., Resident 8 was observed in bed. Resident 8's bed was not in the lowest position. Resident 8 was observed not wearing non-skid socks. During an interview with the DON on 10/4/17 at 5:00 p.m., the DON stated that they will re-evaluate if the interventions were still appropriate for Resident 8. 2 (b). A review of the clinical record indicated Resident 16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 7/27/17, indicated Resident 16 was cognitively intact. Resident 16 required extensive assistance (resident involved in activity, staff provide weight bearing support) with bed mobility, transfer, dressing, eating, toilet use and personal hygiene. Resident 16 required two person physical assist with bed mobility, transfer and toilet use. Resident 16 required one person physical assist with dressing, eating and personal hygiene. A review of Resident 16's Progress Note dated 9/5/17 at 5:23 p.m. (Type: IDT (Interdisciplinary Team) Review) indicated the following: - On 9/1/17 at 11:50 p.m., found on the floor on left side of bed supine position with pillows underneath head and blanket on top. - On 9/2/17 at 7:45 a.m., found on floor lying on his left side, head resting on his left arm, noted skin discoloration on left inner elbow 0.5 cm x 0.5 cm. - On 9/2/17 at 3:30 p.m., found on the floor in supine position on the floor with pillow underneath the head; no injury noted. - On 9/5/17 found resident on the floor left side next to the end of the bed with his head resting on his left arm; no injury noted. Progress notes further indicated previous interventions included were frequent visual checks and safety reminders. IDT recommendations included the following: - In service staff to assess and provide extra blanket at bedtime if needed to keep warm - Continue frequent safety monitoring - Nonskid strips on both sides of the bed - Transfer to hospital for further evaluation A review of Resident 16's Fall Risk assessment dated [DATE] as reflected in the Admission/Readmission Nursing Data Tool indicated the resident was at risk for falls. A review of Resident 16's comprehensive care plan initiated on 8/8/17 indicated the resident was at risk for falls related to gait/balance problems requiring staff assistance during transfers. The goal was for the resident to be free from falls through the review date. Identified interventions included the following but not limited to: - Nonskid strips on both sides of bed. - Frequent visual and safety reminders. During an interview with the MDS coordinator on 10/6/17 at 12:35 p.m., the MDS coordinator stated that residents who had a fall incident were considered high risk for falls and were added to the list of hourly monitoring. On 10/6/17 at 3:15 p.m. Resident 16 was observed sleeping in bed. Three nonskid strips were observed on the floor on right side of the resident's bed. There were no nonskid strips observed on the floor on the left side of the resident's bed as indicated in the plan of care. During a concurrent observation and interview with certified nursing assistant (CNA5) on 10/6/17 at 3:20 p.m., he verified and stated that there were non-skid strips on the right side of Resident 16's bed. CNA 5 stated the care plan on the Kardex (summary of a resident's plan of care) indicated both sides of the bed must have nonskid strips on the floor. CNA 5 stated that he did not have time to read all that was written on the Kardex. CNA 5 further stated that non-skid strips should have been present on the left side of Resident 16's bed. A review of the clinical record for Resident 16 did not indicate a documented evidence that hourly monitoring was done from 9/1/17-9/17/17. 3 (a). A review of the Admission Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. to pump an adequate supply of blood), anxiety (state of excessive uneasiness and apprehension), psychosis (severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality), and hypertension (elevated blood pressure). A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/26/17 indicated Resident 1's brief interview of mental status (BIMS, screening that aids in detecting cognitive impairment) score was 10 (a score of 8-12 indicated moderate cognitive impairment). It also indicated that Resident 1 required extensive assistance (resident was involved in the activity, staff provided weight bearing support) with bed mobility, dressing and was totally dependent with personal hygiene and bathing. On 10/4/17 at 8:55 a.m., during concurrent observation and interview with licensed vocational nurse (LVN 2), she stated Resident 1 had a recent incident of fall and should have a star beside his name on the name plate outside the resident's room to indicate high risk for fall. A review of Resident 1's clinical record indicated a fall incident on 9/21/17 at 10:30 a.m. which resulted to a right forehead discoloration, right arm abrasion, left knee redness, and complaint of 9/10 (severe pain) headache and left knee pain. On 10/6/17 at 12:35 p.m., during interview, administrator stated residents who were identified as high risk for falls are included on the high risk for fall list and are monitored through rounding. On 10/6/17 at 12:38 p.m., during interview, the Director of nursing (DON) stated that part of the facility's fall protocol was to include residents who had a previous fall on the list of high risk for falls and were monitored every hour. A review of the facility form titled, Fall Prevention Program High Risk Residents, dated 9/21/17, 9/22/17, 9/23/17, 9/24/17, 9/25/17, 9/26/17 (3-11 and 11-7 shifts), 9/27/17, 9/28/17 and 9/29/17 (3-11 and 11-7 shifts), and 9/30/17 (7-3 and 3-11 shifts) did not indicate that Resident 1 was added on the list to be monitored every hour. Resident 1 was added on the list on 9/29/17 for the 7-3 shift, but there was no documented entry on the hourly monitoring from 7:00 a.m. to 2:30 p.m. A review of Resident 1's care plan titled, Resident is Moderate Risk for Falls, revised on 3/2/17, indicated staff interventions included were to follow facility fall protocol, anticipate and meet resident needs, and to ensure that call light is within resident's reach. 3 (b). A review of the Admission Face Sheet indicated Resident 12 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/28/17 indicated Resident 12's brief interview of mental status (BIMS, screening that aids in detecting cognitive impairment) score was 15 (a score of 13-15 indicated intact cognitive skills for daily decision making). It also indicated that Resident 12 required extensive assistance (resident was involved in the activity and staff provided weight bearing support) with bed mobility and transfer. A review of Resident 12's clinical record indicated a fall incident on 9/7/17 at 8:45 a.m. Resident 12 slid from bed unto floor in sitting position. Resident 12 was transferred to the hospital on [DATE] due to low blood pressure and oxygen desaturation. Resident 12 was readmitted on [DATE] at 5:30 p.m. and had a fall incident at 10:38 p.m. Resident 12 was found lying on the floor. Resident 12 stated her bed felt slippery when she moved and slid off the bed to the ground. On 9/12/17 at 11:09 a.m., interdisciplinary team (IDT) notes indicated interventions were frequent visual checks and safety reminders and recommended non-skid strips on the floor and reassessment of the mattress to minimize sliding. A review of Resident 12's care plan titled, Resident is at High Risk for Falls, initiated on 9/7/17 indicated staff interventions included were to assist in reorientation to room and facility with verbal cues, frequent visual checks, and monitor for sedation, dizziness, unsteady standing/sitting balance, and report to physician. Care plan indicated intervention for low air loss mattress with bolster was initiated on 9/14/17. On 10/6/17 at 8:05 a.m., during concurrent record review and interview with DSD, he stated that the fall care plan interventions was not coded with a k. The DSD stated that because of this, Kardex in the I-pad for Resident 12 did not reflect interventions for fall. On 10/6/17 at 12:35 p.m., during interview, administrator stated residents who are identified as high risk for falls are included on the high risk for fall list and are monitored through rounding. On 10/6/17 at 1:21 p.m., during interview, director of nursing (DON) stated the hourly monitoring for residents who were high risk for falls were documented by the certified nursing assistant (CNA) who provided direct resident care on the monitoring log. A review of the facility form titled, Fall Prevention Program High Risk Residents, dated 9/22/17 (3-11 shift), 9/23/17 (7-3), 9/25/17 (7-3 shift), 9/26/17 (3-11 shift), 9/27/17 (7-3 and 3-11 shifts), and 9/29/17 (7-3 shift), did not show documented evidence that Resident 12 was monitored every hour. There was no documented evidence that hourly monitoring was done for Resident 12 from 9/12/17 to 9/17/17. The Medical records director (MRD) and director for staff development (DSD) indicated the forms were missing. A review of the facility policy titled, Falls-Clinical Protocol, revised 10/2010 indicated if the interventions have been successful in preventing falling, the staff will continue with current approaches or reconsider whether these measures are still needed if the problem that required the intervention. Policy also stipulated that if the individual continues to fall, the staff and physician will reevaluate the situation and consider other possible reason for the resident's falling (besides those that have already been identified) and will reevaluate the continued relevance of current interventions. 3-4. On 10/4/17 at 7:50 a.m. to 9:04 a.m., during an initial tour of the facility conducted with licensed vocational nurse (LVN 2), it was observed that the name plates outside the residents' rooms had a star beside some of the resident's name. During interview, LVN 2 stated the star indicated that the residents were high risk for falls. On 10/4/17 at 2:20 p.m., it was observed that the director of staff development (DSD) was removing the stars beside the residents' names outside the rooms across the DSD office. DSD stated he was instructed to remove the stars because the facility no longer follows the falling star protocol. On 10/4/17 at 6:36 p.m., during interview, certified nurse assistant (CNA 11) stated the star beside resident's name indicated high risk for falls. CNA 11 stated this would alert staff that resident was at high risk for falls which required specific interventions such as hourly monitoring and more assistance with ADL. On 10/5/17 at 4:10 p.m., during interview, director of nursing (DON) stated residents who were at risk for falls were monitored every two hours while residents who were at high risk for falls were monitored every hour. DON stated after the fall assessment was completed, charge nurse would update list of residents on the hourly monitoring log for high risk for falls. DON stated the MDS coordinator will then update the care plan so the interventions will be reflected on the Kardex in the I-pad which will be accessible to the CNAs. DON stated the CNAs received in-service/training with the use of Kardex in the I-pad when it was implemented more than a year ago and was given by DSD on orientation for new employees. A review of the facility's New Employee Checklist Form did not indicate an orientation for Kardex and Fall Protocol Program. A review of the facility's Employee Roster indicated there were 13 CNAs hired since last facility recertification survey (2016). During an interview with the DSD on 10/7/17 at 9:58 a.m., the DSD stated that the orientation for CNAs upon hire does not include the use the fall protocol using the Kardex. On 10/6/17 at 2:15 p.m., during interview, CNA 9 stated that she was not given orientation with the use of kardex to identify residents at high risk for falls and interventions to prevent falls. CNA 9 stated she received orientation from her previous employment for the use of I-pad to document ADLs. CNA 9 stated she was unable to use I-pad at the beginning of her shift due to other responsibilities such as answering call lights and assisting residents with breakfast. On 10/6/17 at 5:00 p.m., during interview, CNA 1 stated that he did not receive in-service on how to use the I-pad. CNA 1 stated CNA 5 showed him how to use it a little bit. CNA1 stated he was not aware that Resident 1 was a high risk for fall. CNA1 stated he did not know the difference between low risk and high risk for fall or the interventions for it. CNA 1 stated he knew how to use the I-pad for ADL documentation, but did not know how to use the Kardex in the I-pad computer. On 10/5/17 at 4:42 p.m., during interview, MDS coordinator stated care plan interventions should be coded with a k for it to be reflected on the Kardex in the I-pad. During concurrent record review with the MDS c (TRUNCATED)